Download Parkin et al, 2005

Prostate Cancer
Radical Prostatectomy
A.Ariafar MD
Fellowship of Urology-Oncology
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Prostate cancer is the fifth most common malignancy
worldwide and the second most common in men
Parkin et al, 2005
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Prostate cancer makes up 11.7% of new cancer cases
overall, 19% in developed countries, and 5.3% in developing
countries
The lowest yearly incidence rates occur in Asia (1.9 cases
per 100,000 in China) and the highest in North America and
Scandinavia, especially in African-Americans (249 cases per
100,000)
Parkin et al, 2005; American Cancer Society, 2008
Prostate cancer has been the most common noncutaneous
malignancy in U.S.
The estimated lifetime risk of disease is 16.72%, with a
lifetime risk of death at 2.57%.
American Cancer Society, 2008
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Prostate cancer is rarely diagnosed in men younger than 50
years old, accounting for only 2% of all cases Jani et al, 2008.
The median age at diagnosis is 68 years, with 63%
diagnosed after age 65
Ries et al, 2011
Since the introduction of PSA testing, the incidence of
local-regional disease has increased, whereas the incidence
of metastatic disease has decreased
Newcomer et al, 1997
Nonpalpable cancers (clinical stage T1c) now account for
60% to 75% of newly diagnosed disease
Derweesh et al, 2004; Gallina et al, 2008
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Clinical stage migration has also been associated with
improvements in 5- and 10-year disease-specific survival,
which for all stages combined now are 99% and 91%,
respectively
American Cancer Society, 2008
The Changing Face of Prostate Cancer
Cooperberg et al. J Urol 2007; 178:S14
Risk stratification of surgical population over time.
Low risk: prostate-specific antigen (PSA) less than
10, and stage T1 or T2a, and biopsy Gleason score
= 6 or lower. Intermediate risk: PSA 10 to 20, or
stage T2b or T2c, or biopsy Gleason score = 7.
High risk: PSA more than 20, or stage T3, or
biopsy Gleason score = 8 or higher, or any two or
more intermediate risk factors.
Declining rate of extracapsular extension
(resulting in increased rate of organ-confined
disease) on radical prostatectomy specimens at the
Cleveland Clinic, 1987-2005. Trends in pathologic
stage migration with joinpoint regression analysis.
Annual change: 1987 to 1992: −2.9%; 1992 to 1995:
−16.9%; 1995 to 2005: −4.2%. NOCD, non–organconfined disease.
Definitive Therapy for Localized Prostate
Cancer
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CONSERVATIVE MANAGEMENT
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RADICAL PROSTATECTOMY
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Active Surveillance
Watchful Waiting
Perineal
Retropubic
Laparoscopic
Robotic
RADIATION THERAPY
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External Beam Radiotherapy (Three-Dimensional Conformal
Radiotherapy)
Brachytherapy
RADICAL PROSTATECTOMY
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Radical prostatectomy was the first treatment used for
prostate cancer and has been performed for more than 100
years
Kuchler, 1866; Young, 1905.
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No treatment has supplanted radical prostatectomy, and it
still remains the gold standard because of the realization
that hormone therapy and chemotherapy are never curative,
and not all cancer cells can be eradicated consistently by
radiation or other physical forms of energy, even if the
tumor is contained within the prostate gland
Campbell’s urology 2011 ,chapter 100
Advantage of RP
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The main advantage of radical prostatectomy is that when
skillfully performed, it offers the possibility of cure with
minimal collateral damage to surrounding tissues
Han et al, 2001b; Hull et al, 2002.
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Further, it provides more accurate tumor staging by
pathologic examination of the surgical specimen.
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Also, treatment failure is more readily identified, and the
postoperative course is much smoother than in the past
Campbell’s urology 2011 ,chapter 100
Advantage of RP
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Radical prostatectomy significantly reduces local
progression and distant metastases and improves cancerspecific and overall survival rates compared with watchful
waiting
Bill-Axelson et al,2008
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Patients with tumor recurrence after radical prostatectomy
can be salvaged with potentially curative postoperative
radiotherapy
Stephenson et al, 2004b; Trock et al, 2008.
Disadvantages of RP
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The potential disadvantages of radical prostatectomy are
the necessary hospitalization and recovery period
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Possibility of incomplete tumor resection, if the operation is
not performed properly or if the tumor is not contained
within the prostate gland
Risk for erectile dysfunction and urinary incontinence
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Erectile dysfunction and rectal complications are less likely
with nerve-sparing surgery than with radiotherapy, and
good treatment options are available for both urinary
incontinence and erectile dysfunction
Rabbani et al, 2000; Stanford et al, 2000, Kundu et al, 2004; Sanda et al, 2008
Selection of Patients for Radical
Prostatectomy
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An ideal candidate for radical prostatectomy is healthy and
free of comorbidities that might make the operation
unacceptably risky.
He should have a life expectancy of at least 10 years, and
his tumor should be deemed to be biologically significant
and completely resectable.
The generally accepted upper age limit for radical
prostatectomy is about 75 years.
Campbell’s urology 2011
Because imaging studies are not accurate for staging
prostate cancer, preoperative clinical and pathologic
parameters are often used to predict the pathologic stage
and thus identify patients most likely to benefit from the
operation
Partin et al, 1997, 2001
Risk Assessment of Pca
Low-risk, localized PCa
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Patients with low-risk, localized PCa should be
informed about the results of the randomized
trial comparing retropubic RP versus watchful
waiting in localized PCa
In this study, RP reduced prostate cancer
mortality and the risk of metastases in men
younger than 65 years with little or no further
increase in benefit 10 or more years after surgery
J Natl Cancer Inst 2008 ;100(16):1144-54.
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Stage T1a-T1b Pca
A Swedish register-based study of 23,288 men with stage
T1a-T1b showed a 10-year PCa mortality of 26.6%.
Br J Cancer 2009;100(1):170-3
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It is shown that the risk of disease progression of untreated
T1a PCa after 5 years is only 5%,but these cancers can
progress in about 50% of cases after 10-13 years
In contrast, most patients with T1b tumours were expected
to show disease progression after 5 years, and aggressive
treatment was often warranted
J Urol 1988;140(6):1340-4
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Stage T1c and T2a Pca
StageT1c has become the most prevalent type of PCa.
In an individual patient, it is difficult to differentiate
between clinically insignificant and life-threatening PCa.
Most reports, however, stress that cT1c tumours are mostly
significant and should not be left untreated as up to 30% of
cT1c tumours are locally advanced disease at final
histopathology
J Urol 1997 Jan;157(1):244-50.
In Stage T2a patients 35-55% of them will have disease
progression after 5 years if not treated
Cancer 1990;66(9):1927-32
Low risk Treatment Trends
Intermediate-risk, localized PCa
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Patients with intermediate-risk, localized PCa should be
informed about the results of the randomized trial
comparing RRP versus watchful waiting in localized PCa.
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In this study, RP reduced prostate cancer mortality and risk
of metastases in men younger than 65 years with little or no
further increase in benefit 10 or more years after surgery
J Natl Cancer Inst 2008 ;100(16):1144-54.
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Stage T2b cancer will progress in more than 70% of
patients within 5 years
Urology 1990;36(6):493-8.
Oncological results of RP in organ-confined
disease
High-risk localised PCa
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Despite the trends towards lower-risk PCa, 20-35% of
patients with newly diagnosed PCa are still classified as
high risk, based on either PSA > 20 ng/mL, Gleason score
> 8, or an advanced clinical stage
JNatl Cancer Inst 2009;101(18):1280-3
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There is no consensus regarding the optimal treatment of
men with high-risk Pca
EAU 2011
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Locally advanced PCa: cT3a
Several randomized studies of radiotherapy combined with
androgen-deprivation therapy (ADT) versus radiotherapy
alone have shown a clear advantage for combination
treatment, but no trial has ever proven combined treatment
to be superior to RP
Lancet 2002 :360(9327):103-6
In recent years, there has been renewed interest in surgery
for locally advanced PCa, and several retrospective caseseries with excellent 5-, 10- and 15-year overall survival (OS)
and cancer-specific survival (CSS) rates have been
published
Over-staging of cT3 PCa is relatively frequent and occurs in
13-27% of cases.
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High-grade PCa: Gleason score 8-10
Although most poorly differentiated tumours extend
outside the prostate, the incidence of organ-confined
disease is between 26% and 31%.
One-third of patients with a biopsy Gleason score > 8 may
in fact have a specimen Gleason score < 7 with better
prognostic characteristics
The biochemical recurrence-free survival after RP at 5 and
10 yr of follow-up was 51% and 39%, respectively
Eur Urol 2008;53(2):253-9
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PCa with PSA > 20
Yossepowitch et al. reported the results of RP as a
monotherapy in men with PSA > 20 ng/mL in a cohort
with mostly clinically organ-confined tumours and found a
PSA failure rate of 44% and 53% at 5 and 10 years,
respectively
J Urol 2007;178(2):493-9
Inman and co-workers described the long-term outcomes
of RP with multimodal adjuvant therapy in men with PSA >
50.
Systemic progression-free survival rates at 10 years were
83% and 74% for PSA 50-99 and > 100, respectively, while
CSS was 87% for the whole group
Cancer 2008 ;113(7):1544-51.
Overall and cancer-specific survival rates for
locally advanced prostate cancer
Very high-risk localised prostate
cancer
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cT3b-T4 N0
Men with very high-risk PCa generally have a significant
risk of disease progression and cancer-related death if left
untreated
There is a need for local control as well as a need to treat
any microscopic metastases
The optimal treatment approach will therefore often
necessitate multiple modalities
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A recent US study showed that patients who underwent RP
(n = 72) for cT4 disease had a better survival than those
who received HT alone or RT alone and comparable
survival to that of men who received RT plus HT
Cancer 2006 Jun;106:2603-9.
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Another study compared the outcomes of RP in very highrisk PCa (T3-T4 N0-1, N1, M1a) with those in localized
PCa. Overall survival and CSS at 7 years were 76.69% and
90.2% in the advanced disease group and 88.4% and 99.3%
in the organ-confined disease group, respectively
Eur Urol 2007;51(4):922-9
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Any T, N1
Most urologists are reluctant to perform RP for clinical N+
disease, or will cancel surgery if a frozen section shows
lymph node invasion
A recent study has shown a dramatic improvement in CSS
and OS infavour of completed RP versus abandoned RP in
patients who were found to be N+ at the time of surgery
Eur Urol 2010 Jan 20. http://www.ncbi.nlm.nih.gov/pubmed/20106588
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The combination of RP and early adjuvant hormonal
treatment in N+ PCa has been shown to achieve a 10-year
CSS rate of 80%
J Urol 1999;161(4):1223-7;
Lancet Oncol 2006 ;7(6):472-9.
Neoadjuvant hormonal treatment
and RP
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Neoadjuvant hormonal therapy before RP does not provide
a significant OS advantage over prostatectomy alone.
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Neoadjuvant hormonal therapy before RP does not provide
a significant advantage in disease-free survival over
prostatectomy alone.
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Neoadjuvant hormonal therapy before RP does
substantially improve local pathological variables such as
organ-confined rates, pathological down-staging, positive
surgical margins and rate of lymph node involvement.
Complications of RP
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Urinary Continence
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For high-volume radical prostatectomy surgeons, more
than 90% of men recover complete urinary continence.
The return of urinary continence is associated with the
patient’s age: approximately 95% of men younger than 60
years can attain pad-free urinary continence after surgery;
85% of men older than 70 years regain continence.
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Campbell’s urology 2011 ,chapter 100
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Erectile Function
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The return of erectile function after radical retropubic
prostatectomy correlates with the age of the patient,
preoperative potency status, extent of nerve-sparing
surgery, and era of surgery.
In the most favorable candidates in whom preoperative
potency is normal and bilateral nerve-sparing surgery can
be performed, up to 95% in their 40s, 85% in their 50s, 75%
in their 60s, and 50% in their 70s can attain recovery of
erections sufficient for penetration and intercourse
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Campbell’s urology 2011 ,chapter 100
Guidelines and recommendations for
radical prostatectomy
EAU 2011
Thanks