Radical Prostatectomy

1
Radical Prostatectomy

• Amy Opperer, D.O.
• Michigan State University-COM
• January 29, 2004

2
Objectives

• Understand the rationale for surgical treatment
• Become familiar with staging and prognostic
  factors
• Learn the operative and postoperative
  complications
• Evaluate role of adjuvant therapies

3
Introduction

• Second most common cancer death in men
• Cause death of 3 men gt50years
• Slow growing
• Doubling time 2-4 years

4
Rationale for Surgical Treatment

• Autopsy men gt50
• 30 have undetected prostate cancer
• 16 lifetime risk of clinically evident disease
• Currently diagnosed cancers ARE clinically
  important and more likely curable with surgery
• 319 T1c (Ohori, et al 1994)
• 55 high grade (Gleason 4/5)
• 40 extraprostatic extension
• 23 had advanced pathologic features (v. 40 T2)

5
Rationale for Surgical Treatment

• Model to predict insignificant tumor
• Epstein and associates (1994)
• Criteria 1
• PSA density lt0.1
• NO Gleason grade of 4/5
• lt3/6 biopsy cores positive
• No core with gt50 positive
• Criteria 2
• PSA density lt0.15
• NO Gleason grade 4/5
• lt3mm cancer on only 1/6 cores

PPV 95 NPV 66
6
Rationale for Surgical Treatment

• Natural history
• Chodak et al
• 828 patients (6 medical centers)
• 10 year risk of metastasis
• 19 well-differentiated
• 42 moderately-differentiated
• 74 poorly-differentiated

Cancer Specific Mortality _at_ 10yr
13
66
7
Rationale for Surgical Treatment

• Albertsen et al (1995)
• 451 men aged 65-75 treated conservatively
• Cancer specific mortality at 10 years
• 9 well-differentiated
• 24 moderately-differentiated
• 46 poorly-differentiated
• 3.8-5.2 lost years of life
• No significant loss for well-differentiated
• Albertsen et al (1998)
• 767 men aged 55-74 treated conservatively
• Cancer specific mortality at 15 years
• Gleason 2-4 minimal
• Gleason 5-6 moderate
• Gleason 7-10 significant

8
Outcomes of Surgical Treatment

• PSA increase precedes clinical recurrence by 6-8
  years
• Hazard rate-risk of tumor recurrence each year
• High rate early understaging
• High rate several years out incomplete
  eradication
• Highest recurrence within 1 year
• 5-15 recurrence gt5 years postop
• Thusrecurrence usually due to understaging

9
Prognostic Factors

• Clinical stage
• 85 5 year non-progression for T1c
• Gleason score of biopsy
• 5 year non-progression
• 2-4 89-100
• 5 80-97
• 6 89-92
• 7 60-66
• 8-10 41-74

10
Prognostic Factors

• Serum PSA
• 5 year non-progression
• 0-4 94-95
• 4.1-10 82-93
• 10.1-20 65-72
• gt20 41-54

11
Prognostic Factors

• Pathologic stage
• Single most powerful prognostic factor
• Five year disease free survival
• 90 organ confined
• 76 microscopic extension
• 37 seminal vesicle
• 18 lymph nodes

12
Prognostic Factors

• Positive Surgical Margins
• 2-4 fold increased hazard rate
• Steps to reduce positive margins
• Wide dissection at apex, including posteriorly
• Deep dissection posterior layer Denonvilliers
• Neurovascular bundles posteriolaterally
• Divide bladder neck proximally
• Gleason grade of specimen
• Volume of higher grade (4/5) cancer

13
Locally Advanced Tumors

• Most T3 located in peripheral zone
• Posterolateral and rectal extension increased
• Widely resect neurovascular bundle
• T3 tumors
• 30-50 lymph node metastasis
• Small T3 tumors (Gervasi et, 1989)
• 67 seminal vesicle
• 20 lymph node

14
Locally Advanced Tumors

• Surgical treatment YES or NO?
• Healthy men with limited T3 disease YES
• 26 with surgery alone (organ confined)
• Adjuvant hormone therapy if locally extensive
• 25-50 decreased survival v. general population
• Neoadjuvant androgen deprivation
• No change in long-term recurrence

15
Complications

• Anastomotic stricture
• 0.5-9
• Contributing factors
• TURP
• High EBL
• Urinary extravasation

16
Complications

• Urinary Incontinence
• 10 - centers with broad expertise
• Murphy et al 1994 American College of Surgeons
  Committee on Cancer
• 330/1796 (19) wore pads daily
• 3.6 totally incontinent
• Fowler (1990) Medicare patients
• 31 some incontinence

17
Complications

• Majority minimally bothered (Litwin et al, 1995)
• Decreased risk
• Younger age, neurovascular bundles, modified
  anastomosis technique, lack of stricture
• Small bite urethra and large bite lateral pelvic
  fascia surrounding oversewn dorsal vein complex
  (fully everted bladder neck)
• Kegel exercises
• Biofeedback

18
Complications

• Improved continence up to 1 year (even 2years)
• Defer invasive treatment at least 1 year
• Evaluate cause
• Bladder neck contracture
• Dribbling stream, overflow
• Cysto
• Bladder dysfunction
• Urodynamics
• Tx fluid restriction, clocked voids,
  anticholinergics, imipramine hydrochloride,
  bladder augmentation

19
Complications

• Sphincteric insufficiency
• Collagen injections
• 80 dry if using lt3ppd (Cespedes, 1996)
• Poor efficacy with radiation, bladder neck
  incision
• Artificial urinary sphincter (AUS)

20
Complications

• Erectile dysfunction
• Positive factors
• Younger age
• Preop potency
• Preservation of neurovascular bundles
• Potency 3 years postop (Rabbani et al, 2000)
• 76 lt60yo
• 56 60-65yo
• 47 gt65yo

Full preop erections B neurovasc bundles
21
Complications

• Quinlan et al (1991)
• 503 potent men 34-72yo
• lt50yo 90 if uni/bil preservation of bundles
• gt50yo better if bil preservation of bundles
• Catalona et al (1999)
• 1870 men 18mo postop
• 68 bilateral preservation
• 47 unilateral preservation
• ACS Committee on Cancer
• 65-69yo with 39 stage C/D
• 27 potency postop

22
Complications

• Critical steps
• Oversewing back-bleeders from prox dorsal vein
• Dividing striated sphincter when placing urethral
  sutures
• Dividing posterior striated sphincter
• Achieving hemostasis
• Early treatments
• Intraoperative neurostimulation
• Sural nerve grafts
• Injection therapy
• Viagra

23
Indications/Contraindications

• Men likely to be cured and live long enough to
  benefit from cure
• Risk/benefit factors
• Age, health, nature of cancer, prognostic
  features, probability of cure, risk of
  complications, patients utilities or values
• Mortality from localized cancer
• 8-10 years untreated
• NO specific age as cutoff
• Life expectancy lt10?watchful waiting

24
Prognostic Factors

• Clinical stage
• T3 significantly worse prognosis than T1-T2
• Surgical tx only for small T3a without mets
• No significant difference between substages
• PSA
• Cannot distinguish stage in individual patient
• Gleason grade
• Important prognostic factor
• Cannot used alone to determine management

25
Risk Stratification

• Very low risk tumors
• Watchful waiting, deferred tx, brachy
• Intermediate-risk tumors
• Definitive surgery, external beam radiation
• High-risk tumors
• Combined modality

26
Prognostic Models

• Partin et al (1997)
• 4133 undergoing RRP
• Identified significant predictors of pathologic
  stage
• PSA, TNM, Gleason
• Kattan et al (1998)
• Predict five-year recurrence after RRP
• PSA, TNM, Gleason
• Fig 89-9 89-10
• Nomograms also available for XRT and brachy

27
Adjuvant Therapy

• Neoadjuvant androgen ablation
• Positive surgical margin
• 47?22
• Preop PSA
• 96 decrease
• Prostate volume
• 34 decrease
• 3 year results? no improvement in progression

28
Adjuvant Therapy

• Negative effects
• Expense
• Delay treatment
• Periprostatic fibrosis alters tissue planes
• Impotence
• Mask surgical margin status
• Missed raidation treatment

29
Adjuvant Therapy

• Postoperative adjuvant therapy
• Pelvic lymph node dissection
• 2-7 lymph node mets in localized disease
• High 10-yr progression without hormonal therapy
• Do not recommend routine BPLND prior to radiation
  or radical perineal prostatectomy
• Unless high-grade, high stage, markedly high
  PSA
• Routine in radical retropubic prostatectomy
• No further morbidity
• Do not obtain frozen section

30
Adjuvant Therapy

• Node positive patients (2-3)
• Hormone therapy
• Immediate v. delayed
• Postoperative adjuvant radiation
• Microscopic extracapsular extension
• 71 free of progression without treatment
• Seminal vesicle invasion (No PSA)
• Rarely local recurrence
• Positive surgical margin (No PSA, nodes)
• 40-50 progress without radiation

31
PSA Failure

• PSA progression
• 0.2ng/mL and rise on at least 2 repeats
• PSA ? 4-8y prior to clinical recurrence
• 5 year median to death after metastatic dz
• Site of progression
• lt5 positive bone scan if PSA lt40
• ProstaScint scan??

32
PSA Progression

• Local recurrence more likely if
• Normal nodes and seminal vesicles
• Gleason 7
• First elevated PSA after 1 year
• PSA doubling time gt10months

33
Salvage Radiotherapy

• Only treatment for local recurrence
• Improved outcome
• Low pathologic stage
• Low tumor grade
• Initiation while PSA lt2ng/mL
• Radiation dose gt64Gy
• NO improvement in overall survival

34
Salvage Prostatectomy

• Indications
• Excellent health
• 10 year life expectancy
• No metastatic disease
• Localized disease (pre/post treatment)
• Highly motivated
• Accept high morbidity
• PSA level
• lt10?15 advanced pathologic features
• gt10?86 advanced pathologic features

35
Salvage Prostatectomy

• Higher complications
• Rectal injuries
• Full bowel prep?primary repair
• Urinary incontinence
• 58? 2 pads per day
• 20?AUS
• 27?anastamotic strictures

36
Salvage Prostatectomy

• Actuarial non-progression
• 5 year 57
• Organ confined 100
• Extracapsular extension 71
• Seminal vesicle invasion 28
• 10 year 35

37
Conclusion

• Median loss of life?9 years
• Definitive tx localized disease
• Good health and life expectancy 10 years
• Assess benefits of treatment
• Life expectancy
• Risk of metastasis untreated
• Likelihood of eradication and prevention of
  metastasis with surgery
• Tolerance of complications