Role of Surgery in localised prostate...
Transcript of Role of Surgery in localised prostate...
Role of Surgery in localised prostate cancer
Lee Lui ShiongDepartment of Urology, SGH
Director Urologic Oncology and Robotic [email protected]
Background
• 1947 – Milin retropubic prostatectomy
• 1982 – Walsh – nerve sparing RP
• 2000 – Montsouris team – lap RP
J Urol. 1982 Sep. 128(3):492-7J Urol. 2000; 163: 1643-9.
Modality
• Open
– Retropubic
– Perineal ( limited access to lymph nodes)
• Laparoscopic
• Robotic Assisted
Indication for surgery
• Organ confined disease- monotherapy
• High risk disease – as part of multimodality
• Radiorecurrent disease
• Cytoreductive prostatectomy - controversial
• PSA <50
• cT1-2
• Negative bone scan
• Age <75
• Life expectancy >10 years
• N=695 (recruitment complete)
• Mean PSA 13
• Only 12 % T1c disease
• watchful waiting ≠ active surveillance
• Progression – clinical progression , not PSA
• Benefit for radical surgery in prostate cancer in the pre-PSA era
• Proportion would be considered high risk/ locally advanced by current definition
• Under-powered
• Most subjects died in <10 years – “healthy”
• 20% did not receive allocated treatment option
• Take Home (PIVOT)
• Co-morbidities, life expectancy <10 years – don’t operate
Value of surgery (treatment)
• Surgery provides cancer specific survival and metastatic free survival
– intermediate to high risk disease ( Bill Axelson)
– low grade/ risk disease, poor ECOG -> marginal
• (active surveillance)
Additional benefit of surgery 1st line
• Relieve obstruction more expediently
• Treatment duration shorter - ? SBRT
• PSA – exquisitely sensitive
• Definite staging – stratify need for adjuvant therapy
Predictive models
• Partin tables – features at RP
• MSK nomogram – pre and post RP
• Briganti nomogram – nodal involvment pre-RP
Surgical quality indices
• Trifecta– Cancer control
– Continence
– Sexual
• Pentafecta– Trifecta +
– No complications
– Negative surgical marginsEur Urol 2011, 59:702-707
• Prostate Cancer Outcomes Study
• Diagnosed 1994-1995
• Age 55-74 yrs
• Surgery (n=1164), RT (n= 491)
• Surgery
• Urinary incontinence and ED more prevalent 2-5 years
• 15 years no difference
• RT
• Bowel symptoms more prevalent 2-5 years
• 15 years -> no difference
Penile rehabilitation
• Potent ( IIEF >16/25)
• Nerve sparing
• Early PDE5i after IDC removed
• 75-90% spontaneous potency with/without aids– Less than 65 yo
– Potent
– Bilateral nerve sparing
– Healthy ( DM, smoking)
Radiorecurrent disease
• PSA recurrence• Is it localised or systemic disease?
• Pheonix definition “2+ nadir”
• What defines an ideal nadir?• Should we waiting for 2 + to occur?
• Effect of ADT confounds assessment– Tail end of ADT– PSA Rebound
Take Home
• Surgery has a defined role in organ confined disease
• Survival benefit is best seen in the intermediate to high risk disease
• Defined quality indices for surgery
• Side effects include urinary and sexual dysfunction
• Salvage prostatectomy -> increased morbidity