Role of Surgery in localised prostate cancer...Role of Surgery in localised prostate cancer Lee Lui...
Transcript of Role of Surgery in localised prostate cancer...Role of Surgery in localised prostate cancer Lee Lui...
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Role of Surgery in localised prostate cancer
Lee Lui ShiongDepartment of Urology, SGH
Director Urologic Oncology and Robotic [email protected]
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Disclosures
• Advisory board
– Janssen
– Bayer
– MSD
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Scope of Discussion
• Background
• Modality
• Indication
• Outcome indicators
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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.
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Modality
• Open
– Retropubic
– Perineal ( limited access to lymph nodes)
• Laparoscopic
• Robotic Assisted
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Indication for surgery
• Organ confined disease- monotherapy
• High risk disease – as part of multimodality
• Radiorecurrent disease
• Cytoreductive prostatectomy - controversial
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• PSA <50
• cT1-2
• Negative bone scan
• Age <75
• Life expectancy >10 years
• N=695 (recruitment complete)
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• Mean PSA 13
• Only 12 % T1c disease
• watchful waiting ≠ active surveillance
• Progression – clinical progression , not PSA
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• Benefit for radical surgery in prostate cancer in the pre-PSA era
• Proportion would be considered high risk/ locally advanced by current definition
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• PSA <50
• cT1-2
• Negative bone scan
• Age <75
• Life expectancy >10 years
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• “ Life expectancy of 10 years or more”
• 10 years – 50% mortality
• 15 years – 70% mortality
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• 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
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• Median age 62 yrs
• Median PSA 4.6
• 77% Gleason 6
• 76% T1c
• Follow-up median 10 years
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• Low risk prostate cancer
• PCSM 10 years – limited value of surgical treatment
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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)
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Additional benefit of surgery 1st line
• Relieve obstruction more expediently
• Treatment duration shorter - ? SBRT
• PSA – exquisitely sensitive
• Definite staging – stratify need for adjuvant therapy
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Predictive models
• Partin tables – features at RP
• MSK nomogram – pre and post RP
• Briganti nomogram – nodal involvment pre-RP
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Surgical quality indices
• Trifecta– Cancer control
– Continence
– Sexual
• Pentafecta– Trifecta +
– No complications
– Negative surgical marginsEur Urol 2011, 59:702-707
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• N=725
• F/U median 22.4 months
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SGH 69 22 9 0.1
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SGH 186 ( 80-480) 215 (50-2000) 2.1 7 (3-32) 3 (2-62)
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Low et al pT2 15 pT3a/3b 50
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Low et al 725 All 0-1 safety pad Patient reported 93%
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• Prostate Cancer Outcomes Study
• Diagnosed 1994-1995
• Age 55-74 yrs
• Surgery (n=1164), RT (n= 491)
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• 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
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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)
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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
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Urol Int 2015;94:373-382
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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
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Surgical volume and outcomes
• Institution volume of surgery affects
– Surgical margins
– Complication rate
– Length of stay
– Functional outcomes