Radical prostatectomy has changed dramatically over the past 20 years. A procedure that once carried a significant degree of perioperative morbidity, particularly in high-risk patients, has become relatively routine in high-volume centers.
San Francisco-Radical prostatectomy has changed dramatically over the past 20 years. A procedure that once carried a significant degree of perioperative morbidity, particularly in high-risk patients, has become relatively routine in high-volume centers. In fact, radical prostatectomy is a safe and effective treatment for high-risk prostate cancer, Judd Moul, MD, professor and chief of urology at Duke University, Durham, NC, told attendees at the 2010 Genitourinary Cancers Symposium in San Francisco.
"This is not your father's radical prostatectomy," Dr. Moul said. "Radical prostatectomy today is incorporated in a multidisciplinary, multimodality context. These high-risk patients need more treatment, not less."
Radical prostatectomy today can be performed with limited morbidity in experienced hands, Dr. Moul said. The transfusion rate is typically low (in the range of 5% to 15%), the hospital stay is short at 1 or 2 days, and long-term incontinence rates are low. One major risk that concerns patients and surgeons alike is erectile dysfunction. There are doubts that nerve-sparing procedures are the most effective or appropriate type of radical prostatectomy for high-risk patients.
"We need to be thinking of adequate treatment to reduce their risk of mortality from prostate cancer."
Adequate treatment typically means multiple treatment modalities, he added. Multiple phase I studies support external beam radiation before radical prostatectomy. A Duke trial using escalating radiation doses followed by radical prostatectomy found that even with preoperative radiotherapy, surgery was performed safely, transfusion rates were reasonable for the high-risk population, operation and hospitalization times were reasonable, and the complication rate was relatively low.
"This would not even have been dreamed of 20 years ago," he said. "You can approach these multidisciplinary trials and still expect very good surgical results. The results to date are quite respectable. This looks like something that is ready to go on to phase II."
Multidisciplinary care indicated
All high-risk patients should be seen in a multidisciplinary setting with a multimodal treatment plan, Dr. Moul advised. Radical prostatectomy should never be performed or even planned in a vacuum. Clinical trial opportunities should be emphasized to refine therapy and outcomes. Multidisciplinary approaches might include different combinations of radiotherapy, hormonal therapy, chemotherapy, and surgery to achieve the best possible treatment outcome.
It is also important to note that not every high-risk patient will need further treatment following radical prostatectomy. Between 30% and 40% of high-risk patients have organ-confined disease and can expect no recurrence.
For other patients, the debate over adjuvant versus salvage radiotherapy following surgery continues. New randomized controlled trials support the use of adjuvant radiation therapy if the patient has an undetectable PSA following surgery. Many urologists wait until PSA rises and use radiation in the salvage setting, but there are no published randomized controlled trials in this setting.
The debate over robot-assisted laparoscopic radical prostatectomy (RALP) versus open radical prostatectomy continues. RALP has clearly become a popular option due to the perceived advantages of the minimally invasive procedure, but strong data are scarce.
"The objective outcome improvements compared to open radical prostatectomy have been exceedingly difficult to prove," Dr. Moul said. "The skill set of the surgeon is a greater driver of the outcome than is the procedure. I wish we could focus our energies on doing a better job in high-risk disease than on this debate of open versus robotic."
What is known, he continued, is that RALP is not cost effective compared to open prostatectomy, and that randomized trials are highly unlikely. But there are still more questions than answers for high-risk patients: What are the comparative effects of enhanced visualization in RALP and the lack of tactile sensation? How does the lower estimated blood loss with RALP, especially in less experienced hands, justify its use? Is there a risk of peritoneal seeding?
"We know that RALP costs more, but whether it offers clinical advantages remains unclear. I would underline that when it comes to high-risk disease. There is clearly not evidence that robotic prostatectomy is superior to open prostatectomy, especially in high-risk patients."