Radical prostatectomy: Still the gold standard for prostate cancer

Paris--Radical prostatectomy remains the gold standard for treating localized prostate cancer, according to William J. Catalona, MD, professor of urology at Northwestern University's Feinberg School of Medicine, Chicago. The procedure is not without challengers, however, a number of which are showing promise.

"It is a technically formidable operation and, because of this, simpler treatments are constantly being sought for early prostate cancer," said Dr. Catalona, one of several speakers for a committee discussing developments in teatment of localized prostate cancer at the International Consultation on New Developments in Prostate Cancer and Prostate Diseases. "However, none of these treatments has supplanted RP because of the realization that hormone therapy is never curative, and not all cancer cells can be eradicated by radiation or other physical forms of energy, even if the tumor is totally contained within the prostate."

Optimizing RP outcomes

"The postoperative course is much smoother than it was in the past, and it has been demonstrated that RP in prospective randomized trials reduces local progression and metastases and improves cancer-specific and overall survival rates compared with watchful waiting," said Dr. Catalona.

"There is great appeal to patients who view this as a high-tech, less-invasive form of performing RP," explained Dr. Catalona, adding that robotic technology has made this method easier to perform. "However, it has not been convincingly demonstrated that cancer-free surgical margins and preservation of potency can be achieved as well with laparoscopic approaches as with open prostatectomy, and long-term outcome data are lacking for laparoscopic approaches."

Patients selected for radical prostatectomy should have a completely resectable tumor and at least 10 years of life expectancy, according to the committee. Preoperatively, biopsy is a useful predictor, and bone scans also may be appropriate. Patient counseling before surgery should include explanations of nerve sparing and the potential for postoperative erectile dysfunction and Peyronie's disease, as well as the treatment of these adverse events.

"Patients should be warned that if their cancer is so far advanced that the nerves will have to be resected, after that operation, there is a great likelihood that they will need radiation or hormone therapy that could then nullify any potential benefits of nerve grafts," Dr. Catalona advised.

Postoperatively, patients normally require 1 to 3 days of hospitalization and up to 2 weeks of catheterization. Most can resume normal activity within weeks.

Erections normally begin to resume within 3 to 6 months and usually continue to improve for up to 36 months after surgery, and continence returns by 18 months after surgery.

In Dr. Catalona's series, men who had normal erections preoperatively and who had bilateral nerve-sparing surgery were followed for at least 18 months postoperatively and did not require postoperative radiotherapy or hormonal therapy. Ninety-five percent in their 40s, 85% in their 50s, 75% in their 60s, and 50% in their 70s recovered erections sufficient for penetration and intercourse with or without the help of phosphodiesterase type-5 inhibitors. In most community series, the reported success rate has been considerably lower, usually about 50%.