Role of Surgery in localised prostate cancer
Lee Lui ShiongDepartment of Urology, SGH
Director Urologic Oncology and Robotic [email protected]
Disclosures
• Advisory board
– Janssen
– Bayer
– MSD
Scope of Discussion
• Background
• Modality
• Indication
• Outcome indicators
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
• PSA <50
• cT1-2
• Negative bone scan
• Age <75
• Life expectancy >10 years
• “ Life expectancy of 10 years or more”
• 10 years – 50% mortality
• 15 years – 70% mortality
• 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
• Median age 62 yrs
• Median PSA 4.6
• 77% Gleason 6
• 76% T1c
• Follow-up median 10 years
• Low risk prostate cancer
• PCSM 10 years – limited value of surgical treatment
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
• N=725
• F/U median 22.4 months
SGH 69 22 9 0.1
SGH 186 ( 80-480) 215 (50-2000) 2.1 7 (3-32) 3 (2-62)
Low et al pT2 15 pT3a/3b 50
Low et al 725 All 0-1 safety pad Patient reported 93%
• 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
Urol Int 2015;94:373-382
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
Surgical volume and outcomes
• Institution volume of surgery affects
– Surgical margins
– Complication rate
– Length of stay
– Functional outcomes