|Year : 2021 | Volume
| Issue : 1 | Page : 5-9
Role of laparoscopic radical prostatectomy in locally advanced and high-risk prostate cancer: Whether safe and effective approach?
Gurunam Singh Girniwale1, Alok Srivastava1, Anjana Singh2, Chandrakant Munjewar1, Sanjeet K Singh1
1 Department of Urology and Renal Transplantation, Dr. Ram Manohar Lohia Institute of Medical Sciences, Gomti Nagar, Lucknow, India
2 Deparment of Pathology, Mayo Medical Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
|Date of Submission||17-May-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||31-Jul-2021|
Dr. Sanjeet K Singh
Department of Urology and Renal Transplantation, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow 226010, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Introduction: Historically, patients with locally advanced and high-grade diseases have not been viewed as a good candidate for radical prostatectomy (RP). The role of RP for locally advanced and high-grade diseases is controversial and the focus of debate. The objective of this study is to evaluate the role of RP in the treatment of locally advanced and high-grade disease. Materials and Methods: In this retroprospective study, all the laparoscopic RPs done for prostate cancer between January 2014 and January 2016, in the Department of Urology, DRRMLIMS, Lucknow, were enrolled and followed for five years. A total of 116 patients were included in this study. They were divided into two groups: group 1 includes 78 patients with localized carcinoma prostate and group 2 includes 38 patients with locally advanced and high-grade prostate cancer. The following characteristics were noted in both groups: margin status, biochemical progression, local recurrence, distant metastasis, clinical progression, and overall and cancer-specific survival (CSS). The primary endpoints were CSS and overall survival. Postoperative survival was estimated using Kaplan–Meier method and compared using log-rank test. Univariate and multivariate analysis of features associated with outcomes were conducted using Cox proportional hazards regression models. Result: The resulting survival estimates at the last follow-up after RP were 83%, 81.58% and 76.92%, 76.31% in groups 1 and 2 for prostate CSS and overall survival, respectively. Overall, 3.85% in group 1 and 21.05% in group 2 patients received salvage radiotherapy for biochemical recurrence, whereas 7.69% in group 1 and 15.79% in group 2 patients were treated with salvage androgen deprivation therapy during clinical follow-up. Margin status was positive in 10.25% and 21.05% of cases in groups 1 and 2, respectively. Conclusion: RP forms an important part of the multimodality approach to locally advanced prostate cancer. It can provide a better outcome (combined with adjuvant and salvage treatment if needed) than radiotherapy (RT) or hormonal therapy (HT) alone or a combination of RT and HT.
Keywords: Gleason score, overall survival, prostate cancer-specific survival, radical prostatectomy
|How to cite this article:|
Girniwale GS, Srivastava A, Singh A, Munjewar C, Singh SK. Role of laparoscopic radical prostatectomy in locally advanced and high-risk prostate cancer: Whether safe and effective approach?. J Curr Oncol 2021;4:5-9
| Introduction|| |
Locally advanced prostate cancer is defined as cancer that extended beyond the prostatic capsule, with the invasion of the pericapsular tissue, apex, bladder, neck, or seminal vesicle (SV) but without lymph node involvement or distant metastasis. A significant proportion of patients present with locally advances disease with an inherently high risk of local recurrence and systemic relapse after initial treatment.
Historically, patients with locally advanced and high-grade diseases have not been viewed as a good candidate for radical prostatectomy (RP). The role of RP for locally advanced and high-grade diseases is controversial and the focus of debate.,,, The objective of this study is to evaluate the role of RP in the treatment of locally advanced and high-grade disease.
| Materials and Methods|| |
In this retroprospective study, all the laparoscopic RPs done for prostate cancer between January 2014 and January 2016, in the Department of Urology, DRRMLIMS, Lucknow, were enrolled and followed for five years. A total of 116 patients were included in this study. They were divided into two groups: group 1 includes 78 patients with localized carcinoma prostate and group 2 includes 38 patients with locally advanced and high-grade prostate cancer. The following characteristics were noted in both groups: margin status, biochemical progression, local recurrence, distant metastasis, clinical progression, and overall survival (OS) and cancer-specific survival (CSS). High-risk prostate cancer was defined as clinical stage ≥T2c, serum prostate specific antigen (PSA) ≥20 ng/mL, or biopsy Gleason score of ≥8.
Physical examinations and serum PSA measurements were done quarterly for the initial two years, semiannually for an additional two years, and annually thereafter in postoperative assessments. Adjuvant therapy was defined as treatment received ≤90 days of RP and was given at the discretion of the treating physician. Biochemical recurrence was defined as a PSA level of ≥0.2., Local recurrence was defined as cancer on biopsy of the prostatic bed or clinically evident disease within the prostatic fossa on physical examination or imaging studies. Systemic progression involved demonstrable metastasis on radionuclide bone scan or on biopsies outside the prostatic bed. Vital status was identified from death certificates or physician correspondence.
The data were collected on a predesigned schedule and subsequently entered in Microsoft Excel®. The proportions were presented as percentages, and continuous data were presented as mean ± SD (for normal data) or median and interquartile range (for data not distributed normally). Unpaired student t-test was used for comparing differences between continuous normally distributed data from two samples, and nonparametric tests were applied for continuous data not distributed normally. The proportions were analyzed using chi-squared tests. P values of less than 0.05 were considered significant.
The primary endpoints were CSS and OS. Postoperative survival was estimated using Kaplan–Meier method and compared using log-rank test. Univariate and multivariate analyses of features associated with outcomes were conducted using Cox proportional hazards regression models.
| Result|| |
Clinical and pathological demographics of patients included in the study are shown in [Table 1]. The median (range) postoperative follow-up was 6.5 years. During this time, biochemical recurrence, local recurrence, and systemic progression were seen as shown in [Table 2]. In all, 23 (23.07%) and nine (23.68%) had died at the last follow-up, with 18 (16.67%) and seven (18.42%) (15%) dying from prostate cancer, respectively, in groups 1 and 2 [Table 2]. The resulting survival estimates at the last follow-up after RP were 83%, 81.58% and 76.92%, 76.31% in groups 1 and 2 for prostate CSS and OS, respectively [Figure 1][Figure 2][Figure 3][Figure 4]. Overall, 3.85% in group 1 and 21.05% in group 2 patients received salvage radiotherapy for biochemical recurrence, whereas 7.69% in group 1 and 15.79% in group 2 patients were treated with salvage androgen deprivation therapy during clinical follow-up. Margin status was positive in 10.25% and 21.05% of cases in groups 1 and 2, respectively.
|Figure 1: Kaplan–Meier survival estimates for cancer survival at two years|
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|Figure 2: Kaplan–Meier survival estimates for overall survival at two years|
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|Figure 3: Kaplan–Meier survival estimates for cancer survival at five years|
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|Figure 4: Kaplan–Meier survival estimates for overall survival at five years|
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| Discussion|| |
In organ-confined disease, RP is considered as a standard of care, but traditionally, it has been discouraged as a definitive treatment option for locally advanced prostate cancer. It is due to the concern of positive surgical margins, increased risk of lymph node metastasis, local and distant relapse, and consequently death from prostate cancer. So for locally advanced prostate cancer, its role is a focus of debate and is highly controversial. But there are several advantages of RP in locally advanced prostate cancer; it decreases the tumor burden and allows accurate and precise pathological staging, and can identify the patients who are at high risk of recurrence and can be subsequently managed by other combination (adjuvant treatment). It has also shown longer and durable results in terms of CSS compared with other options.
In locally advanced prostate cancer, special expertise is required. It includes the removal of the whole prostate gland en-bloc (between urethra and bladder) with good apical dissection, the wide resection of neurovascular bundle, and the complete resection of both SVs. The incidence of urinary incontinence and impotence are therefore higher in this group as compared to early prostate cancer. With increased surgical experience, the functional outcome can be improved, and morbidity can be minimized.,
In cT3 disease, there is a higher risk of lymph node involvement, so pelvic lymphadenectomy should be done. The reported incidence of lymph node involvement is between 27% and 41% in different series., Briganti, et al. recommended extended lymph node dissection to be carried out in patients with locally advanced prostate cancer. Heidenreich and Ohlmann compared the progression-free survival (PFS) in patients with standard versus extended lymphadenectomy and found a 35% benefit in favor of the latter. Adjuvant treatment is defined as radiotherapy (RT) or hormonal therapy (HT) given within 90 days after RP, whereas salvage treatment is given postoperatively after 90 days.
European Association of Urology (EAU) guidelines now support the role and recommend RP to be an appropriate option for selected patients with small, low-volume T3 tumors, PSA <20 ng/mL, Gleason score <8, and life expectancy of >10 years.
RP is superior for locally advanced prostate cancer and has not been investigated or systematically reviewed. There is no large-scale, randomized controlled trial available. Due to a heterogeneous group of patients and inherent selection bias, comparison of RP with other treatment modalities for locally advanced prostate cancer is difficult.,
In a multicenter, nonrandomized two-staged study (EORTC 30001), RP was done in clinical staging T3 patients with good prognosis factors (age <70 years, PSA ≤20 ng/mL, biopsy Gleason score ≤7, performance status 0–1, and unilateral cT3a disease). The authors concluded that RP with extensive resection can be beneficial as monotherapy for T3aN0M0 patients.
Van Poppel, et al. in their study determined the efficacy of RP monotherapy in men with clinically T3 disease. They mainly included patients with PSA values <10 ng/mL without the involvement of SVs or lymph nodes and showed a five-year biochemical recurrence-free survival to be >60%.
This study result is comparable to Gontero, et al. This is a single-institution study that showed that RP is technically feasible in any clinical “T” extension up to M1a disease with acceptable morbidity. This consists of two groups: 51 patients with advanced disease in group 1, whereas 152 patients with organ-confined disease in group 2. There is no significant difference in terms of surgical morbidity except for the blood transfusion, operative time, and lymphocele formation, which were higher in group 2. The OS and CSS rates were 77% and 90% in group 2 versus 88% and 99% in group 1, respectively, at seven years. This study also proposed that a possible advantage of surgery will be debulking the disease and therefore the prevention of complications related to local cancer progression.,
Hsu, et al. in their study attempted to determine the prognostic factors for advanced prostate cancer after RP in cT3 patients in terms of biochemical PFS (BPFS), clinical PFS (CPFS), CSS, and OS after 10 years. On multivariate analysis, they found that surgical tumor grade, and margin and lymph node status were significant factors in CPFS and CSS, whereas surgical tumor grade, node status, and preoperative PSA levels were significant factors in BPFS.
Xylinas, et al. studied the role of RP for cT3 disease with the aim of disease control and showed that surgical experience is the main factor responsible to reduce perioperative complications and to produce better functional results. This meta-analysis shows that the BPFS, i.e. PSA <0.2 ng/mL and 10- and 15-year survival, ranges from 45% to 62%, 43% to 51%, and 10% to 49%, respectively. In fact, these results were better than some of the series of external beam radiotherapy (EBRT) alone or EBRT in combination with HT. The results, however, are not comparable because of a lack of homogeneity.
Recently, a meta-analysis was published regarding the role of robot-assisted RP for managing high-risk prostate cancer showing comparable short-term results to open prostatectomy in terms of its safety and functional outcome; however, the long-term oncological data are still awaited.
A group of urologists at Mayo clinic has long been advocating RP as the first-line treatment in the multimodality approach for cT3 disease. Ward and colleagues in a large retrospective study with a follow-up of 15 years showed that 78% of patients with pT3 disease received adjuvant and salvage treatment (HT, RT, or both) following RP. They categorized RP as an important part of the multimodality approach for cT3.
So it can be concluded that all patients with advanced prostate cancer must be fully counseled and informed about the likelihood of a multimodel approach after RP, i.e. EBRT for positive surgical margin, extracapsular extension, or SVs invasion and HT in cases of lymph node involvement.
| Conclusion|| |
RP forms an important part of the multimodality approach to locally advanced prostate cancer. It can provide a better outcome (combined with adjuvant and salvage treatment if needed) than RT or HT alone or a combination of RT and HT. However, this can be confirmed by large-volume prospective studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]