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Salvage Radical Prostatectomy

Salvage Radical Prostatectomy. RJ Karnes MD, FACS Vice-Chair Associate Professor and Consultant Dept. of Urology/Urologic Oncology Mayo Clinic-Rochester. Professor Horst Zincke 1937-2011. "He was a man, take him for all in all, I shall not look upon his like again.". Radiation Recurrence?.

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Salvage Radical Prostatectomy

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  1. Salvage Radical Prostatectomy RJ Karnes MD, FACS Vice-Chair Associate Professor and Consultant Dept. of Urology/Urologic Oncology Mayo Clinic-Rochester

  2. Professor Horst Zincke 1937-2011 "He was a man, take him for all in all,I shall not look upon his like again."

  3. Radiation Recurrence? • Most radiation failures treated with “palliative” hormonal therapy (HT) • CAPSURE: 63% treated - recurrent or secondary treatment at mean f/u of 38 months (93% HT) • Long-term HT not without side effects • Agarwal, Cancer, 2008 • Better definition? • ASTRO: 2ng/ml >from nadir; predictive of progression not local recurrence • Nadir PSA above 1 or 1.5 ng/ml-probably worrisome?

  4. Local Recurrence: Chance for Cure? • EORTC Bolla trial= ~20% LR only (EBRT and EBRT + ADT) • Lancet Oncology 2010 • Even at dosages to 78 Gy almost 1/3 will have a positive biopsy at 2 years • Predictive of progression compared to negative biopsy • Crook J • Late wave of metastasis from local persistence • Coen et al, Shipley, JCO 2002

  5. My workup • Radiographic imaging: • CT scan • Bone scan • Endorectal coil MRI (3 Tesla) • Investigational:11C-choline PET/CT scan (PPV >95%)

  6. CT Scan

  7. MRI-Endorectal coil

  8. My workup (after “OK” imaging) Standard 12 core TRUS prostate biopsy including 2 cores of SVs (seminal vesicles) • Severe treatment effect= Behave like – • Wait at least 12-24 months • Office flexible cystoscopy (anatomy, high risk disease, secondary bladder cancer) • Rare-Urodynamic study • Colonoscopy within 5 years • Stoma counseling/marking/enema bowel prep

  9. Pattern of Spread: Importance of Seminal Vesicles • Sanctuary

  10. Brachytherapy Failures Treated by Surgeryn=9 • All specimens whole mounted and step-sectioned • Iodine or Palladium seeds collected and counted

  11. Benign Cancer

  12. Rt SV Lt SV P A • Prostate map created for each specimen A Base P P A P P P P P A R L A A A = Anterior P = Posterior 33 Seeds Gleason 4+3 Tx Vol=12.5cc pT3bN0 Apex

  13. Results

  14. Results Seminal Vesicle Involvement (n=6) 5 4 3 Count 2 1 0 T2aN0 T2bN0 T3aN0 T3bN0 T3bN1 T4Nx Pathologic Stage Importance of Seminal Vesicles!

  15. Kill Zone Seed

  16. Kill Zone Seed Cancer “Re-Growth”

  17. Oncologic Outcomes

  18. “Ideal” Surgical Candidate….not unlike radiation naive • >10 year life expectancy • Coping skills • PSA < 10 ng/ml • Lower Gleason score (non 8-10) • cT1-T2 • cN- • However I do not rule out others…..

  19. Mayo Clinic • Before 2000, Largest series n=108 (106 EBRT), `66-`96 • pT2 39%, pTxN+ 18%, R1 36% • 10 yr BCR(PSA)-free 34% • 10 yr Cancer specific survival (CSS) 70% • Amling, J Urol 1999 • Update to 2000, n=138 (127 EBRT), Median F/U 84 mths. Median age 65 yo • 10 yr CSS 77% • Ward, J Urol 2005

  20. International Collaboration • Salvage Radical Prostatectomy (SRP)

  21. Chade D, Eur Urol, 2011

  22. Results

  23. Results • Low risk subgroup: biopsy Gleason score before SRP ≤ 7 and pre-SRP PSA ≤ 4 ng/ml • 96 pts (25%) • 35 pts BCR, 4 metastases, 1 death from PCa • BCR-free probability • 62% (95% CI 49%, 72%) at 5 years • 46% (95% CI 31%, 60%) at 10 years.

  24. Multivariable Cox proportional hazards regression to evaluate predictors of biochemical recurrence and metastases following salvage prostatectomy.

  25. Multivariable Cox proportional hazards regression to evaluate predictors of biochemical recurrence and metastases following salvage prostatectomy.

  26. Functional Outcomes • Urinary Incontinence • 0 ppd= 21-90% • Artificial Urinary Sphincter @ 6 mths/stabilization • Erectile Function • Pre-op EF=9-50% • Sufficient for intercourse 0-20% • Bladder neck contracture <10-20% • Rectal injury <10%

  27. Cryo does not treat LNI and SVI Pisters, J Urol, 2009

  28. Surgical Technique: RP+EPLND • Catheter in for 3 weeks and assess with cystogram • 5 point anastomosis (2-0 Monocryl) over 20 Fr catheter • Prepare perineum for possible Vest sutures

  29. HIGH RISK PROSTATE CANCER SURGICAL TECHNIQUE: EXTENDED PELVIC NODE DISSECTION Spermatic Cord Common Iliac Hypogastric (Internal Iliac)

  30. General Approach • EBRT only • Assess tissue/fat plane at bladder neck if developed then approach similar to radiation naïve, i.e. retrograde otherwise antegrade • Brachytherapy or Combined • Antegrade (take down bladder first) • Non-nerve sparing

  31. Wide Local Excision Resection Rt NVB Beyond Prostate Apex Pararectal Fat

  32. Wide Local Excision Rhabdosphincter Peri/Pararectal Fat

  33. Wide Local Excision versus Bilateral Nerve Sparing Edge of pelvic fascia lateral to resected NVB Superior pedicle preserved (pelvic plexus) Superior pedicle resected to tip of SV NVB preserved

  34. Wide Resection Specimen

  35. Wide Local Excision versus Bilateral Nerve Sparing Superior pedicle preserved (pelvic plexus) Superior pedicle resected to tip of SV Resected NVB NVB

  36. Conclusions • Importance of staging (pT3b and pTxN+) • Technically challenging • Reasonable morbidity? • Survival outcomes acceptable • Diagnose earlier? • Goal-Cure; Avoid long-term hormonal therapy

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