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Radical Prostatectomy for Prostate Cancer

Radical Prostatectomy for Prostate Cancer. Murali K. Ankem , M.D, F.A.C.S Associate Professor of Surgery Division of Urology. Background. Most common non-skin cancer Second leading cause of cancer death 240,890 cases will be diagnosed in 2011 33,720 will die of prostate cancer in 2011

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Radical Prostatectomy for Prostate Cancer

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  1. Radical Prostatectomy for Prostate Cancer Murali K. Ankem, M.D, F.A.C.S Associate Professor of Surgery Division of Urology

  2. Background • Most common non-skin cancer • Second leading cause of cancer death • 240,890 cases will be diagnosed in 2011 • 33,720 will die of prostate cancer in 2011 • 1 in 6 lifetime risk • Black men higher incidence & mortality • 9.9 billion spent on prostate cancer/year • 300 million NCI grant support for research www.nci.gov/cancerstatitics/

  3. Diagnosis & Staging • Serum PSA • psa velocity, density, % free psa, age specific PSA • DRE • TRUS Biopsy • Gleason score, number of cores positive, % of core, perineural/lymphovascular invasion • Prediction tables/Nomograms • eMRIbeing popular- local spread • Bone scan and CT scan- high risk patients

  4. Management • Active surveillance • Hormone Ablation • Cryoablation • Radiofrequency ablation • HIFU • Radiation • Chemotherapy • Radical Prostatectomy

  5. Management • Active surveillance • Semi annual psa/dre • Annual /biannual TRUS biopsy • PSA progression/ positive dre • Intervention if Gleason 4/5, > cores positive, >50% of core • “is cure possible when it is necessary?” • “is cure necessary when it is possible?” Willett Whitmore Jr.

  6. Management • Primary Hormone Therapy • Never Curative, long remissions • Older men with significant co-morbidities • Refuse curative therapy • Primary androgen ablation for localized prostate cancer did not improve survival compared to active surveillance- Lu-Yao et al 08 • Beneficial effects may be negated by increase in non prostate cancer deaths with no overall benefit- Loblaw et al 07.

  7. Management • Cryoablation • Destroys cancer by freezing whole or portions of prostate gland • Less complications with new technology • Less invasive, repeat treatment possible • potency preserved?! • Salvage after curative therapy short term cure rates 34-74% Babaian et al 2008 • Efficacy not established

  8. Management • Radiofrequency (>38 C) interstitial tumor ablation is not well studied • HIFU: ultrasound based heat (>100 C) leading to coagulative necrosis of prostate • 70% progression free with 24 months follow up • Pending FDA approval • Not enough data to recommend

  9. Management • Radiation: • 3D CRT and IMRT are popular curative therapies for aggressive localized prostate cancer • Androgen deprivation is beneficial with XRT • 5 year progression free survival 70-85% Bolla et al 97; Kuban et al 2008

  10. Management • Brachytherapy • Iodine125 or Palladium 103 • 125-145 Gy • Excellent for low grade low risk prostate cancer • Can be combined with External beam therapy • 7 year progression free survival is 80% Rhagde et al • LUTS after seed implantation

  11. Management • Cyber Knife • Linear accelerator mounted on a robotic arm delivers high dose in small fractions. • More data is needed • Adjuvant radiotherapy • Consider in high risk pathology • 64-68 Gy • Wait for 3-4 months till healing is complete

  12. How to Chose?! If you go to MIDAS they will fit your car with a Muffler because they are good at what they do!

  13. Radical Prostatectomy • First treatment used for prostate cancer • 100 years history Young 1905 • Gold Standard • Complete removal of prostate with seminal vesicles and ejaculatory ducts • Open radical prostatectomy Walsh & Donker 1982 • Laparoscopic RRP Schuessler et al 1997 • RALP Binder et al 2000

  14. R.P - Advantages • Offers best chance of cure • Accurate tumor staging • Predictable post operative follow-up • Minimal morbidity • RRP failures can be salvaged with XRT Stephenson et al 2004

  15. R.P- Disadvantages • Major surgery • Hospitalization • Foley for 10-14 days • Incomplete resection • Possible blood transfusion • Injury to adjacent structures • Urinary and sexual dysfunction

  16. R.P- Approaches • Open • Retropubic • Perineal • Laparoscopic • Intra or extraperitoneal • Robotic • Intra or extraperitoneal

  17. O.R.P- Retropubic • Most popular with urologists • Excellent exposure to urethra, sphincter, neurovascular bundles • Risk of rectal injury and fecal incontinence low • Access to pelvic lymph nodes • Nerve sparing • Positive surgical margins low

  18. O.R.P

  19. O.R.P-Perineal • Select urologists are familiar with Sx • Short operative times • Less blood loss • Rectal injury high • Fecal incontinence • No access to pelvic lymph nodes • Nerve sparing difficult

  20. P.R.P

  21. L.R.P • Difficult procedure • Needs advanced laparoscopic skills • Less bleeding, faster recovery • Better visualization, Better anastomosis • Better nerve sparing?! • Long-term data are lacking for oncologic control Menon et al 2007

  22. L.R.P Brosman at al

  23. RALP Intuitive surgical

  24. RALP

  25. R.A.L.P • Robotic RRP is very popular among patients and surgeons • Technique is similar to laparoscopic approach • robotic platform with 3D • 6 degrees freedom at wrists • Master slave robotic system • Expensive

  26. R.A.L.P • Dramatic shift to RALP • >80% are RALP • Aggressive marketing • Internet savvy educated patients • Most hospitals have at least one Robot • Lack of tactile sensation • Data is maturing

  27. R.P- RESULTS • TRIFECTA Eastham et al 2008 • Cancer control, continence, erectile function • Initial results supports a shift in standard of care from ORP to RALP Torrey et al 2011 • Results of RALP are misleading • ORP patients recover as fast as RALP Wood et al 2007 • Hu et al 2008 reported higher complication rate with RALP with strictures and PSA failure • Patient satisfaction data after RALP- high regret rates Schroeck et al 2008

  28. R.P Salvage • An option for primary therapy failure Chen & Wood 2003 • Difficult open operation • High complication rates Sanderson et al 2008 • P.O incontinence rates 44% and BN contracture 22% Ward et al 2005 • Long term progression free survival rates with out hormone therapy have not been well documented

  29. sRALP • Feasible and safe • Technically challenging • Results comparable to open procedure • Complication rate 20% • Continence 71.4% • Progression 28% (follow-up 4 months) Chauhan et al 2011

  30. RALP patient selection • Young • Healthy • Life expectancy >10 years • Low to intermediate prostate cancer • General age limit 70 years • Partin tables and Kattannomograms • No role for neoadjuvant hormone or chemotherapy Chi et al 2008

  31. RRP and Potency • Young healthy patients ED low • Nerve sparing is not feasible nor advisable • Extensive palpable disease • PSA >10 • Gleason > 7 • Poor quality erection preop • Co morbidities DM, HTN • PO penile rehabilitation beneficial Glina et al 2011

  32. R.P Technique Removal of prostate with seminal vesicles 1pelvic lymphadenectomy (optional)2 opening of the endopelvic fascia 3 suture ligation and transection of the Santorini dorsal venous complex;4 dissection of the urethra at the apex of the prostate and transection of the urethra 5 dissection of the prostate from the neurovascular bundles;6 securing and transection of the prostatic pedicles;7transection and reconstruction of the bladder neck;8 dissection of the seminal vesicles and ampullary portions of the vasadeferentia9 performance of the vesicourethral anastomosis.

  33. R.P P.O Care • 1-2 days hospital stay • Foley 10-14 days • Kegel exercises for continence • Aggressive penile rehabilitation • Oral drugs, VED, Penile injections • PSA in 3 months • Pathology review and Plan

  34. R.P Results • Depends on tumor characteristics • Best Open RRP results Catalona et al • 10 year progression free • Organ confined: 85% • 65% ECE • 25% SV extension • 10% Lymph node extension Best RALP results from Menon et al 2010 86.6% Biochemical free survival at 7 years.

  35. RALP Results • Continence • >90 continence in skilled hands • Younger better results • Artificial sphincter/male sling rarely done • Erectile function • Ability to maintain rigidity adequate for sex with or without medications 85-90% • Usually return between 3-9 months • Aggressive rehab beneficial montorsi et al 2008

  36. R.P Complications • Overall complication rate 10% Kundu et al 2004 • Early: • Bleeding, infection, injury to rectum, ureter, vessels, nerve, urine leak, lymphocele, DVT and CVS complications. • Late complications • Incontinence • ED • BNO

  37. Summary Radical Prostatectomy is gold standard for the management of localized prostate cancer with excellent results and minimal morbidity. Robotic assisted laparoscopic prostatectomy is at least comparable to open approach and long term follow-up is necessary to see if results are durable

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