Role of Surgery in localised prostate cancer

Lee Lui ShiongDepartment of Urology, SGH

Director Urologic Oncology and Robotic SurgeryLee.lui.shiong@singhealth.com.sg

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