Surgery for Prostate Cancer
Study of 2643 RP PCA patients showed 79% low risk and 59% medium risk post-prostatectomy had PSA <0.05. (1) While earlier studies showed no difference between robot assisted laparoscopic prostatectomy (RALP) vs. open, later studies have found significant reduction in complications, including cardiac and respiratory adverse events in the perioperative period favoring the robotic-assisted laparoscopic technique. (4,5,6) In study of 1360 men with after RP for PCA, 10 year event free survival (ADT, salvage radiotherpy or death) was 87% for gleason 6 and 74% gleason 7. (7)
Incontinent rates from surgeon reports range from 4-31% at 12 months in a systematic analysis in 2012 of RALP (26). When compared to patient reported incontinence rates, they are at the higher end of the systematic analysis results. (27) However, a stricter definition of incontinence at 12 months gives a 50.8% rate in one study. (28) PIVOT found 30% higher rate of incontinence up to 10yrs after RP (40%) compared to observation (10%). (18) Male transobturator slings have improved continence after radical prostatectomy. (8) Advanced age (10), larger prostate size (11), shorter membranous urethral length (on MRI) (12) have been shown to have increased risk of incontinence. The majority of men will be continent by 1st year. (13) One study found 8% rate of severe incontinence after RP at 18months with worse results for older patients. (25)
PIVOT trial noted a 25% increase incidence of erectile dysfunction (80%) vs observation (55%). (18) Nomograms to predict ED after RP has recently been studied. (21) AStudy of 1643 w/ prostate cancer patients from PROTECT found 21% of RP pts having erections sufficient for intercourse at 36mo, then 17% at 6yrs. In RT, this was 27% at 6yrs compared to 30% of AS at 6yrs. (23) Large study of 2550 people w/ prostate cancer found at 3yrs RP had increased ED compared to RT with RT and AS not significantly different. (24) Another large study found 60% of men were impotent at 18mo after surgery with worse results for older patients. (25)
RALP with PLND in patients high risk for PLND has 6% rate and 7.9% in open RP with PLND. The risk of VTE in prostatectomies varied by procedure, from 0.2-0.9% in robotic prostatectomy without pelvic lymph node dissection (PLND) to 3.9-15.7% in open prostatectomy with extended PLND. The risk of bleeding was 0.1-1.0%. (19,20)
OTHER SIDE EFFECTS
1 of 3 men have depression after RP even months after surgery. (9) Multiple studies including a 2020 systematic review and meta-analysis suggest increased risk of inguinal hernia after RP with 13.7% after open and 7.9% after RALP. (22)
RP AFTER TURP
RARP after TURP has higher risk of complications, and higher odds of worse functional and oncologic outcomes. (17)
Pelvic Lymph Node Dissection
In a retrospective review of 728 men with a rising PSA after RP treated with sRT, those who had increased number of lymph nodes (LN) resected at surgery had improved outcomes after salvage radiation therapy, supporting extended LN dissection. (2)
Salvage PLND has significant potential. (14-16)
Salvage PLND has significant potential. (14-16)
A 2017 meta-analysis of patients from 2000-2014 (73,448 patients) found that nerve sparing did not increase the risk of positive surgical margins in patients with pT2 (RR 0.92, 95% CI 0.75–1.13) or pT3 disease (RR 0.83, 95% CI 0.71–0.96). The risk of incontinence was lower in nerve sparing cases (RR 0.75, 95% CI 0.65–0.85 and RR 0.61, 95% CI 0.44–0.84) at 3 and 12 months, respectively. The relative risk of erectile dysfunction with nerve sparing was 0.77 (95% CI 0.70–0.85) at 3 months and 0.53 (95% CI 0.39–0.71) at 12 months. Subgroup analyses of unilateral and bilateral nerve sparing approaches demonstrated similar results. These results are potentially due to appropriate patient selection for nerve sparing. (3)
- Louis, Alyssa S., et al. "Oncologic outcomes following radical prostatectomy in the active surveillance era." Canadian Urological Association Journal 7.7-8 (2013): E475.
- Fossati, Nicola, et al. "More Extensive Lymph Node Dissection at Radical Prostatectomy is Associated with Improved Outcomes with Salvage Radiotherapy for Rising Prostate-specific Antigen After Surgery: A Long-term, Multi-institutional Analysis." European urology (2018).
- Nguyen, Laura N., et al. "The risks and benefits of cavernous neurovascular bundle sparing during radical prostatectomy: a systematic review and meta-analysis." The Journal of urology 198.4 (2017): 760-769.
- Kowalczyk, Keith J., et al. "Temporal national trends of minimally invasive and retropubic radical prostatectomy outcomes from 2003 to 2007: results from the 100% Medicare sample." European urology 61.4 (2012): 803-809.
- Trinh, Quoc-Dien, et al. "Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample." European urology 61.4 (2012): 679-685.
- Williams, Stephen B., et al. "Trends in the care of radical prostatectomy in the United States from 2003 to 2006." BJU international 108.1 (2011): 49-55.
- Peacock, Michael, et al. "Population-based 10-year event-free survival after radical prostatectomy for patients with prostate cancer in British Columbia." Canadian Urological Association Journal 9.11-12 (2015): 409.
- Kahokehr, A. A., Selph, J. P., Belsante, M. J., Bashir, M., Sofue, K., Tausch, T. J., … Walter, J. R. (2018). Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging. Urology, 116, 185–192.
- Boeri, L., Capogrosso, P., Ventimiglia, E., Cazzaniga, W., Pederzoli, F., Gandaglia, G., … Montanari, E. (2018). Depressive Symptoms and Low Sexual Desire after Radical Prostatectomy: Early and Long-Term Outcomes in a Real-Life Setting. The Journal of Urology, 199(2), 474–480.
- Novara, G., et al. “Evaluating Urinary Continence and Preoperative Predictors of Urinary Continence After Robot Assisted Laparoscopic Radical Prostatectomy.” The Journal of Urology, vol. 184, no. 3, 2010, pp. 1028–1033.
- Mandel, Philipp, et al. “High Chance of Late Recovery of Urinary and Erectile Function Beyond 12 Months After Radical Prostatectomy.” European Urology, vol. 71, no. 6, 2017, pp. 848–850.
- Kadono, Yoshifumi, et al. “Use of Preoperative Factors Including Urodynamic Evaluations and Nerve-Sparing Status for Predicting Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy: Nerve-Sparing Technique Contributes to the Reduction of Postprostatectomy Incontinence.” Neurourology and Urodynamics, vol. 35, no. 8, 2016, pp. 1034–1039.
- Sacco, Emilio, et al. “Urinary Incontinence after Radical Prostatectomy: Incidence by Definition, Risk Factors and Temporal Trend in a Large Series with a Long‐term Follow‐up.” BJUI, vol. 97, no. 6, 2006, pp. 1234–1241.
- Ost, Piet, et al. “Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence: A Prospective, Randomized, Multicenter Phase II Trial.” Journal of Clinical Oncology, vol. 36, no. 5, 2017, pp. 446–453.
- Fossati, Nicola, et al. “Identifying the Optimal Candidate for Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer: Results from a Large, Multi-Institutional Analysis.” European Urology, vol. 75, no. 1, 2019, pp. 176–183.
- Ploussard, Guillaume, et al. “Salvage Lymph Node Dissection for Nodal Recurrent Prostate Cancer: A Systematic Review.” European Urology, vol. 76, no. 4, 2019, pp. 493–504.
- Veccia, Alessandro, et al. “Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.” The Journal of Urology, vol. 202, no. 3, 2019, pp. 511–517.
- Wilt, Timothy J., et al. “Follow-up of Prostatectomy versus Observation for Early Prostate Cancer.” The New England Journal of Medicine, vol. 377, no. 2, 2017, pp. 132–142.
- Klaassen, Zachary W. A., et al. “Extended Venous Thromboembolism Prophylaxis after Radical Cystectomy: A Call for Adherence to Current Guidelines.” The Journal of Urology, vol. 199, no. 4, 2017, pp. 906–914.
- Tikkinen, Kari A. O., et al. “Procedure-Specific Risks of Thrombosis and Bleeding in Urological Non-Cancer Surgery: Systematic Review and Meta-Analysis.” European Urology, vol. 73, no. 2, 2016, pp. 242–251.
- Mulhall, John P., et al. “Development of Nomograms to Predict the Recovery of Erectile Function Following Radical Prostatectomy.” The Journal of Sexual Medicine, vol. 16, no. 11, 2019, pp. 1796–1802.
- Alder, Rasmus, Dennis Zetner, and Jacob Rosenberg. "Incidence of Inguinal Hernia after Radical Prostatectomy: A Systematic Review and Meta-analysis." The Journal of urology (2019): 10-1097.
- Donovan, Jenny L., et al. "Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer." N Engl J Med 375 (2016): 1425-1437.
- Barocas, Daniel A., et al. "Association between radiation therapy, surgery, or observation for localized prostate cancer and patient-reported outcomes after 3 years." Jama 317.11 (2017): 1126-1140.
- Stanford, Janet L., et al. "Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study." Jama 283.3 (2000): 354-360.
- Ficarra, Vincenzo, et al. "Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy." European urology 62.3 (2012): 405-417.
- Barry, Michael J., et al. "Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men." Journal of Clinical Oncology 30.5 (2012): 513.
- Grivas, Nikolaos, et al. "Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robot‐assisted radical prostatectomy." Neurourology and urodynamics 37.1 (2018): 417-425.