Pathological Assessment of FollowUp

Cure of the treated localized prostate cancer represents the first goal of radical prostatectomy as mentioned in the first part of this chapter. Because of the limited follow-up, laparoscopic radical prostatectomy can only provide short-term results. All of the few published series report only on a three-year progression-free survival (Table 11). On the other hand, the evaluation of the oncologic outcome of recent technical modifications of open radical prostatectomy can only be based on a similar follow-up. Since the overall results of the different series mainly depend on the case selection (i.e., with or without adjuvant radiation or antiandrogen therapy), we have

TABLE 10 ■ Comparison of Transperitoneal Laparoscopic Radical Prostatectomy and Open Radical Prostatectomy-Review of the Literature: Peri-and Postoperative Complications

Rectal injury

Extravasation

Bleeding

Epigastric

Rectourethral

Ileus

Overall complication

Laparoscopic

(%)

(%)

(%)

injury (%)

fistula (%)

(%)

rate (%)

Türk et al. (2001)

2.4

13.6

1.6

0.8

3.2

14.4

Hoznek et al. (2001)

1.5

3.0

1.2

-

0.7

2.4

8.9

Gill et al (2001)

2.5

NA

5

NA

NA

10

Guillonneau et al. (2002)

1.4

8.1

5

0.5

1.0

18.5

Rassweiler (present

1.2

5.1

1.4

0.1

0.5

0.4

15.7a

series)

Rectal injury

Extravasation

Bleeding

Lymphoceie

Rectourethral

Ileus

Overall complication

Open

(%)

(%)

(%)

(%)

fistula (%)

(%)

rate (%)

Dillioglugil et al. (1997)

0.6

NA

1.1

1.1

NA

1.7

27.8

Lepor et al. (2001)

0.5

0.5

0.1

NA

0.2

6.6

Augustin et al.(2003)

0.2

12.9

0.3

2.3

NA

0.3

19.9

Rassweiler et al.(2003)

1.3

2.3

2.9

6.8

0.4

0.4

15.9

a12.3% major complications, 3.4% minor complication.

Source: From Rassweiler et. al., Eur Urol 2006.

TABLE 11 ■ Oncologic Results of Transperitoneal Laparoscopic Radical Prostatectomy in the Literature

Author (Year)

n

Overall positive margin (%)

Stage

Location

PT2a pT2b

pT3a

pT3b

Apex

Bladder

Postero-lateral neck

Fromont et al. (2002)

139

13.7

10

23.1

61

10.5

26.3

Guilloneneau et al. (2003) 1000

18.8

6.9 18

30

32

50

20

30

El-Feel et al.(2003)

100

25

18 18

45

50

52

20

12

Salomon et al.(2003)

169

18.9

NA

NA

44.4

13.9

41.6

Rassweiler et al.

(present series)

1500

22.5

5.9

34.2 50.8

58.7

16.0

9.6

analyzed the current literature with a stratification according to the pathologic stage (pT2 vs. pT3).

For an objective evaluation of the positive margins, the specimen should be inked with two different colors for each lobe and examined with gross sections according to the Stanford protocol (41). In our routine follow-up protocol, the prostate-specific antigen was determined on the 10th postoperative day, after three weeks, and then every three months. If not performed in our laboratory, the data were obtained by telephone contact or transmitted via fax from the referring urologist. In the studies of the literature, patients were usually followed every three months in the first year, and every six months until year 5 (42-45).

We could not detect a significant difference when comparing the rate of positive margins after open or laparoscopic radical prostatectomy, neither for pT2 stages (2.1-16.4% vs. 7.4-21.9%) nor for pT3 tumors (26.4-67.7% vs. 31.1-45.7%).

However, there is a remarkable range in the different series. A recent paper found a higher positive margin rate (34% vs. 19%) after laparoscopic radical prostatectomy among junior surgeons compared to experienced surgeons (39). In our recently published comparative study, the overall rate of positive margins (SM+) did not differ significantly (28.7% vs. 21.0% vs. 23.7%) in the open versus the early and late laparoscopic groups (37). Similarly, no significant difference in the rates of positive surgical margin with 16.9% and 20% has been reported between biopsy grade and clinical stage-matched laparoscopic and open radical prostatectomy (46). However, there was significant difference in location at apex with 5.1% vs. 11.7% (p < 0.05) and multiple positive margin locations with 0% versus 8.3%. On the other hand, Katz et al. (47) were able to reduce the rate of positive margins continuously after technical changes of laparoscopic radical prostatectomy.

Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins (47). In accordance to our own observation, nerve preservation did not increase the incidence of positive margins.

Prostate specific antigen relapse, defined as increase of serum levels more than 0.2 ng/mL, was observed in 4.1-11.0% of pT2 stages and 12.0-43.2% of pT3 tumors three years after laparoscopic radical prostatectomy (Table 11). In our first 500 patients followed up for five years, the overall progression-free survival rate was 82.5%, while prostate specific antigen-relapse rates were 15.8%, 19.2%, and 45.5% for pT2, pT3a, and pT3c/4, respectively (Table 12). As mentioned before, only a few centers are able to provide such results. Oncologic studies after open prostatectomy usually present a longer follow-up ranging from five to 15 years. When we have analyzed the Kaplan-Meier curves of the respective studies to calculate three years' results, this revealed similar results for open radical prostatectomy (pT2: 3.7-15%; pT3: 14.7-33.1%) compared to the laparoscopic group (14). The data about clinical progression could not be compared because of the different follow-up and presentation.

Current data indicate that the oncologic outcome after laparoscopic radical prostatectomy will not differ from open surgery. Most importantly, recent studies could not detect any specific oncologic risk related to the laparoscopic technique, such as port site metastases (48).

In summary, we did not detect any significant differences with respect to positive margins and short-term PSA recurrence comparing laparoscopic versus open radical prostatectomy. Of course, we have to wait for the long-term results of laparoscopy. However, until now there are no results indicating specific risk factors or deterioration of the oncologic outcome in comparison with open surgery.

We could not detect a significant difference when comparing the rate of positive margins after open or laparoscopic radical prostatectomy, neither for pT2 stages (2.1-16.4% vs. 7.4-21.9%) nor for pT3 tumors (26.4-67.7% vs. 31.1-45.7%).

Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. In accordance to our own observation, nerve preservation did not increase the incidence of positive margins.

Current data indicate that the oncologic outcome after laparoscopic radical prostatectomy will not differ from open surgery. Most importantly, recent studies could not detect any specific oncologic risk related to the laparoscopic technique, such as port site metastases.

TABLE 12 ■ Positive Surgical Margins and Oncologic Results in Laparoscopic Radical Prostatectomy with the Heilbronn Technique

Laparoscopic radical prostatectomy

n: 1

n: 500

Positive margins (%)

332/1495 (22.2)

99 (19.8)

pT2

51/859 (5.9)

26/296 (8.8)

pT3a

126/368 (34.2)

30/107 (28.0)

pT3b

91/179 (50.8)

28/69 (40.6)

Laparoscopic radical prostatectomy (n: 700)

3-Yr follow-up

5-Yr follow-up

PSA recurrence

86/636 (13.5%)

63/246 (25.6%)

(>0.2 ng/mL)

pT2

37/379 (9.8%)

19/134 (14.2%)

pT3a

26/153 (16.9%)

22/57 (38.6%)

pT3c/4

23/104 (22.1%)

22/55 (40.0%)

Overall survival

638/649 (98.3%)

246/252 (97.6%)

Progression-free survival

620/638 (97.2%)

234/246 (95.1%)

Adjuvant treatment

137/649 (21.1%)

36/252 (14.3%)

Secondary therapy

44/649 (6.8%)

23/252 (9.1%)

(e.g. radiotherapy,

antiandrogen therapy)

The definition of continence varies considerably from one study to another. Such different definitions usually contribute to a difference of about 10% in continence rates.

0 0

Post a comment