Robotic radical prostatectomy as the initial step in multimodal therapy for men with high-risk localised prostate cancer: initial experience of 160 men

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The choice of therapy with high‐risk localised prostate cancer is difficult and, in the stark absence of any randomised trials, comparative retrospective analyses of case series continue to be necessary. Radical surgery has been considered by many to be inferior to a combination of radiotherapy (RT) and androgen deprivation therapy (ADT), but this changing perhaps coincidentally with the widespread acceptance of robot‐assisted laparoscopic prostatectomy surgery (RALP). Further evidence has now described the long‐term toxicities related to ADT, and this has strengthened a desire amongst many to at least defer, if not avoid, ADT unless absolutely necessary. This article presents a single‐centre experience of RALP in the setting of high‐risk localised disease, and concludes that RALP incorporating the use of post‐operative RT represents a strong perhaps optimum management strategy.

OBJECTIVES

• ? To report the outcome of robotic‐assisted laparoscopic radical prostatectomy (RALP) for men with localised high‐risk prostate cancer at diagnosis.
• ? Although commonly managed by radiotherapy (RT) with prolonged androgen‐deprivation therapy (ADT), we hypothesize that initiation of multimodal therapy with RALP is oncologically efficacious and may allow many men to avoid ADT.

PATIENTS AND METHODS

• ? Between December 2003 and September 2010, 1480 men underwent RALP of whom 160 fulfilled the National Comprehensive Control Network criteria for high‐risk disease (prostate‐specific antigen (PSA) >20 ng/mL and/or clinical stage, cT ≥ 3 and/or biopsy Gleason score ≥8).
• ? Biochemical recurrence (postoperative PSA ≥ 0.2) was used to assess outcome after RALP monotherapy.
• ? Treatment failure was defined as either a rising PSA level after salvage RT or the initiation of ADT.

RESULTS

• ? The mean age ± standard deviation was 63.1 ± 6.3 years. Median PSA level was 9.95 ng/mL (interquartile range 6.0–21.4).
• ? Analysis of prostatectomy specimen showed Gleason 8–10 cancers in 65 (41%), and extracapsular disease, pT ≥ 3, in 96 (60%) of which seminal vesicle invasion was evident in 36 (23%). Downgrading by prostatectomy occurred in 64 (40% of total group) and five (3%) were downstaged to pT2 disease. By contrast, any upgrading occurred in 29 (18% of total group) and upstaging occurred in 68 (43%). The overall positive surgical margin rate was 38%, correlating with stage pT2 (15%) or pT3 (53%).
• ? With median follow‐up of 26.2 months (interquartile range 5.5–37.3), two non‐cancer‐related deaths have occurred (overall survival 98.8%; cancer‐specific survival 100%), and biochemical recurrence has occurred in 53 men (33%). RALP surgery has served as monotherapy (n= 117, 73%), or has been followed by salvage RT (n= 24, 15%) and/or ADT (n= 43, 27%). Overall 2‐year and 3‐year treatment failure was 31 and 41%, respectively.
• ? Serum PSA level was the only independent predictor of overall treatment failure (hazard ratio [HR] 1.02, P= 0.001) although a strong trend was observed for both clinical stage (HR 1.22, P= 0.058) and the number of positive biopsy cores on transrectal biopsy (HR 1.06, P= 0.057).

CONCLUSIONS

• ? RALP incorporating the use of postoperative RT is a good multimodal management strategy for men with this aggressive variant of prostate cancer.
• ? At median follow‐up in excess of 2 years, we found low rates of treatment failure enabling a high proportion of men to remain free of ADT.