22 Is radical prostatectomy useful for localized prostatc cancer patients more than 71 years old?

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21 E X T E N D E D R E T R O P U B I C R A D I C A L P R O S T A T E C T O M Y IN C L I N I C A L L Y S T A G E T3 P R O S T A T E C A N C E R (PCA) - S I G N I F I C A N T R E D U C T I O N O F P O S I T I V E S U R G I C A L M A R G I N S IN A C A S E C O N T R O L STUDY

IS R A D I C A L P R O S T A T E C T O M Y USEFUL FOR LOCALIZED P R O S T A T I C C A N C E R PATIENTS M O R E T H A N 71 Y E A R S O L D ?

Heidenreich A / , Ohlmaun C.H. 2, 0zgiir Eft, Braun M.z, Engelmann U.H. z

University of Tokyo, Urology, Tokyo, Japan

tKlinikum der Universit~lt zu K61n, Dept. of Urology, Cologne, Germany, 2Klinikum der Universit~t zu K61n, Division of Ontological Urology, Dept. of Urology, Cologne, Germzny

I N T R O D U C T I O N & O B J E C T I V E S : There is a consensus that radical prostatectomy is usually indicated for localized prostatic cancer patients less than 70 years old in several Western countries taking life expectancy in consideration. In Japan, an average of life expectancy of healthy 75- year old Japanese men is 11.09 years. Radical prostatectomy is indicated for the patients more than 71 years old at several hospitals based on a request from the patient with good general condition. We compared a background and survival between the patients less than 70 and more than 71 years old who underwent radical prostatectomy.

INTRODUCTION & OBJECTIVES: Based on validated preoperative nomograms the presence of locally advanced PCA can be predicted with a high accuracy. If radical surgery is considered as therapeutic option, radical retropubic prostatectomy (RPE) requires an individualized surgical technique to reduce positive surgical margins and to detect occult micrometastatic pelvic lymph node disease. We report on our experience with an extended RPE combined with extended pelvic lymph node dissection (epLA) compared to a matched control group of men undergoing classical RPE. MATERIAL & METHODS: 112 consecutive patients with histologically proven PCA and preoperative prediction of locally advanced disease based on the Kattan nomograms underwent extended RPE and epLA: the membraneous urethra is dissected approx. 3-4ram distally to the apex without intraprostatic preparation, dorsolateral resection includes wide resection of the neuroascular bundle including the lateral endopelvic fascia and the perirectal fat, Denunvillier's fascia is only opened at the tip of the seminal vesicles and the bladder neck is widely excised without a bladder sparing technique. EpLA included the resection of all lymph nodes in the obturator fossa, external, internal and common iliac area as described previously. Functional outcome, pathohistological findings, and complications were compared to a matched control group of 112 patients having undergone classical RPE with epLA. RESULTS: Both groups did not differ significantly in terms of preoperative PSA serum levels and distribution of pathohistol0gical stage. Lymph node metastases were detected in 23% and 26% of patients having undergone eRPE or RPE, respectively. Positive urethral and vesical margins were identified in 36/112 (32%) and in 10/112 (9.8%) patients. Following eRRP positive urethral and vesical surgical margins were identified in 10/112 (8.9%) and in 4/112 (3.5%) cases (p < 0.01). We did not encounter significant differences with regard to patency of the vesicourethral anastomosis on postoperative day 4 (89% vs. 85%) and early continence on postoperative day 5 (66% vs. 69%). Due to the short follow-up period, no valid information can be given with regard to the oncological outcome in terms of biochemical recurrence and survival. CONCLUSIONS: Preoperative prediction of locally advanced prostate cancer requires an individualized surgical technique if radical prostatectomy is going to be performed. Extended RPE significantly reduces the frequency of positive surgical margins (9% versus 32%) associated with a poor prognosis. Extended RPE has no negative impact on surgical complications and functional outcome. Longer follow-up has to demonstrate if this type of extended surgical technique results in better oncological results with regard to progressionfree survival and overall survival.

Tomita K_., Kume H., Takahashi S., Takenchi T., Kitamura T.

M A T E R I A L & M E T H O D S : We divided the patients who underwent radical prostatectomy into two groups; group I(n=190): patients less than 70 years old and group 2(n-60): patients more than 71 years old from 1984 to 2003 at Tokyo University Hospital. We analyzed two groups in terms of each background, overall survival, cancer specific survival and cancer free survival. RESULTS: The mean age of group 1 was 64.6 years (ranged from 51 to 70). The mean age of group 2 was 73.4 years (ranged from 71 to 78). Total follow-up ranged from lto 240 months (mean 46.5 months). Eleven out of 250 patients died of prostate cancer and 8 died of others during follow-up. There is no significant difference of the background including PSA level, pT stage, tumour grade, lymph nodes metastasis and seminal vesicle invasion in two groups. The ratio of 5- and 10-years overall survival rate for each group were as follows: group 1 (93.14% and 73.20%) and group 2 (81.60% and 65.28%), respectively (p=0.51683). The ratio of 5- and 10-years cancer specific survival rate for each group were as follows: group 1 (94.18% and 86.69%) and group 2 (81.60%and 81.60%), respectively (p=0.34541). The ratio of 5- and 10-years cancer free survival rate for each group were as follows: group 1 (71.65% and 42.29%) and group 2 (59.95% and 31.97%), respectively (p=0.5621). No significant differences were found in two groups. C O N C L U S I O N S : There is no significant difference of survival between the patients less than 70 and more than 71 years who underwent radical prostatectomy. Radical prostatectomy may be meaningful for Japanese patients with localized prostatic cancer more than 71 years old taking life expectancy in consideration.

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23 IS T H E P R E D I C T I V E A C C U R A C Y OF T H E 1997, 2001 PARTIN TABLES, T H E P R E O P E R A T I V E AS W E L L A S T H E P O S T O P E R A T I V E N O M O G R A M S A F F E C T E D BY T E M P O R A L STAGE M I G R A T I O N IN E U R O P E A N PATIENTS?

PROSTATE C A N C E R W I T H A L O W PSA - A H A R M L E S S T U M O U R ? Bader P., Spa/an M., Huber R., Frohneberg D. Staedtisches Klinikum, Urology, Karlsruhe, Germany

Karakiewicz p.i, Steuber T.2, Perrotte P?, Graefen M. 2, Haese A. 2, Walz j.2, Huland H. z ~University of Montreal Health Center, Urology, Montreal, Canada, 2University of Hamburg, UroIogy, Hamburg, Germany INTRODUCTION & OBJECTIVES: Temporal stage migration has been reported in a large multi-insdtutional study of RP patients (Cagiannos JUro12004), which included a large subset &European men. We explored the effect of year of surgery on the predictive accuracy of the 1997 and 2001 partin Tables, as well as on the pro-operative and postoperative nomogram predictions of biochemical recurrence (BCR), in a large cohort of European men treated with radical prostateetomy (RP). M A T E R I A L & M E T H O D S : A cohort of 2396 evaluable patients was used in the analyses of the pro-operative BCR nomogram. Of these 1277 were evaluable in analyses of the post-operative BCR nomogram. Finally, a cohort of 1442 men was used to assess the effect of year of s~trgery on the predictive accuracy of the 1997 and 2001 Parth~ tables. Predictive accuracy of the Partin Tables was tested in logistic regression models (LRM). The multivariate LRM predictive accuracy was assessed using receiver-operating characteristics curves, and was quantified with the area under the curve. The accuracy of the pre- and postoperative BCR predictions was tested with multivariate Cox regression models. Harrell's concordance index was used to quantify their predictive accuracy. All models were subjected to 200 bootstrap resamples to reduce overfit bias. To compare the effect of the year of surgery, all models were initially built without incorporating the year of surgery, and subsequently were redesigned with the year of surgery. In all scenarios, two distinct modelling techniques of the year of surgery were used: categorical and continuous RESULTS: Table 1 shows the predictive accuracy results Table l. Predictive accuracy of models with and without year of surgery 200 bootstrap-corrected

predictive accuracy

Prognostic model

Model without year of surgery

Model with categorically coded year of sllrgery

Model with eontinuously coded year of surgery

1997 Partin E C E 2001 Partin E C E

0.771 0.77I

0.774 0.772

0.771 0.769

1997 Partin SVI

0.789

2001 Partin SVI 1997 Partin LNI

0.784 0.779

0.792 0.790

0.753

0.738

0.754

0.759 0.789 0.788 0.782

0.737 0.786 0.787 0.771

0.751 0.787 0.788 0.779

0.771

0.772

0.769

2001 Partin LNI 1997 Partin O C 2001 Partin OC Pre-operative B C R nomogram Post-operative B C R nomogram

CONCLUSIONS: Temporal stage migration does not affect the predictive accuracy of either the i997 or the 2001 Pardn Tables. The preoperative and post-operative nomograrns are also unaffected by the year of surgery. Therefore, based on statistical and on practical considerations, it does not seem necessary to include the year of surgery in prognostic models addressing RP outcomes in European patients.

European Urology Supplements 4 (2005) No. 3, pp. 8

INTRODUCTION & OBJECTIVES: In the era of screening for prostate cancer (PCa) the question remains whether PCa with a low PSA value is a significant tumour which should be treated by radical prostatectomy or whether these cancers are harmless tumours where watchful waiting is advisable. Additionally, in the PSA era the digital rectal examination (DRE) as a routine procedure in screening for prostate cancer is under discussion. Our goal was to evaluate tumour stage, grading, lymph node involvement and clinical importance of prostate cancer with a low PSA value (PSA _<8 ng/ml). MATERIAL & METHODS: All patients who underwent radical prostatectomy at our hospital between 11/89 and 12/02 were evaluated retrospectively. Patients with a low PSA level were subdivided in 4 groups (PSA <_2ng/ml, PSA 2-4 ng/ml, PSA 4-6 ng/ml and PSA 6-8 ng/ml) and their tumour characteristics were compared to each other and to the patients with higher PSA levels (> 8 ng/ml). RESULTS: Between 11/89 and 12/02 1779 patients underwent radical prostatectomy and in 1731 patients preoperative PSA was available. 49 of them (2.8%) had a PSA <2 ng/ml, 106 (6.1%) PSA 2-4 ng/ml, 233 (13.5%) PSA 4-6 ng/ml, 245 (14.5%) PSA 6-8 ng/ml and 1098 (63.4%) a PSA >8 ng/ml. Prostate cancer was mainly diagnosed by prostate biopsy, done routinely in patients with a PSA >4 ng/ml or in case of suspicious DRE. Only 53 of 633 patients (8.4%) with a PSA.<8 ng/ml were diagnosed as incidental carcinoma by transurethral resection of the prostate or adenomectomy. 38%, 39% and 44% of the patients with a PSA 2-4 ng/ml, 4-6 ng/ml and 6-8 ng/ml, respectively, histologically showed capsular surpassing disease (_>pT3). In the group with PSA < 2ng/ml the percentage of capsular surpassing disease was only 22%. Distribution level of tumour grading was not significantly different in the 4 "low PSA" groups with a range between 13 and 23% of G3/G4 tumours. In the three patient groups with PSA level 2-4 ng/ml, 4-6 ng/ml and 6-8 ng/ml lymph node metastases (pN1) could be detected in 6 to 7%. No lymph node involvement was fotmd in patients with a PSA .<2 ng/ml. CONCLUSIONS: Prostate cancer with a low PSA level (_<8 ng/ml) does not seem to be a harmless cancer, because in more than one third of the patients the tumour is not organ confined and 6% even show regional lymph node metastases, urpassing disease and lymph node metastases seem to be a rarity. Despite the high sensitivity of PSA to predict PCa, we conclude that DRE is still important in tumour screening in patients with low PSA levels.