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506 EFFECT OF ADVANCED AGE (≥70 YRS) ON PROSTATE CANCER CHARACTERISTICS, SURVIVAL AND POSTOPERATIVE CONTINENCE IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY
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THE JOURNAL OF UROLOGY姞
CONCLUSIONS: Mapping of index cancer lesion by 3D-TRUS tracking biopsy had high accuracy as confirmed by step-sectioned RP specimens. Needle biopsy accurately provided 3D location and Gleason score of the index lesion in 84% and 100% of patients, respectively. Image-guided biopsy strategies appear to provide superior precision as compared to current systematic (image-blind) biopsies. These data have implications for lesion-targeted active surveillance and focal therapy protocols. Source of Funding: None
506 EFFECT OF ADVANCED AGE (>70 YRS) ON PROSTATE CANCER CHARACTERISTICS, SURVIVAL AND POSTOPERATIVE CONTINENCE IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY Inga Kunz*, Ulla Roggenbuck, Virgilijus Klevecka, Michael Musch, Darko Kroepfl, Essen, Germany INTRODUCTION AND OBJECTIVES: In elderly prostate cancer (PCA) patients conservative treatment is frequently advocated due to a presumed short life expectancy. However, in Germany men aged 70 and 80 yrs still have an average life expectancy of 13 and 8 yrs, respectively. We examined the effect of advanced age on PCA characteristics and outcome after radical prostatectomy (RP). METHODS: Of 1636 patients who underwent RP between 06/97 and 09/09 1225 were ⬍70 yrs (group PAT<70) and 411 were ⬎70 yrs (group PAT>70). Both groups were compared for PCA characteristics, postoperative continence, and overall (OS) and cancerspecific survival (CSS). Multivariate analyses were conducted to estimate the effect of advanced age on OS, CSS and postoperative continence. RESULTS: The median ages of PAT⬎70 and PAT⬍70 were 72 yrs (range 70-85) and 64 yrs (range 40-69) (p⬍0.0001), respectively. PAT⬎70 were assigned higher ASA classes (ASA 3 19.5 vs. 11.3%; p⬍0.0001) and presented more cT2c-3 tumors (21.8 vs. 16.2%; p⫽0.0301), biopsy Gleason scores 8-10 (13.4 vs. 8.3%; p⫽0.0020), pT3a-4a tumors (55.2 vs. 47.8%; p⫽0.0096) and prostatectomy Gleason scores 7 (37.8 vs. 31.8%) and 8-10 (16.4 vs. 12.8%) (p⫽0.0040). Accordingly, PAT⬎70 presented a higher proportion of high risk PCA (24.3 vs. 20.6%; p⫽0.0600). No differences were observed concerning preoperative PSA (8.2 vs. 8.0 ng/mL; p⫽0.8980), rate of pelvic lymph node dissection (94.7 vs. 95.0%; p⫽0.2313), pN⫹ (11.9 vs. 10.8%; p⫽0.5248) and R⫹ status (32.1 vs. 33.6%; p⫽0.5904). The Kaplan-Meier curves showed a significantly lower 10-year OS (67% vs. 82%; p⫽0.01) and a trend towards a lower 10-year CSS (70% vs. 83%; p⫽0.06) in PAT⬎70. However, on multivariate analysis advanced age was not an independent predictor of OS (p⫽0.1020) and CSS (p⫽0.1949), whereas pN⫹ status (p⬍0.0001), prostatectomy Gleason scores 8-10 (p⫽0.0009 and p⬍0.0001, respectively) and ASA class 3 (p⫽0.0369 and p⫽0.0279, respectively) were. Two-year postoperative continence was comparable (ICSmaleSF incontinence symptom score 2.10 vs. 2.01; p⫽0.9843). In multivariate analysis it depended only on the preoperative ICSmaleSF incontinence symptom score (p⬍0.0001) but not on advanced age (p⫽0.3410). CONCLUSIONS: Advanced age was not an independent predictor of postoperative continence or survival after RP. Rather, survival was associated with adverse PCA features and severe comorbidities. Consequently, it seems unjustifiable to generally exclude elderly patients from RP. Source of Funding: None
Vol. 187, No. 4S, Supplement, Sunday, May 20, 2012
507 TRENDS IN THE USE OF INCONTINENCE PROCEDURES AFTER RADICAL PROSTATECTOMY: A POPULATION-BASED ANALYSIS Philip H. Kim*, Laura C. Pinheiro, Coral L. Atoria, Jaspreet S. Sandhu, Elena B. Elkin, New York, NY INTRODUCTION AND OBJECTIVES: Urinary incontinence is a common complication of both open and minimally-invasive radical prostatectomy (RP), with a potentially significant impact on quality of life. Surgical options for severe post-prostatectomy incontinence include endoscopic bulking agents, male urethral slings, and the artificial urinary sphincter (AUS). Our objectives were to identify predictors of these procedures and describe trends in their use over time. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, we identified men aged 66 years or older with prostate cancer who had open or minimally-invasive RP from 2000 through 2007. The primary outcome was receipt of an incontinence procedure, identified by Medicare claims for a bulking agent, male sling, or AUS. Demographic and clinical predictors of incontinence procedures were identified using multivariable logistic regression. RESULTS: We identified 16,348 men who had RP, including 3,523 who had a minimally-invasive prostatectomy (22%). Overall, 1,057 men (6%) received any incontinence procedure, with similar utilization rates between those having open and minimally-invasive prostatectomy. Older age, white race, residence in the South, and more comorbidity were associated with greater odds of having incontinence surgery, while non-metropolitan residence was associated with lower odds. Of those who had any incontinence surgery, 163 (15%) had more than one type of procedure. Thirty-nine percent of men receiving an endoscopic bulking agent also required a sling and/or AUS, and 13% of men receiving a male sling also had an AUS. For 34% of those who had any incontinence surgery, AUS was the only procedure performed. The median time from prostatectomy to incontinence surgery was 20 months in 2000, which increased to 29 months in 2003, and decreased thereafter to 16 months in 2007. CONCLUSIONS: RP carries a risk of urinary incontinence that may ultimately require surgical intervention. In this population-based cohort of older patients, only 6% had an incontinence procedure following prostatectomy. While it is likely that these were men who had the most severe or persistent post-prostatectomy incontinence, the low utilization rate we observed may reflect underuse of potentially beneficial procedures. Men with persistent post-prostatectomy incontinence should be informed of the risks and benefits of available treatment options and counseled to make a decision that is consistent with their values and preferences. Source of Funding: Sidney Kimmel Center for Prostate and Urologic Cancers
508 A COMPARISON OF BIOCHEMICAL RECURRENCE RATES OF OPEN AND ROBOTIC PROSTATECTOMY AT A LARGE TERTIARY CARE CENTER Jonathan Silberstein*, New York City, NY; Daniel Su, New Brunswick, NJ; Leonard Glickman, Gal Keren-Paz, Matthew Kent, Andrew Vickers, Jonathan Coleman, James Eastham, Peter Scardino, Vincent Laudone, New York City, NY INTRODUCTION AND OBJECTIVES: To compare the biochemical recurrence (BCR) rates of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporaneous cohort patients at a tertiary care center. METHODS: We conducted a retrospective review of patients who underwent RP for localized prostate cancer, by the highest volume surgeons performing ORP (JAE, PTS) or RALP (JAC, VPL), respectively, at a single center from 2007-2010. Patients were excluded from
THE JOURNAL OF UROLOGY姞
CONCLUSIONS: Mapping of index cancer lesion by 3D-TRUS tracking biopsy had high accuracy as confirmed by step-sectioned RP specimens. Needle biopsy accurately provided 3D location and Gleason score of the index lesion in 84% and 100% of patients, respectively. Image-guided biopsy strategies appear to provide superior precision as compared to current systematic (image-blind) biopsies. These data have implications for lesion-targeted active surveillance and focal therapy protocols. Source of Funding: None
506 EFFECT OF ADVANCED AGE (>70 YRS) ON PROSTATE CANCER CHARACTERISTICS, SURVIVAL AND POSTOPERATIVE CONTINENCE IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY Inga Kunz*, Ulla Roggenbuck, Virgilijus Klevecka, Michael Musch, Darko Kroepfl, Essen, Germany INTRODUCTION AND OBJECTIVES: In elderly prostate cancer (PCA) patients conservative treatment is frequently advocated due to a presumed short life expectancy. However, in Germany men aged 70 and 80 yrs still have an average life expectancy of 13 and 8 yrs, respectively. We examined the effect of advanced age on PCA characteristics and outcome after radical prostatectomy (RP). METHODS: Of 1636 patients who underwent RP between 06/97 and 09/09 1225 were ⬍70 yrs (group PAT<70) and 411 were ⬎70 yrs (group PAT>70). Both groups were compared for PCA characteristics, postoperative continence, and overall (OS) and cancerspecific survival (CSS). Multivariate analyses were conducted to estimate the effect of advanced age on OS, CSS and postoperative continence. RESULTS: The median ages of PAT⬎70 and PAT⬍70 were 72 yrs (range 70-85) and 64 yrs (range 40-69) (p⬍0.0001), respectively. PAT⬎70 were assigned higher ASA classes (ASA 3 19.5 vs. 11.3%; p⬍0.0001) and presented more cT2c-3 tumors (21.8 vs. 16.2%; p⫽0.0301), biopsy Gleason scores 8-10 (13.4 vs. 8.3%; p⫽0.0020), pT3a-4a tumors (55.2 vs. 47.8%; p⫽0.0096) and prostatectomy Gleason scores 7 (37.8 vs. 31.8%) and 8-10 (16.4 vs. 12.8%) (p⫽0.0040). Accordingly, PAT⬎70 presented a higher proportion of high risk PCA (24.3 vs. 20.6%; p⫽0.0600). No differences were observed concerning preoperative PSA (8.2 vs. 8.0 ng/mL; p⫽0.8980), rate of pelvic lymph node dissection (94.7 vs. 95.0%; p⫽0.2313), pN⫹ (11.9 vs. 10.8%; p⫽0.5248) and R⫹ status (32.1 vs. 33.6%; p⫽0.5904). The Kaplan-Meier curves showed a significantly lower 10-year OS (67% vs. 82%; p⫽0.01) and a trend towards a lower 10-year CSS (70% vs. 83%; p⫽0.06) in PAT⬎70. However, on multivariate analysis advanced age was not an independent predictor of OS (p⫽0.1020) and CSS (p⫽0.1949), whereas pN⫹ status (p⬍0.0001), prostatectomy Gleason scores 8-10 (p⫽0.0009 and p⬍0.0001, respectively) and ASA class 3 (p⫽0.0369 and p⫽0.0279, respectively) were. Two-year postoperative continence was comparable (ICSmaleSF incontinence symptom score 2.10 vs. 2.01; p⫽0.9843). In multivariate analysis it depended only on the preoperative ICSmaleSF incontinence symptom score (p⬍0.0001) but not on advanced age (p⫽0.3410). CONCLUSIONS: Advanced age was not an independent predictor of postoperative continence or survival after RP. Rather, survival was associated with adverse PCA features and severe comorbidities. Consequently, it seems unjustifiable to generally exclude elderly patients from RP. Source of Funding: None
Vol. 187, No. 4S, Supplement, Sunday, May 20, 2012
507 TRENDS IN THE USE OF INCONTINENCE PROCEDURES AFTER RADICAL PROSTATECTOMY: A POPULATION-BASED ANALYSIS Philip H. Kim*, Laura C. Pinheiro, Coral L. Atoria, Jaspreet S. Sandhu, Elena B. Elkin, New York, NY INTRODUCTION AND OBJECTIVES: Urinary incontinence is a common complication of both open and minimally-invasive radical prostatectomy (RP), with a potentially significant impact on quality of life. Surgical options for severe post-prostatectomy incontinence include endoscopic bulking agents, male urethral slings, and the artificial urinary sphincter (AUS). Our objectives were to identify predictors of these procedures and describe trends in their use over time. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, we identified men aged 66 years or older with prostate cancer who had open or minimally-invasive RP from 2000 through 2007. The primary outcome was receipt of an incontinence procedure, identified by Medicare claims for a bulking agent, male sling, or AUS. Demographic and clinical predictors of incontinence procedures were identified using multivariable logistic regression. RESULTS: We identified 16,348 men who had RP, including 3,523 who had a minimally-invasive prostatectomy (22%). Overall, 1,057 men (6%) received any incontinence procedure, with similar utilization rates between those having open and minimally-invasive prostatectomy. Older age, white race, residence in the South, and more comorbidity were associated with greater odds of having incontinence surgery, while non-metropolitan residence was associated with lower odds. Of those who had any incontinence surgery, 163 (15%) had more than one type of procedure. Thirty-nine percent of men receiving an endoscopic bulking agent also required a sling and/or AUS, and 13% of men receiving a male sling also had an AUS. For 34% of those who had any incontinence surgery, AUS was the only procedure performed. The median time from prostatectomy to incontinence surgery was 20 months in 2000, which increased to 29 months in 2003, and decreased thereafter to 16 months in 2007. CONCLUSIONS: RP carries a risk of urinary incontinence that may ultimately require surgical intervention. In this population-based cohort of older patients, only 6% had an incontinence procedure following prostatectomy. While it is likely that these were men who had the most severe or persistent post-prostatectomy incontinence, the low utilization rate we observed may reflect underuse of potentially beneficial procedures. Men with persistent post-prostatectomy incontinence should be informed of the risks and benefits of available treatment options and counseled to make a decision that is consistent with their values and preferences. Source of Funding: Sidney Kimmel Center for Prostate and Urologic Cancers
508 A COMPARISON OF BIOCHEMICAL RECURRENCE RATES OF OPEN AND ROBOTIC PROSTATECTOMY AT A LARGE TERTIARY CARE CENTER Jonathan Silberstein*, New York City, NY; Daniel Su, New Brunswick, NJ; Leonard Glickman, Gal Keren-Paz, Matthew Kent, Andrew Vickers, Jonathan Coleman, James Eastham, Peter Scardino, Vincent Laudone, New York City, NY INTRODUCTION AND OBJECTIVES: To compare the biochemical recurrence (BCR) rates of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporaneous cohort patients at a tertiary care center. METHODS: We conducted a retrospective review of patients who underwent RP for localized prostate cancer, by the highest volume surgeons performing ORP (JAE, PTS) or RALP (JAC, VPL), respectively, at a single center from 2007-2010. Patients were excluded from