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Editorial: Prostate Cancer
0022-5347/96/1562-0459$03.00/0
THE JOURNAL OF UROLOGY Copyright 0 1996 by AMERICAN UROLOGICAL ASSOCIATION,INC
Vol. 156,459,August 1996 Printed in U S A .
EDITORIAL: PROSTATE CANCER This issue of the Journal contains 3 articles on prostate cancer. Gaker et a1 (page 445) describe a modified technique of radical retropubic prostatectomy in which the bladder neck is preserved and the prostatic urethra is dissected free from within the prostate itself. With this technique total continence was achieved immediately after catheter removal in 46% of men and within 7 weeks in 88%.These results compare favorably with continence rates in other men at their institution undergoing standard radical prostatectomy. The improved continence rates are attributed to preservation of the bladder neck, increased urethral length and ability to perform a true urethra-to-urethra anastomosis. Obviously, a major concern with this technique is possible compromise of cancer control. Although the authors found no increased incidence of positive surgical margins, this technique would appear to be appropriate only in men with low volume peripheral tumors. Men with more extensive cancer, or tumors involving the transurethral or periurethral zone of the prostate would not be good candidates for this procedure. Never having seen or performed this technique personally, I a m concerned about cutting into the prostate in an attempt to dissect the urethra free but this does not appear to have been a problem in the experience of Gaker et al. The modifications described certainly make sense anatomically in terms of improving urinary continence but further experience documenting equivalent cancer control is required before recommending this technique. Lee et a1 (page 450) examine whether the prostate specific antigen (PSA) nadir achieved following external beam radiation therapy predicts biochemical disease-free survival. Indeed, in a multivariate analysis they found that a PSA nadir of less than 1.0 ng./ml. was an independent predictor of biochemical survival, defined by a nonincreasing serum PSA. The 3-year biochemical survival rate was 93,49 and 16%for PSA nadir less than 1.0, 1 to 1.99 and 2.0 or more ng./ml., respectively ( p = 0.0001). The authors conclude that strategies to improve results of radiotherapy should focus on techniques that increase the likelihood of achieving PSA nadir less than 1.0 ng./ml. Similar results have been reported by Powell et al.' In 147 men with clinically localized prostate cancer treated with external beam radiation therapy, they reported significantly improved disease specific survival of those achieving PSA nadir less than 1.5 ng./ml. compared to those with PSA nadir less than 4.0 ng./ml. Critz et a1 reported further improvement in biochemical survival rates for PSA nadir less than 0.5 ngJml.2 The 5 and 10-year actuarial PSA
relapse-free survival rates were 95 and 84%, respectively for PSA nadir less than 0.5 ng./ml. compared to 29% at 5 years for PSA nadir 0.6 to 1.0 ng./ml. (p = 0.0001). In that series, all men with PSA nadir more than 1.0 ng./ml. ultimately had relapse. Smith et a1 (page 454) update an earlier study on the effects of wide excision of the neurovascular bundles on disease-free survival in men with clinically localized prostate cancer but extensive capsular penetration pathologically.3 Previously, they found that negative surgical margins with extensive capsular penetration did not result in enhanced long-term survival. With more than 2 years of further followup, however, they found that negative margins obtained by wide excision of the periprostatic soft tissue do result in improved biochemical disease-free survival. In their original study patients with negative surgical margins had improved disease-free survival at 20 months but this result was not sustained at 43 months. Now, with an additional mean followup of 28 months, the probability of having undetectable PSA at 5 years was 47% in men with negative versus 6% in those with positive surgical margins (p <0.001). Not surprisingly, disease-free survival was better in men with moderately compared to poorly differentiated disease. The authors conclude that wide excision of the periprostatic soft tissue in men with extensive capsular penetration results in extended disease-free survival, and they recommend wide excision whenever there is adjacent palpable induration, particularly a t the apex of the prostate.
Charles B. Brendler Section of Urology /Surgery University of Chicago Chicago, Illinois REFERENCES
1. Powell, C. R.,Huisman, T. K, Saunders, E. L. and Johnstone, P. A,: Outcome for surgically staged localized prostate cancer treated with external beam radiation therapy. J. Urol., part 2, 155 560A, abstract 998, 1996. 2. Critz, F.A.,Levinson, K, Williams, W. H. and Holladay, D. A.: Is an undetectable nadir PSA a reasonable goal following irradiation for prostate cancer? J. Urol., part 2, 155 557A, abstract 984, 1996. 3. Partin, A.W., Borland, R. N., Epstein, J. I. and Brendler, C. B.: Influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer with established capsular penetration. J. Urol., 150. 142, 1993.
459
THE JOURNAL OF UROLOGY Copyright 0 1996 by AMERICAN UROLOGICAL ASSOCIATION,INC
Vol. 156,459,August 1996 Printed in U S A .
EDITORIAL: PROSTATE CANCER This issue of the Journal contains 3 articles on prostate cancer. Gaker et a1 (page 445) describe a modified technique of radical retropubic prostatectomy in which the bladder neck is preserved and the prostatic urethra is dissected free from within the prostate itself. With this technique total continence was achieved immediately after catheter removal in 46% of men and within 7 weeks in 88%.These results compare favorably with continence rates in other men at their institution undergoing standard radical prostatectomy. The improved continence rates are attributed to preservation of the bladder neck, increased urethral length and ability to perform a true urethra-to-urethra anastomosis. Obviously, a major concern with this technique is possible compromise of cancer control. Although the authors found no increased incidence of positive surgical margins, this technique would appear to be appropriate only in men with low volume peripheral tumors. Men with more extensive cancer, or tumors involving the transurethral or periurethral zone of the prostate would not be good candidates for this procedure. Never having seen or performed this technique personally, I a m concerned about cutting into the prostate in an attempt to dissect the urethra free but this does not appear to have been a problem in the experience of Gaker et al. The modifications described certainly make sense anatomically in terms of improving urinary continence but further experience documenting equivalent cancer control is required before recommending this technique. Lee et a1 (page 450) examine whether the prostate specific antigen (PSA) nadir achieved following external beam radiation therapy predicts biochemical disease-free survival. Indeed, in a multivariate analysis they found that a PSA nadir of less than 1.0 ng./ml. was an independent predictor of biochemical survival, defined by a nonincreasing serum PSA. The 3-year biochemical survival rate was 93,49 and 16%for PSA nadir less than 1.0, 1 to 1.99 and 2.0 or more ng./ml., respectively ( p = 0.0001). The authors conclude that strategies to improve results of radiotherapy should focus on techniques that increase the likelihood of achieving PSA nadir less than 1.0 ng./ml. Similar results have been reported by Powell et al.' In 147 men with clinically localized prostate cancer treated with external beam radiation therapy, they reported significantly improved disease specific survival of those achieving PSA nadir less than 1.5 ng./ml. compared to those with PSA nadir less than 4.0 ng./ml. Critz et a1 reported further improvement in biochemical survival rates for PSA nadir less than 0.5 ngJml.2 The 5 and 10-year actuarial PSA
relapse-free survival rates were 95 and 84%, respectively for PSA nadir less than 0.5 ng./ml. compared to 29% at 5 years for PSA nadir 0.6 to 1.0 ng./ml. (p = 0.0001). In that series, all men with PSA nadir more than 1.0 ng./ml. ultimately had relapse. Smith et a1 (page 454) update an earlier study on the effects of wide excision of the neurovascular bundles on disease-free survival in men with clinically localized prostate cancer but extensive capsular penetration pathologically.3 Previously, they found that negative surgical margins with extensive capsular penetration did not result in enhanced long-term survival. With more than 2 years of further followup, however, they found that negative margins obtained by wide excision of the periprostatic soft tissue do result in improved biochemical disease-free survival. In their original study patients with negative surgical margins had improved disease-free survival at 20 months but this result was not sustained at 43 months. Now, with an additional mean followup of 28 months, the probability of having undetectable PSA at 5 years was 47% in men with negative versus 6% in those with positive surgical margins (p <0.001). Not surprisingly, disease-free survival was better in men with moderately compared to poorly differentiated disease. The authors conclude that wide excision of the periprostatic soft tissue in men with extensive capsular penetration results in extended disease-free survival, and they recommend wide excision whenever there is adjacent palpable induration, particularly a t the apex of the prostate.
Charles B. Brendler Section of Urology /Surgery University of Chicago Chicago, Illinois REFERENCES
1. Powell, C. R.,Huisman, T. K, Saunders, E. L. and Johnstone, P. A,: Outcome for surgically staged localized prostate cancer treated with external beam radiation therapy. J. Urol., part 2, 155 560A, abstract 998, 1996. 2. Critz, F.A.,Levinson, K, Williams, W. H. and Holladay, D. A.: Is an undetectable nadir PSA a reasonable goal following irradiation for prostate cancer? J. Urol., part 2, 155 557A, abstract 984, 1996. 3. Partin, A.W., Borland, R. N., Epstein, J. I. and Brendler, C. B.: Influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer with established capsular penetration. J. Urol., 150. 142, 1993.
459