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Radical Prostatectomy for Carcinoma in Men More Than 69 Years Old
0022-534 7/87 /1385-1185$02,00/0 VoL 138, November
THE JOURNAL OF UROLOGY
Printed in U g A
Copyright© 1987 by The Williams & Wilkins Co,
RADICAL PROSTATECTOMY FOR CARCINOMA IN MEN MORE THAN 69 YEARS OLD ANTHONY W. MIDDLETON, JR.* From the Division of Urology, University of Utah College of Medicine, Salt Lake City, Utah
ABSTRACT
\
Between 1974 and 1986, 193 men with prostatic cancer were treated with bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Of the 193 patients 65 were 70 years or older (5 were 78 years old). Of the 32 men in this series who underwent a potency-sparing modification of the radical prostatectomy 7 were 70 years or older, the oldest being 77 years. A comparison of the morbidity and mortality of the 65 men in the older group with the 128 men in the group less than 70 years old revealed no significant difference. Long-term followup data demonstrated 57 men in the older age group to be well with no evidence of disease, with 10 in that group well with no evidence of disease greater than 5 years after the radical prostatectomy. We recommend radical prostatectomy for patients with clinically localized prostatic carcinoma whose general health suggests a 10-year or greater probable life expectancy, aside from tumor. (J. Ural., 138: 1185-1188, 1987) A widely held viewpoint among urologists has been that clinically locally confined prostatic adenocarcinoma should not be treated with radical prostatectomy when found in men more than 70 years old. 1- 3 Instead, hormonal manipulation, radiation therapy or other methods are believed to be more appropriate. Because we thought that anything short of radical prostatectomy was inadequate for long-term tumor control, we began in 1974 to perform pelvic lymphadenectomy and radical retropubic prostatectomy in men of any age whose general health suggested a 10-year or longer life expectancy, aside from tumor. Our experience is reported.
preoperatively, modified from the technique described by Walsh and associates.6-8 Of the 32 men who underwent the potency-sparing operation 7 were 70 years or older, the oldest being 77. lnterm.ittent pressure boots on the lower extremities have been used routinely during the operation, with support stockings being used in the postoperative period. Prophylactic anticoagulation was started in most patients by 2 days postoperatively. Perioperative and postoperative broad-spectrum antibiotics were used parenterally and/or orally in all patients, and TABLE l
MATERIALS AND METHODS
Selection methods. Between May 1974 and January 1986, 193 men with prostatic cancer were treated with bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Of the 193 patients 65 were 70 or more years old (table 1 and figure). We recommended this operation for patients with biopsy proved, clinically localized prostatic carcinoma who subsequently had a normal serum acid phosphatase and no metastasis on a bone scan, who were in good health generally and who had a 10-year or greater probable life expectancy, aside from tumor. Candidates for an operation were limited to patients with clinical stage A2, Bl, B2 or, occasionally, C disease. Table 1 gives a breakdown of the clinical stage preoperatively of the older patients. As noted, of the 65 patients 70 or more years old only 1 had clinical stage C disease preoperatively, while 19 had stage A2, 28 stage Bl and 17 stage B2 cancer. The radical prostatectomies in this series were performed by myself (143 cases) and my partner, George W. Middleton (50 cases) with identical selection methods, technique and management philosophy. Management technique. The precise surgical technique used has been described previously. 4 •5 Five men in the older age group underwent subsequent implantation of a penile prosthesis, none having had a potency-sparing radical prostatectomy. Since early 1984 a potency-sparing modification to the surgical technique has been used in men who were sexually active Accepted for publication March 17, 1987. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 27-31, 1986. • * Requests for reprints: 1060 E. First St. South, Salt Lake City, Utah 84102. 1185
Age at Operation 70 71 72 73 74
75 76 77 78
Clinical Stage No. Pts,
AZ
Bl
B2
C
4 2 8 2 3 1 3
1 3 3 1 2 2 3
0 0 0 0 1
3
6 4 3 2 1 1 1 0
3
0
5
1
2
2
0 0
11 9
14 5
7 4
7
0
0
18 16 14
z 12 w 2
"- 10 0 0:
w 8
CD
2
::,
z
6 4 2
50 52 54 56 58 60 62 64 66 68 70 72 74
AGE
Age distribution
76 78
1186
MIDDLETON
the subcutaneous fat was irrigated with a broad-spectrum antibiotic mixed with saline in every case. There have been no postoperative wound infections. Early in the series patients were hospitalized 2 or 3 days preoperatively for a bowel preparation and they remained hospitalized until the catheter was removed, generally IO to 14 days postoperatively. Since early 1982 we have accomplished the bowel preparation at home in 2 days using mechanical and antibiotic (neomycin and erythromycin) preparations, and then same-day admission surgery. The patient is discharged from the hospital with the catheter in place as soon as he is eating and ambulatory, and the pain is manageable with oral analgesics. Patients with positive nodes on frozen section did not undergo radical prostatectomy. Early in this series 16 consecutive patients were assigned randomly to undergo or omit pubectomy with the lymphadenectomy and radical prostatectomy. 4 In the younger group (less than 70 years old) postoperative irradiation was given to 32 men with tumor in the surgical margins or seminal vesicles (20), or with microscopic tumor in the nodes on permanent section that was not seen on frozen section (12). In the older age group no patient had nodes negative for tumor on frozen section that, subsequently, proved to be positive on permanent section. Radiation to the pelvis was given postoperatively in 13 older patients, in every instance because of tumor in the surgical margins or seminal vesicles. In each case irradiation was deferred until a few weeks postoperatively when urinary control was complete or nearly so. RESULTS
A comparison of the morbidity and mortality of the 65 patients 70 years and older with the 128 patients less than 70 years old revealed no significant difference between the 2 groups. In the .older group 1 patient died of a pulmonary embolus 3 days postoperatively, while there were no perioperative deaths among the men less than 70 years old. Four men in the older and 8 in the younger age groups were lost to followup, defined as no followup for 2 years or greater. TABLE 2.
Complications %Men %Men <70 Yrs. Old ia::70 Yrs. Old
Early complications
Ileus Prolonged sacroiliac pain with pubectomy Lower extremity deep vein thrombophlebitis Pulmonary embolus (nonfatal) Pulmonary embolus (fatal) Sacroiliac pain without pubectomy Vertigo Cardiac arrhythmia Rectal injury, closed primarily Protracted pubic pain Lymphatic leak that sealed spontaneously Clot retention requiring catheter replacement Vesicocutaneous fistula, closed spontaneously in 4 wks. Cerebrovascular accident without lasting sequelae Footdrop secondary to peroneal compression during surgery, resolved in 6 mos. Spontaneous pneumothorax Wound infection
3.9 3.9 2.3 2.3 0 1.6 1.6 1.6 1.6 0.8 0.8 0.8 0.8
4.6 4.6 1.5 1.5 1.5 0 0 1.5 1.5 0 0 0 0
0.8
0
0.8
0
0 0
1.5 0
3.0
1.5
1.6 0.8
1.5 0
0
1.5
Late complications
Bladder neck contracture requiring dilation only once Persistent significant incontinence Vesicorectal fistula, salvage radical prostatectomy with prior radiation failure, colostomy first, then later ilea! conduit Hemostasis clip migration into bladder 3 mos. postop.
Table 2 lists the early and late complications in each age group. The complication rate was similar. It should be mentioned that the prolonged sacroiliac pain noted primarily ,was in patients who underwent pubectomy early in the series. 4 Pubectomy was discontinued when it was found that the complications were excessive and its use did not facilitate the subsequent radical prostatectomy. The early complications in both age groups were similar to those seen in any major pelvic operation. 9 Lower extremity deep vein thrombophlebitis actually occurred less frequently in the older than in the younger age groups but only by a small margin of difference. There were 4 cases of rectal injury during the operation: 1 in the older and 3 in the younger age groups. The value of the bowel preparation was evident, since the injury was repaired primarily in 3 cases without subsequent problem. The remaining case in the younger age group was a salvage radical prostatectomy performed 12 years after an attempt at cure with high dose radiation therapy. Despite a colostomy at the time of the radical prostatectomy the rectal closure broke down 1 month postoperatively, resulting in a vesicorectal fistula necessitating an ileal conduit. In regard to late complications, it is notable that stricture in the older group occurred in only 1 patient (1.5 per cent) and the stricture responded to a single dilation that has not had to be repeated. All 4 patients in the younger age group who had a postoperative stricture responded to a single dilation except for 1 who has required repeated dilations. The latter patient had stricture disease preoperatively from a prior transurethral prostatic resection for benign prostatic hyperplasia, and he had undergone postoperative irradiation because of tumor at the margin of resection. Long-term incontinence has been a minimal problem throughout this series. In the older age group the average interval between the operation and full return of urinary control was 14. 7 weeks, ranging from immediate control up to 44 weeks. Of those followed in the older series long enough to expect full control to return (at least 6 months) 1 required a Kaufman prosthesis (1.5 per cent) and 2 have mild stress incontinence (not enough to require pad protection). The average interval between surgery and continence in the younger age group was 10.3 weeks. We conclude that a longer period may be required in the older group for full control to return, with 1 patient not regaining full control until 10 months postoperatively. Our results were compared to those of several other series of radical prostatectomy. 10- 17 The results compared favorably and in particular the patients 70 years and older have done well. The prior series reported operative mortality rates of O to 4.8 per cent, rates for significant stress or total incontinence greater than 6 months of 2.5 to 31.5 per cent, bladder neck contracture rates of 2.5 to 23 per cent and rectal injury rates of 0 to 6. 7 per cent. Corresponding rates in our series were 1.5, 1.5, 1.5 and 1.5 per cent, respectively, for patients 70 or more years old, and 0, 2.3, 3.0 and 2.3 per cent, respectively, for patients less than 70 years old. Table 3 outlines survival data comparing the older and TABLE
Total No. in series Alive without evidence of disease ia::5 yrs. since operation Alive without evidence of disease >5 yrs. Alive without evidence of disease >10 yrs. Lost to followup Alive with local disease recurrence Alive with distant metastasis Dead of prostatic Ca Dead without evidence of disease Periop. death
3. Survival data ia::70 Yrs.
<70 Yrs.
65 57 15 10
128 104 60 42
1
6
4 0 0 0 3 1
8 4 5 4
3 0
RADICAL PROSTATECTOMY FOR CARCINOMA IN MEN MORE THAN 69 YEARS OLD
younger age groups. Of the 3 patients who died in the older series, excluding the perioperative death, 1 died 3 years postoperatively of pneumonia, 1 died 3 years postoperatively of a drug reaction to a gout medication and 1 died 3 years postoperatively of gastric carcinoma, with no evidence of recurrent prostatic carcinoma in any of the 3 patients. Of those in the older age group not lost to followup 57 are known to be well with no evidence of disease (10 are well with no evidence of disease 5 years or longer postoperatively, the longest being 12 years) (table 3). One patient in the older group had a cerebrovascular accident 6 years postoperatively with resultant hemiparesis and he still has no evidence of disease recurrence. Local recurrence. Local recurrence developed in 4 patients in the younger group: 1 was treated with radiation alone and 3 had radiation plus orchiectomy. The local tumor disappeared grossly in all 4 patients and none has had evidence of tumor recurrence locally or with distant spread. No patient in the older age group has had a local recurrence. Metastatic recurrence. In the older age group no patient has had metastatic disease. Of the younger patients 5 are alive with metastatic disease and 4 are dead of metastatic tumor. DISCUSSION
Several authors have suggested that clinically localized prostatic carcinoma should be treated with radical prostatectomy only in patients less than 70 years old. 1- 2 The idea is suggested that men older than 70 years who have prostatic carcinoma probably will die of some cause other than the carcinoma. Radiation is used with curative intent by some in patients more than 70 years old. However, Paulson and associates found that the long-term survival rates free of tumor are significantly superior in patients treated initially with radical prostatectomy as opposed to radiation therapy. 18 Therefore, we have not used radiation except in an adjuvant role. Those men who received postoperative radiation in this series have not had a local recurrence to date, which would seem to corroborate the observation of Gibbons and associates on the importance of adjuvant radiation therapy in this situation. 19 Life-table statistics. An analysis of 3 different life tables suggests a life expectancy of 11.2 to 15.5 years for any man 70 years old, aside from tumor, decreasing with each progressive year of age to 9.5 to 7.7 years at 79 years, aside from tumor (table 4). 20--22 These life tables were established without regard to the health of the men in the age group analyzed. If life tables were established for a selected population of men without evident life-shortening illnesses, as is done by the selection process used in our choice of candidates for radical prostatectomy, the life expectancy probably would be greater than the stated values. Natural history, untreated. The natural history of untreated prostatic carcinoma is not known precisely. 23 There are no large recent series of men with untreated prostatic carcinoma but 3 large series several years ago are of some interest. In 1946 Nesbit and Plumb noted a 5-year survival of 10 per cent in 701 patients presenting with localized disease. 24 In 1926 Bumpus noted that the average duration from diagnosis to death in 485 TABLE
4. Life tables-years of life expectation, male subject
Adjusted Age
New York Life20
National Center21
70 71 72 73 74
15.5 14.7 14.0 13.3 12.6
11.5 11.0 10.5 10.0 9.5
)
11.2
75 76
12.0 11.3 10.7 10.1 9.5
9.0 8.6 8.1 7.7 7.3
)
8.6
77 78 79
Utah Abridged22
1187
patients with clinically localized disease was about 1 year. 25 In 1950 Nesbit and Baum noted a 10 per cent survival at 5 years after initial diagnosis in 273 patients. 26 Recognizing that these early series consisted of patients whose disease was staged with outdated methodology and patients who did not have competing disease processes managed with modern methods, nonetheless, because they are the largest reported series of untreated prostatic carcinoma patients they are worth citing. In 1972 Hanash and associates found only a 20 per cent 5year survival rate in clinical stage B cancer patients treated only by transurethral resection. 27 Similarly, Walsh observed that not all patients with untreated stage Al lesions are doing well in long-term followup, with 16 per cent of such patients having tumor progression. 28 Since the impression is widespread that life expectancy is not increased by hormonal manipulation, the only advantage of hormonal manipulation being control of symptoms, the implication of these studies is obvious with regard to older patients who have a 10-year or greater life expectancy, aside from tumor. Even making allowance for the problems with the cited studies, it seems likely that patients with localized prostatic carcinoma and a 10-year or greater life expectancy probably will either die of the carcinoma or they will have significant morbidity before death if local tumor ablation is not achieved. Walsh noted that 25 per cent of the patients who underwent potency-sparing radical prostatectomy subsequently required dilation of bladder neck strictures. 28 In an attempt to improve that figure he recently modified the technique by over-sewing the bladder mucosa over the raw edges of the bladder neck and then making the urethral anastomosis. 8 We used our standard 8-suture vesicourethral anastomosis in all of our potency-sparing radical prostatectomies, and our stricture and incontinence incidence remains equally low whether a potency-sparing or conventional prostatectomy is done. Animal experiments suggest that a meticulous and precise urethral anastomosis, as we strive toward, enhances the result. 29 Some authors have claimed that prostatic carcinoma behaves in a more virulent fashion in younger than in older men, 27 while others believe that prostatic carcinoma in older men runs a more rapid course. 30 Whichever view is more accurate, the fact remains that men in both groups will die of prostatic carcinoma if they are not treated vigorously early in its course. With the morbidity and mortality of the surgery as minimal as has been achieved in this series, there is no apparent basis for withholding what appears to be potentially curative therapy for older men who fit appropriate health and life expectancy parameters. REFERENCES
1. Jewett, H. J.: Radical perinea! prostatectomy in the treatment of carcinoma of the prostate. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., chapt. 5, essay 1, p. 81, 1972. 2. Walsh, P. C.: Radical retropubic prostatectomy. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, sect. XV, chapt. 76, p. 2758, 1986. 3. Von Eschenbach, A. C. and Johnson, D. E.: Radical retropubic prostatectomy. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger, sect. V, chapt. 17, p. 166, 1982. 4. Middleton, A. W., Jr.: A comparison of the morbidity associated with radical retropubic prostatectomy with and without pubectomy. J. Urol., 117: 202, 1977. 5. Middleton, A. W., Jr.: Pelvic lymphadenectomy with modified radical retropubic prostatectomy as a single operation: technique used and results in 50 consecutive cases. J. Urol., 125: 353, 1981. 6. Walsh, P. C. and Donker, P. J.: Impotence following radical prostatectomy: insight into etiology and prevention. J. Urol., 128: 492, 1982. 7. Walsh, P. C., Lepor, H. and Eggleston, J. D.: Radical prostatectomy with preservation of sexual function: anatomical and pathologi-
1188
MIDDLETON
cal considerations. Prostate, 4: 473, 1983. 8. Walsh, P. C.: Radical prostatectomy with preservation of sexual function: evolution of a surgical procedure. AUA Update Series, vol. 5, lesson 5, 1986. 9. McCullough, D. L., McLaughlin, A. P. and Gittes, R. F.: Morbidity of pelvic lymphadenectomy and radical prostatectomy for prostatic cancer. J. Urol., 117: 206, 1977. 10. Boxer, R. J., Kaufman, J. J. and Goodwin, W. E.: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients. J. Urol., 117: 208, 1977. 11. Kopecky, A. A., Laskowski, T. Z. and Scott, R., Jr.: Radical retropubic prostatectomy in the treatment of prostatic carcinoma. J. Urol., 103: 641, 1970. 12. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977. 13. Hudson, H. C. and Howland, R. L., Jr.: Radical retropubic prostatectomy for cancer of the prostate. J. Urol., 108: 944, 1972. 14. Crawford, E. D. and Kiker, J. D.: Radical retropubic prostatectomy. J. Urol., 129: 1145, 1983. 15. Lindner, A., deKernion, J.B., Smith, R. B. and Katske, F. A.: Risk of urinary incontinence following radical prostatectomy. J. Urol., 129: 1007, 1983. 16. Turner, R. D. and Belt, E.: A study of 229 consecutive cases of total perinea! prostatectomy for cancer of the prostate. J. Urol., 77: 62, 1957. 17. Campbell, J. L., Thomley, M. W. and Parsons, R. L.: Complications of radical prostatic surgery. J. Urol., 89: 253, 1963. 18. Paulson, D. F., Lin, G. H., Hinshaw, W., Stephani, S. and the UroOncology Research Group: Radical surgery versus radiotherapy for adenocarcinoma of the prostate. J. Urol., 128: 502, 1982. 19. Gibbons, R. P., Cole, B. S., Richardson, R. G., Correa, R. J., Jr.,
20. 21. 22. 23. 24.
25. 26. 27. 28. 29. 30.
Brannen, G. E., Mason, J. T., Taylor, W. J. and Hafermann, M. D.: Adjuvant radiotherapy following radical prostatectomy: results and complications. J. Urol., 135: 65, 1986. New York Life Insurance Table: Expectation of Life. New York Life Insurance Co., January 1982. Patterson, J. E., Hetzel, A. M., Greville, T. N. E., Armstrong, R. J. and Zugzda, M. J.: Interpolated Abridged Life Table, U. S. Division of Vital Statistics. 1982 Abridged Life Table-Male. Utah State Life Table: 1969-1971: U.S. Decennial Life Tables for 1969-1971. U. S. Department of Health, Education and Welfare, 1975. Whitmore, W. F., Jr.: Natural history and staging of prostate cancer. Urol. Clin. N. Amer., 11: 205, 1984. Nesbit, R. M. and Plumb, R. T.: Prostatic carcinoma: a followup on 795 patients treated prior to the endocrine era and a comparison of survival rates between these and patients treated by endocrine therapy. Surgery, 20: 263, 1946. Bumpus, H. C., Jr.: Carcinoma of the prostate: a clinical study of 1,000 cases. Surg., Gynec. & Obst., 43: 150, 1926. Nesbit, R. M. and Baum, W. C.: Endocrine control of prostatic carcinoma: clinical and statistical survey of 1,818 cases. J.A.M.A., 143: 1317, 1950. Hanash, K. A., Utz, D. C., Cook, E. N., Taylor, W. F. and Titus, J. L.: Carcinoma of the prostate: a 15-year followup. J. Urol., 107: 450, 1972. Walsh, P. C.: Personal communication. McRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of repair. J. Urol., 104: 724, 1970. Parry, W. L.: Radical perinea! prostatovesiculectomy. In: Urologic Surgery, 3rd ed. Edited by J. F. Glenn. Philadelphia: J. B. Lippincott Co., chapt. 93, p. 960, 1983.
THE JOURNAL OF UROLOGY
Printed in U g A
Copyright© 1987 by The Williams & Wilkins Co,
RADICAL PROSTATECTOMY FOR CARCINOMA IN MEN MORE THAN 69 YEARS OLD ANTHONY W. MIDDLETON, JR.* From the Division of Urology, University of Utah College of Medicine, Salt Lake City, Utah
ABSTRACT
\
Between 1974 and 1986, 193 men with prostatic cancer were treated with bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Of the 193 patients 65 were 70 years or older (5 were 78 years old). Of the 32 men in this series who underwent a potency-sparing modification of the radical prostatectomy 7 were 70 years or older, the oldest being 77 years. A comparison of the morbidity and mortality of the 65 men in the older group with the 128 men in the group less than 70 years old revealed no significant difference. Long-term followup data demonstrated 57 men in the older age group to be well with no evidence of disease, with 10 in that group well with no evidence of disease greater than 5 years after the radical prostatectomy. We recommend radical prostatectomy for patients with clinically localized prostatic carcinoma whose general health suggests a 10-year or greater probable life expectancy, aside from tumor. (J. Ural., 138: 1185-1188, 1987) A widely held viewpoint among urologists has been that clinically locally confined prostatic adenocarcinoma should not be treated with radical prostatectomy when found in men more than 70 years old. 1- 3 Instead, hormonal manipulation, radiation therapy or other methods are believed to be more appropriate. Because we thought that anything short of radical prostatectomy was inadequate for long-term tumor control, we began in 1974 to perform pelvic lymphadenectomy and radical retropubic prostatectomy in men of any age whose general health suggested a 10-year or longer life expectancy, aside from tumor. Our experience is reported.
preoperatively, modified from the technique described by Walsh and associates.6-8 Of the 32 men who underwent the potency-sparing operation 7 were 70 years or older, the oldest being 77. lnterm.ittent pressure boots on the lower extremities have been used routinely during the operation, with support stockings being used in the postoperative period. Prophylactic anticoagulation was started in most patients by 2 days postoperatively. Perioperative and postoperative broad-spectrum antibiotics were used parenterally and/or orally in all patients, and TABLE l
MATERIALS AND METHODS
Selection methods. Between May 1974 and January 1986, 193 men with prostatic cancer were treated with bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. Of the 193 patients 65 were 70 or more years old (table 1 and figure). We recommended this operation for patients with biopsy proved, clinically localized prostatic carcinoma who subsequently had a normal serum acid phosphatase and no metastasis on a bone scan, who were in good health generally and who had a 10-year or greater probable life expectancy, aside from tumor. Candidates for an operation were limited to patients with clinical stage A2, Bl, B2 or, occasionally, C disease. Table 1 gives a breakdown of the clinical stage preoperatively of the older patients. As noted, of the 65 patients 70 or more years old only 1 had clinical stage C disease preoperatively, while 19 had stage A2, 28 stage Bl and 17 stage B2 cancer. The radical prostatectomies in this series were performed by myself (143 cases) and my partner, George W. Middleton (50 cases) with identical selection methods, technique and management philosophy. Management technique. The precise surgical technique used has been described previously. 4 •5 Five men in the older age group underwent subsequent implantation of a penile prosthesis, none having had a potency-sparing radical prostatectomy. Since early 1984 a potency-sparing modification to the surgical technique has been used in men who were sexually active Accepted for publication March 17, 1987. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 27-31, 1986. • * Requests for reprints: 1060 E. First St. South, Salt Lake City, Utah 84102. 1185
Age at Operation 70 71 72 73 74
75 76 77 78
Clinical Stage No. Pts,
AZ
Bl
B2
C
4 2 8 2 3 1 3
1 3 3 1 2 2 3
0 0 0 0 1
3
6 4 3 2 1 1 1 0
3
0
5
1
2
2
0 0
11 9
14 5
7 4
7
0
0
18 16 14
z 12 w 2
"- 10 0 0:
w 8
CD
2
::,
z
6 4 2
50 52 54 56 58 60 62 64 66 68 70 72 74
AGE
Age distribution
76 78
1186
MIDDLETON
the subcutaneous fat was irrigated with a broad-spectrum antibiotic mixed with saline in every case. There have been no postoperative wound infections. Early in the series patients were hospitalized 2 or 3 days preoperatively for a bowel preparation and they remained hospitalized until the catheter was removed, generally IO to 14 days postoperatively. Since early 1982 we have accomplished the bowel preparation at home in 2 days using mechanical and antibiotic (neomycin and erythromycin) preparations, and then same-day admission surgery. The patient is discharged from the hospital with the catheter in place as soon as he is eating and ambulatory, and the pain is manageable with oral analgesics. Patients with positive nodes on frozen section did not undergo radical prostatectomy. Early in this series 16 consecutive patients were assigned randomly to undergo or omit pubectomy with the lymphadenectomy and radical prostatectomy. 4 In the younger group (less than 70 years old) postoperative irradiation was given to 32 men with tumor in the surgical margins or seminal vesicles (20), or with microscopic tumor in the nodes on permanent section that was not seen on frozen section (12). In the older age group no patient had nodes negative for tumor on frozen section that, subsequently, proved to be positive on permanent section. Radiation to the pelvis was given postoperatively in 13 older patients, in every instance because of tumor in the surgical margins or seminal vesicles. In each case irradiation was deferred until a few weeks postoperatively when urinary control was complete or nearly so. RESULTS
A comparison of the morbidity and mortality of the 65 patients 70 years and older with the 128 patients less than 70 years old revealed no significant difference between the 2 groups. In the .older group 1 patient died of a pulmonary embolus 3 days postoperatively, while there were no perioperative deaths among the men less than 70 years old. Four men in the older and 8 in the younger age groups were lost to followup, defined as no followup for 2 years or greater. TABLE 2.
Complications %Men %Men <70 Yrs. Old ia::70 Yrs. Old
Early complications
Ileus Prolonged sacroiliac pain with pubectomy Lower extremity deep vein thrombophlebitis Pulmonary embolus (nonfatal) Pulmonary embolus (fatal) Sacroiliac pain without pubectomy Vertigo Cardiac arrhythmia Rectal injury, closed primarily Protracted pubic pain Lymphatic leak that sealed spontaneously Clot retention requiring catheter replacement Vesicocutaneous fistula, closed spontaneously in 4 wks. Cerebrovascular accident without lasting sequelae Footdrop secondary to peroneal compression during surgery, resolved in 6 mos. Spontaneous pneumothorax Wound infection
3.9 3.9 2.3 2.3 0 1.6 1.6 1.6 1.6 0.8 0.8 0.8 0.8
4.6 4.6 1.5 1.5 1.5 0 0 1.5 1.5 0 0 0 0
0.8
0
0.8
0
0 0
1.5 0
3.0
1.5
1.6 0.8
1.5 0
0
1.5
Late complications
Bladder neck contracture requiring dilation only once Persistent significant incontinence Vesicorectal fistula, salvage radical prostatectomy with prior radiation failure, colostomy first, then later ilea! conduit Hemostasis clip migration into bladder 3 mos. postop.
Table 2 lists the early and late complications in each age group. The complication rate was similar. It should be mentioned that the prolonged sacroiliac pain noted primarily ,was in patients who underwent pubectomy early in the series. 4 Pubectomy was discontinued when it was found that the complications were excessive and its use did not facilitate the subsequent radical prostatectomy. The early complications in both age groups were similar to those seen in any major pelvic operation. 9 Lower extremity deep vein thrombophlebitis actually occurred less frequently in the older than in the younger age groups but only by a small margin of difference. There were 4 cases of rectal injury during the operation: 1 in the older and 3 in the younger age groups. The value of the bowel preparation was evident, since the injury was repaired primarily in 3 cases without subsequent problem. The remaining case in the younger age group was a salvage radical prostatectomy performed 12 years after an attempt at cure with high dose radiation therapy. Despite a colostomy at the time of the radical prostatectomy the rectal closure broke down 1 month postoperatively, resulting in a vesicorectal fistula necessitating an ileal conduit. In regard to late complications, it is notable that stricture in the older group occurred in only 1 patient (1.5 per cent) and the stricture responded to a single dilation that has not had to be repeated. All 4 patients in the younger age group who had a postoperative stricture responded to a single dilation except for 1 who has required repeated dilations. The latter patient had stricture disease preoperatively from a prior transurethral prostatic resection for benign prostatic hyperplasia, and he had undergone postoperative irradiation because of tumor at the margin of resection. Long-term incontinence has been a minimal problem throughout this series. In the older age group the average interval between the operation and full return of urinary control was 14. 7 weeks, ranging from immediate control up to 44 weeks. Of those followed in the older series long enough to expect full control to return (at least 6 months) 1 required a Kaufman prosthesis (1.5 per cent) and 2 have mild stress incontinence (not enough to require pad protection). The average interval between surgery and continence in the younger age group was 10.3 weeks. We conclude that a longer period may be required in the older group for full control to return, with 1 patient not regaining full control until 10 months postoperatively. Our results were compared to those of several other series of radical prostatectomy. 10- 17 The results compared favorably and in particular the patients 70 years and older have done well. The prior series reported operative mortality rates of O to 4.8 per cent, rates for significant stress or total incontinence greater than 6 months of 2.5 to 31.5 per cent, bladder neck contracture rates of 2.5 to 23 per cent and rectal injury rates of 0 to 6. 7 per cent. Corresponding rates in our series were 1.5, 1.5, 1.5 and 1.5 per cent, respectively, for patients 70 or more years old, and 0, 2.3, 3.0 and 2.3 per cent, respectively, for patients less than 70 years old. Table 3 outlines survival data comparing the older and TABLE
Total No. in series Alive without evidence of disease ia::5 yrs. since operation Alive without evidence of disease >5 yrs. Alive without evidence of disease >10 yrs. Lost to followup Alive with local disease recurrence Alive with distant metastasis Dead of prostatic Ca Dead without evidence of disease Periop. death
3. Survival data ia::70 Yrs.
<70 Yrs.
65 57 15 10
128 104 60 42
1
6
4 0 0 0 3 1
8 4 5 4
3 0
RADICAL PROSTATECTOMY FOR CARCINOMA IN MEN MORE THAN 69 YEARS OLD
younger age groups. Of the 3 patients who died in the older series, excluding the perioperative death, 1 died 3 years postoperatively of pneumonia, 1 died 3 years postoperatively of a drug reaction to a gout medication and 1 died 3 years postoperatively of gastric carcinoma, with no evidence of recurrent prostatic carcinoma in any of the 3 patients. Of those in the older age group not lost to followup 57 are known to be well with no evidence of disease (10 are well with no evidence of disease 5 years or longer postoperatively, the longest being 12 years) (table 3). One patient in the older group had a cerebrovascular accident 6 years postoperatively with resultant hemiparesis and he still has no evidence of disease recurrence. Local recurrence. Local recurrence developed in 4 patients in the younger group: 1 was treated with radiation alone and 3 had radiation plus orchiectomy. The local tumor disappeared grossly in all 4 patients and none has had evidence of tumor recurrence locally or with distant spread. No patient in the older age group has had a local recurrence. Metastatic recurrence. In the older age group no patient has had metastatic disease. Of the younger patients 5 are alive with metastatic disease and 4 are dead of metastatic tumor. DISCUSSION
Several authors have suggested that clinically localized prostatic carcinoma should be treated with radical prostatectomy only in patients less than 70 years old. 1- 2 The idea is suggested that men older than 70 years who have prostatic carcinoma probably will die of some cause other than the carcinoma. Radiation is used with curative intent by some in patients more than 70 years old. However, Paulson and associates found that the long-term survival rates free of tumor are significantly superior in patients treated initially with radical prostatectomy as opposed to radiation therapy. 18 Therefore, we have not used radiation except in an adjuvant role. Those men who received postoperative radiation in this series have not had a local recurrence to date, which would seem to corroborate the observation of Gibbons and associates on the importance of adjuvant radiation therapy in this situation. 19 Life-table statistics. An analysis of 3 different life tables suggests a life expectancy of 11.2 to 15.5 years for any man 70 years old, aside from tumor, decreasing with each progressive year of age to 9.5 to 7.7 years at 79 years, aside from tumor (table 4). 20--22 These life tables were established without regard to the health of the men in the age group analyzed. If life tables were established for a selected population of men without evident life-shortening illnesses, as is done by the selection process used in our choice of candidates for radical prostatectomy, the life expectancy probably would be greater than the stated values. Natural history, untreated. The natural history of untreated prostatic carcinoma is not known precisely. 23 There are no large recent series of men with untreated prostatic carcinoma but 3 large series several years ago are of some interest. In 1946 Nesbit and Plumb noted a 5-year survival of 10 per cent in 701 patients presenting with localized disease. 24 In 1926 Bumpus noted that the average duration from diagnosis to death in 485 TABLE
4. Life tables-years of life expectation, male subject
Adjusted Age
New York Life20
National Center21
70 71 72 73 74
15.5 14.7 14.0 13.3 12.6
11.5 11.0 10.5 10.0 9.5
)
11.2
75 76
12.0 11.3 10.7 10.1 9.5
9.0 8.6 8.1 7.7 7.3
)
8.6
77 78 79
Utah Abridged22
1187
patients with clinically localized disease was about 1 year. 25 In 1950 Nesbit and Baum noted a 10 per cent survival at 5 years after initial diagnosis in 273 patients. 26 Recognizing that these early series consisted of patients whose disease was staged with outdated methodology and patients who did not have competing disease processes managed with modern methods, nonetheless, because they are the largest reported series of untreated prostatic carcinoma patients they are worth citing. In 1972 Hanash and associates found only a 20 per cent 5year survival rate in clinical stage B cancer patients treated only by transurethral resection. 27 Similarly, Walsh observed that not all patients with untreated stage Al lesions are doing well in long-term followup, with 16 per cent of such patients having tumor progression. 28 Since the impression is widespread that life expectancy is not increased by hormonal manipulation, the only advantage of hormonal manipulation being control of symptoms, the implication of these studies is obvious with regard to older patients who have a 10-year or greater life expectancy, aside from tumor. Even making allowance for the problems with the cited studies, it seems likely that patients with localized prostatic carcinoma and a 10-year or greater life expectancy probably will either die of the carcinoma or they will have significant morbidity before death if local tumor ablation is not achieved. Walsh noted that 25 per cent of the patients who underwent potency-sparing radical prostatectomy subsequently required dilation of bladder neck strictures. 28 In an attempt to improve that figure he recently modified the technique by over-sewing the bladder mucosa over the raw edges of the bladder neck and then making the urethral anastomosis. 8 We used our standard 8-suture vesicourethral anastomosis in all of our potency-sparing radical prostatectomies, and our stricture and incontinence incidence remains equally low whether a potency-sparing or conventional prostatectomy is done. Animal experiments suggest that a meticulous and precise urethral anastomosis, as we strive toward, enhances the result. 29 Some authors have claimed that prostatic carcinoma behaves in a more virulent fashion in younger than in older men, 27 while others believe that prostatic carcinoma in older men runs a more rapid course. 30 Whichever view is more accurate, the fact remains that men in both groups will die of prostatic carcinoma if they are not treated vigorously early in its course. With the morbidity and mortality of the surgery as minimal as has been achieved in this series, there is no apparent basis for withholding what appears to be potentially curative therapy for older men who fit appropriate health and life expectancy parameters. REFERENCES
1. Jewett, H. J.: Radical perinea! prostatectomy in the treatment of carcinoma of the prostate. In: Current Controversies in Urologic Management. Edited by R. Scott, Jr. Philadelphia: W. B. Saunders Co., chapt. 5, essay 1, p. 81, 1972. 2. Walsh, P. C.: Radical retropubic prostatectomy. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, sect. XV, chapt. 76, p. 2758, 1986. 3. Von Eschenbach, A. C. and Johnson, D. E.: Radical retropubic prostatectomy. In: Genitourinary Cancer Surgery. Edited by E. D. Crawford and T. A. Borden. Philadelphia: Lea & Febiger, sect. V, chapt. 17, p. 166, 1982. 4. Middleton, A. W., Jr.: A comparison of the morbidity associated with radical retropubic prostatectomy with and without pubectomy. J. Urol., 117: 202, 1977. 5. Middleton, A. W., Jr.: Pelvic lymphadenectomy with modified radical retropubic prostatectomy as a single operation: technique used and results in 50 consecutive cases. J. Urol., 125: 353, 1981. 6. Walsh, P. C. and Donker, P. J.: Impotence following radical prostatectomy: insight into etiology and prevention. J. Urol., 128: 492, 1982. 7. Walsh, P. C., Lepor, H. and Eggleston, J. D.: Radical prostatectomy with preservation of sexual function: anatomical and pathologi-
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MIDDLETON
cal considerations. Prostate, 4: 473, 1983. 8. Walsh, P. C.: Radical prostatectomy with preservation of sexual function: evolution of a surgical procedure. AUA Update Series, vol. 5, lesson 5, 1986. 9. McCullough, D. L., McLaughlin, A. P. and Gittes, R. F.: Morbidity of pelvic lymphadenectomy and radical prostatectomy for prostatic cancer. J. Urol., 117: 206, 1977. 10. Boxer, R. J., Kaufman, J. J. and Goodwin, W. E.: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients. J. Urol., 117: 208, 1977. 11. Kopecky, A. A., Laskowski, T. Z. and Scott, R., Jr.: Radical retropubic prostatectomy in the treatment of prostatic carcinoma. J. Urol., 103: 641, 1970. 12. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977. 13. Hudson, H. C. and Howland, R. L., Jr.: Radical retropubic prostatectomy for cancer of the prostate. J. Urol., 108: 944, 1972. 14. Crawford, E. D. and Kiker, J. D.: Radical retropubic prostatectomy. J. Urol., 129: 1145, 1983. 15. Lindner, A., deKernion, J.B., Smith, R. B. and Katske, F. A.: Risk of urinary incontinence following radical prostatectomy. J. Urol., 129: 1007, 1983. 16. Turner, R. D. and Belt, E.: A study of 229 consecutive cases of total perinea! prostatectomy for cancer of the prostate. J. Urol., 77: 62, 1957. 17. Campbell, J. L., Thomley, M. W. and Parsons, R. L.: Complications of radical prostatic surgery. J. Urol., 89: 253, 1963. 18. Paulson, D. F., Lin, G. H., Hinshaw, W., Stephani, S. and the UroOncology Research Group: Radical surgery versus radiotherapy for adenocarcinoma of the prostate. J. Urol., 128: 502, 1982. 19. Gibbons, R. P., Cole, B. S., Richardson, R. G., Correa, R. J., Jr.,
20. 21. 22. 23. 24.
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Brannen, G. E., Mason, J. T., Taylor, W. J. and Hafermann, M. D.: Adjuvant radiotherapy following radical prostatectomy: results and complications. J. Urol., 135: 65, 1986. New York Life Insurance Table: Expectation of Life. New York Life Insurance Co., January 1982. Patterson, J. E., Hetzel, A. M., Greville, T. N. E., Armstrong, R. J. and Zugzda, M. J.: Interpolated Abridged Life Table, U. S. Division of Vital Statistics. 1982 Abridged Life Table-Male. Utah State Life Table: 1969-1971: U.S. Decennial Life Tables for 1969-1971. U. S. Department of Health, Education and Welfare, 1975. Whitmore, W. F., Jr.: Natural history and staging of prostate cancer. Urol. Clin. N. Amer., 11: 205, 1984. Nesbit, R. M. and Plumb, R. T.: Prostatic carcinoma: a followup on 795 patients treated prior to the endocrine era and a comparison of survival rates between these and patients treated by endocrine therapy. Surgery, 20: 263, 1946. Bumpus, H. C., Jr.: Carcinoma of the prostate: a clinical study of 1,000 cases. Surg., Gynec. & Obst., 43: 150, 1926. Nesbit, R. M. and Baum, W. C.: Endocrine control of prostatic carcinoma: clinical and statistical survey of 1,818 cases. J.A.M.A., 143: 1317, 1950. Hanash, K. A., Utz, D. C., Cook, E. N., Taylor, W. F. and Titus, J. L.: Carcinoma of the prostate: a 15-year followup. J. Urol., 107: 450, 1972. Walsh, P. C.: Personal communication. McRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of repair. J. Urol., 104: 724, 1970. Parry, W. L.: Radical perinea! prostatovesiculectomy. In: Urologic Surgery, 3rd ed. Edited by J. F. Glenn. Philadelphia: J. B. Lippincott Co., chapt. 93, p. 960, 1983.