Stories abound about men who undergo prostate cancer surgery only to have the surgery halted when their doctor sees that the cancer has left the gland. The stories go that the doctor stops the surgery leaving the gland and any other visible tumors in place just as they found them.
Current statistics indicate that one can expect similar outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa). However, what role, if any, of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail.
Some researchers prospectively evaluated RALP surgeries performed from October 2005 to November 2008 by a single surgeon. The total number of surgeries was two hundred and twenty (220). Outcomes were assessed in an institutional review board-approved database.
Of two hundred and twenty (220) RALPs, thirty five (35) or fifteen and nine tenths percent (15.9%) were performed for pT3 PCa; none of them had been identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p = 0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p = 0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p = 0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on post-surgery questionnaires.
RALP might be a valuable primary treatment modality for men with pathologically advanced PCa. At thirteen months postoperatively, seventy-one percent (71%) of the men were without evidence of disease at thirteen (13) months. Although thirteen months is a short period, if surgery had been withheld from these men one hundred percent (100%) would still have active prostate cancer cells in their body.
If I were newly diagnosed and I also knew that the cancer has escaped into some surrounding lymph nodes I would give serious consideration to going a head with surgery. However, I would make sure that my doctor understood that I wanted the surgery to be completed even when it was confirmed that the cancer was out of the gland.
J Endourol. 2009 Sep;23(9):1519-22.
doi:10.1089/end.2009.0388 (from the Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.)
Joel T Nowak MA, MSW