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AUA 2019

AUA 2019: Inpatient Morbidity and Cost of Cytoreductive Radical Prostatectomy in the United States

Chicago, IL USA (UroToday.com) Local therapy directed against the primary tumor in the setting of low volume hormone-sensitive metastatic prostate cancer has garnered significantly increased attention since the publication of HORRAD and the data from the H arm of the STAMPEDE trial, both of which suggested a modest benefit in time to PSA progression with the addition of radiotherapy to the primary tumor in this setting. At least 3 ongoing randomized trials - TRoMbone, G-RAMPP, and SWOG 1802 - are currently examining the utility of cytoreductive radical prostatectomy in the same patient population. In this setting, it is of increasing relevance to know whether cytoreductive prostatectomy can be performed with similar safety and efficacy to radical prostatectomy for other indications.

At Podium Session 25 (Advanced Prostate Cancer III), Dr. Sohrab Arora presented the results of an analysis of the Nationwide Inpatient Sample (NIS) examining the perioperative complications of cytoreductive prostatectomy. Patients were identified using ICD-10 and codes and those with pre-existing metastatic cancer are flagged specifically in the NIS database. 1,173 cases of prostatectomy in the setting of metastatic disease were identified as well as 90,662 cases of prostatectomy without metastatic disease between 2008 and 2013. The primary outcome examined was inpatient complications. Secondary outcomes were individual complication types, length of stay, and cost.  

The complication rate for cytoreductive prostatectomy was 19.1% while the rate for nonmetastatic prostatectomy was 14.9% (p-value for difference 0.008). On multivariate analysis, the presence of metastatic disease remained an independent predictor of complications (OR 1.33, p = 0.008). Broken down by the type of complication, cytoreductive prostatectomy seemed to have an evenly increased rate of complications with no particular complication accounting for a disproportionate amount of the difference between the two groups. Similarly, hospital stay was longer (median ~1.2 vs 0.95) and the cost was greater (~140K vs $115K).   

Limitations of this study included the inability to differentiate cytoreductive prostatectomy, which aims to prolong life, and palliative prostatectomy, which aims to improve quality of life by relieving symptoms since both of these patient types would be recorded in the NIS as patients who underwent prostatectomy in the presence of metastatic disease. This limitation is compounded by the date range over which the study was conducted, 2008-2013, during which time there was minimal evidence to suggest a benefit for cytoreductive prostatectomy. Thus the complication rate in this series is very likely representative of at least a large component of palliative rather than cytoreductive therapy. Further, as audience member Dr. Axel Heidenrich, audience member, pointed out during a question, other large single-site studies have failed to demonstrate any difference in short term outcomes between cytoreductive and standard radical prostatectomy. This may suggest that increased surgeon experience negates the increased risks associated with cytoreductive prostatectomy, or it may again stress the importance of palliative prostatectomy in this data set. In either case, practitioners not at a center of excellence are well advised that cytoreductive prostatectomy is not currently the standard of care and this study should give all surgeons pause prior to undertaking prostatectomy in the setting of metastatic disease.

Presented by: Sohrab Arora, MD. Senior Fellow - Robotic Surgery, Henry Ford Health System, Detroit, Michigan

Written by: Marshall Strother, MD, Chief Resident, Division of Urology, University of Pennsylvania, Philadelphia PA at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois