SUO 2017: Clinically Relevant Questions in the Surgical Management of Prostate Cancer
Who should receive a concomitant PLND?
Dr. Montorsi highlighted the recently updated Briganti nomogram [1], a tool for predicting which men undergoing radical prostatectomy could benefit from a pelvic lymph node dissection. Based on data from 681 patients, a pelvic lymph node dissection should be avoided in patients with detailed biopsy information and a risk of nodal involvement below 7% in order to spare ~70% of PLNDs at the cost of missing only 1.5% of cases with lymph node invasion. Citing data in press, Dr. Montorsi and his group assessed when we should remove the common iliac and presacral nodes, suggesting that a PLND including these nodes should be considered in men with a lymph node invasion risk >30% according to the Briganti nomogram.
What is the risk of complications and how can be improve postoperative outcomes?
Dr. Montorsi’s personal opinion is that the concept of the “Learning Curve” only makes sense for those surgeons who carefully follow their patients and are aware of their personal results. Additionally, a surgical technique should be changed to optimize results which are considered unsatisfactory. “In other words, for those who are largely unaware of their surgical results, the concept of a learning curve does not apply.” In September 2016, an integrated method for reporting surgical morbidity based on the EAU recommendations was implemented, as perioperative data were prospectively collected by a physician during a patient interview at 30-day follow-up. Dr. Montorsi’s group noted that this standardized system roughly doubled the complication rate, as more than 15% of patients experienced complications after discharge that would have been missed using methods based on patient chart review.
How can we improve urinary continence recovery?
For Dr. Montorsi’s robotic prostatectomies, he has adapted early DVC ligation. Propensity matching 55 patients to standard DVC ligation, he noted an improvement of urinary continence recovery at 1 month (41.8% vs 25.9%, p=0.001). Furthermore, he and his group have a randomized controlled trial ongoing to further assess the possibility of improving early continence rates with early DVC ligation. Second, Dr. Montorsi is a proponent of pelvic floor muscle training (PFMT). This is achieved through repeated, volitional pelvic floor muscle contraction coordinated against increased intra-abdominal pressure. PFMT may improve urinary continence by enhancing sphincter function and the supporting pelvic floor, and should be offered before radical prostatectomy and continued thereafter.
How can we improve erectile function recovery?
At Dr. Montorsi’s institution, pre- and post-operative pelvic flor muscle exercises are taught by a dedicated physiotherapist. Starting at the 3rd month after surgery, intracavernosal injections (ICI) of a vasoactive mixture (twice a week for at least six months) are started, and on demand PDE5-inhibitors before masturbation on days when injections are not used. Three versions of a four-drug ICI mixture are available at his hospital, with the most common component/dose being: papaverine hydrochloride (4.0 mg/mL), prostaglandin E1 (4.0 mcg/mL), phentolamine mesylate (0.25 mg/mL), and atropine (0.05 mg/mL).
Is there a role for surgery in the recurrence setting? The case of salvage lymph node dissection
According to Dr. Montorsi, the rationale for salvage lymph node dissection (SLND) is that (i) the majority of recurrences are seen in the prostatic fossa and in the lymph nodes, and (ii) patients with nodal recurrence have a more favorable prognosis. 68Ga-PSMA PET/CT has been advocated over 18F-FEC PET/CT, with a recent study noting that patients with lymph node metastases diagnosed on 68Ga-PSMA PET/CT who subsequently underwent a SLND showed a higher rate of complete biochemical recurrence compared to 18F-FEC PET/CT (45.7 vs. 21.7%, p = 0.040) [2]. Dr. Montorsi stated that only patients with pelvic lymph node involvement and those with PSA <4 ng/mL should be considered for SLND. Currently, there are six studies assessing complete PSA response after SLND, ranging from 38-73%. Ultimately, the EAU guidelines have added SLND as an option, giving a grade C recommendation for SLND in men experiencing nodal recurrence after local treatment, however noting in the guideline that BCR occurs after SLND in the majority of cases [3].
References:
1. Gandaglia G, Fossati N, Zaffuto E, et al. Development and internal validation of a novel model to identify the candidates for extended pelvic lymph node dissection in prostate cancer. Eur Urol 2017;72(4):632-640.
2. Herlemann A, Kretschmer A, Buchner A, et al. Salvage lymph node dissection after 68Ga-PSMA or 18F-FEC PET/CT for nodal recurrence in prostate cancer patients. Oncotarget 2017;8(48):84180-84192.
3. Cornford P, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part II: Treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer. Eur Urol 2017;71(4):630-642.
Presented by: Francesco Montorsi, Professor, Urology Research Institute, University Vita-Salute San Raffaele, Milan, Italy
Written by: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC