(UroToday.com) Dr. Benjamin Eilender from UT Southwestern presented an innovative treatment pathway for men with prostate cancer and significant prostate enlargement at the latest medical conference.
This study addresses a pressing challenge in prostate cancer treatment: managing patients with prostatomegaly (enlarged prostate glands), particularly those with prostate volumes of 80cc or greater. In such cases, the standard treatment options—Radiation Therapy (RT) and Robotic-Assisted Laparoscopic Prostatectomy (RALP)—can lead to worse functional outcomes, particularly in terms of urinary toxicity. Dr. Eilender and his team explored an alternative approach, robotic-assisted simple prostatectomy (RASP) - a safe, well-described, reproducible procedure for large prostate adenomas- that could offer better results for these patients.
The research involved a retrospective review of patients treated at UT Southwestern between 2016 and 2021. Specifically, the study focused on men who underwent a novel two-step treatment: RASP followed by RT. The goal of this approach was to reduce urinary toxicity in patients with large prostates, making post-treatment life more manageable. To evaluate the effectiveness of this treatment pathway, the researchers used propensity scoring based on demographic, clinical, and imaging features to create a matched cohort. This cohort included patients who underwent RALP as a primary treatment, allowing for a direct comparison between the two approaches (Table 1).
The findings indicate a potential shift in how prostate cancer with prostatomegaly could be managed. The study included 13 patients who underwent RASP followed by RT, with a median prostate volume of 135cc. These patients were compared to a matched group of 13 patients who underwent RALP alone with the same median prostate volume. Of note, both groups had prostate sizes larger than those typically reported in previous studies.
The most striking difference was in operative time: the RASP procedure was significantly shorter, taking a median of 126 minutes compared to 315 minutes for RALP (p < 0.001) (Table 2).
In terms of outcomes, the RASP pathway showed clear advantages in urinary function. Notably, none of the patients in the RASP group experienced stress urinary incontinence (SUI) at any point during the follow-up period. In contrast, SUI was reported in 92% of the RALP patients at three months and 88% at six months (Table 2), defined as requiring more than one pad per day. This finding is particularly important for patients where preserving urinary function is a priority. Despite these functional improvements, the oncologic and safety outcomes were similar between the two groups and not significant, suggesting that the new pathway does not compromise cancer control or patient safety.
In conclusion, Dr. Eilender's study presents a compelling case for considering RASP followed by RT as a treatment option for patients with large prostates who require prostate cancer management. The significant reduction in operative time and the superior urinary outcomes make this pathway an attractive alternative to traditional RALP, especially in cases where urinary function is a critical concern. Although larger sample sizes, longer-term oncologic follow-ups, and randomized trials are needed, the evolving field of prostate cancer treatment suggests that this approach could become a preferred option for managing patients with prostate cancer and prostatomegaly.
During the Q&A session, Dr. Han raised concerns about the reported SUI rate of over 90% among RALP patients, noting that such a figure is particularly alarming and suggesting that their data may actually be reflecting stress continence. Dr. Eilender confirmed that this statistic indeed referred to SUI, not stress continence, and clarified that the majority of these patients required more than one pad per day. To provide further context, Dr. Gahan, the principal investigator, addressed the audience. He acknowledged the high SUI rates but explained that these results were drawn from a diverse pool of surgeons at their institution. Despite the limited number of cases across 6-7 surgeons, Dr. Gahan emphasized that the study aims to suggest an alternative treatment approach for patients who might benefit from it.
Presented by: Benjamin Eilender, MD, UT Southwestern, Dallas, TX, @benjamineilend1 on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea
Co-Authors: Daniel Segal, Samuel Gold, Ross Gillum, Hal Kominsky, Neil Desai, Jeffrey Gahan
Moderated by: Misop Han, MD, and Tae Heon Kim, MD.
Written by: Seyed Amiryaghoub M. Lavasani, B.A., University of California, Irvine, @amirlavasani_ on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea
References:
- Jaber, A.R., et al., Impact of Prostate Size on the Functional and Oncological Outcomes of Robot-assisted Radical Prostatectomy. Eur Urol Focus, 2024.
- Pinkawa, M., et al., Toxicity profile with a large prostate volume after external beam radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys, 2008. 70(1): p. 83-9.
- Johnson, B., et al., Determining the Learning Curve for Robot-Assisted Simple Prostatectomy in Surgeons Familiar with Robotic Surgery. J Endourol, 2018. 32(9): p. 865-870.