NARUS 2019: Prostate: Post Radiation/Cryo/HiFu
Almost 20,0000 new cases of prostate cancer are seen every year. About a third of patients opt for primary radiotherapy as their definitive therapy. Unfortunately, almost 50% of these patients will demonstrate progression within 10 years of radiotherapy. Approximately 31,000 men per year are at risk of failure, and salvage radical prostatectomy, although a technically difficult procedure, offers the most durable option. However, the data demonstrates that salvage radical prostatectomy is rarely used after radiotherapy (0.9% of cases).
The low utilization of this procedure could stem from the complication rates, which are significantly higher with infection, urinary retention, fistula, abscess, and rectal injury.1 The overall major complication rates range between 30-40% according to a large meta-analysis comprised of 40 studies between 1980-2011.2 The results showed that the rate of Clavien 3-5 complication was 0-25%, with rectal injury rates of 0-28%, continence rates ranging between 21-90%, and very low potency rates of 0-20%.
When assessing the oncological outcomes, salvage radical prostatectomy was shown to harbor the best outcomes, according to a large multi-institutional collaboration.3 This study included 404 patients in 7 centers between 1985-2009, with a 10-year cancer-specific survival rate of 83%. In multivariable analysis, rising PSA and Gleason score were shown to be associated with biochemical recurrence and metastasis.
Next, Dr. Kim gave some important surgical pearls for this specific procedure. The first recommendation was the usage of side docking, which may reduce femoral neuropathy. Dr. Kim also suggests using an insufflation pressure of 20 mm HG to reduce bleeding. Incorporation of the deep venous complex for urethropexy is also recommended in this procedure.
Dr. Kim concluded his talk with some essential take-home messages.
These included use of the side dock, 20 mm Hg pneumoperitoneal pressure, and bowel preparation. It is advisable to use the 30 degree up and down camera in a liberal manner. Additionally, cautery should be minimized on the posterior and lateral dissections. Lastly, if a small rectal injury occurs, primary repair should be attempted.
Presented by: Isaac Kim, MD, Ph.D., MBA, Chief, Urologic Oncology, Executive Director, Prostate Cancer Program, Rutgers Cancer Institue of New Jersey
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at 2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States
References:
1. Gotto GT et al. Impact of prior prostate radiation on complications after radical prostatectomy. J Urol. 2010 Jul;184(1):136-42.
2. Chade DC et al. Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the literature. Eur Urol. 2012 May;61(5):961-71.
3. Chade DC et al. Salvage radical prostatectomy for radiation-recurrent prostate cancer: a multi-institutional collaboration. Eur Urol. 2011 Aug;60(2):205-10.