Society Of Urologic Oncology Meeting - Whitmore Lecture: Radical Prostatectomy - Where We Were And Where We Are Going

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Clinical Trials / Drug Trials
Article Date: 31 May 2008 - 0:00 PDT

email to a friend   printer friendly   view / write opinions   rate article

ORLANDO, FL (UroToday.com) - Dr. Walsh presented the Whitmore Lecture. He discussed the past history of radical prostatectomy (RP). The first RP was performed in 1904 in a perineal approach. The retropubic operation was introduced in 1947. During the Whitmore era, many men did not need to be cured, as they had more comorbidities and died of other causes. Presently, cancer is the leading cause of death in the US. In Whitmore's era, cure was often not possible due to advanced disease and complications for lower risk disease were too high.

In the present era, anatomy, surgical technique and quality of life have made significant advances. The dorsal vein complex was not charted and resulted in bleed, the sphincter and neurovascular anatomy was not understood and resulted in incontinence and impotence. With advances in these areas, surgery increased form 7-15% in 1983 up to 70% 15 years later. Men under the age of 65 had a significant cancer specific survival benefit compared to watchful waiting in a Scandinavian study. It also reduced the number of patients with metastasis and compounded, there will be a potential 30% decrease. He addressed the issue of robotic RP and that time to full recovery is relatively similar. He discussed the veil of Aphrodite and whether its release resulted in improved potency. Early release of the levator fascia during open RP results in better potency according to his data at this meeting. SHIM scores were significantly better at one year with this approach, increasing from 77% to 93%. The major impact is on less traction on the neurovascular bundle.

Dr. Walsh stated that more accurate imaging of tumor within the prostate and molecular markers would be more important than nomograms. Regarding positive surgical margins, extensive positive margins go down but focal positive margins remain unchanged according to data he showed. His positive surgical margin rate is 1.8%, compared to 23% for open RPs in recently published data. This is due to experience, and for this there is no substitute.

Regarding QOL, a cohort study comparing RP to radiotherapy and brachytherapy was recently in the NEJM. He applauded this type of study, as randomized treatment trials for localized prostate cancer have not succeeded. He pointed out the inadequate definitions used to evaluate success in patients undergoing radiotherapy. Objective, comparable criteria are needed. For focal therapies, he stated that they should be judged by the same biochemical freedom from disease criteria. He cited the ASCO guidelines on hormonal therapy that stated that there is a 15-17% cancer specific survival, but is no overall survival benefit.

The challenges of the future include accurate imaging, cohort studies, and adjuvant trials for those men who are not cured by surgery alone.

Presented by Patrick Walsh, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2008 - UroToday