Study shows good long-term cancer control with laparoscopic radical prostatectomy

Key Points

Orlando, FL-Laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is associated with very good long-term oncologic control, according to recent analyses of data based on up to 10 years of follow-up. The study also provides evidence for performing an extended pelvic lymph node dissection (PLND) in order to maximize detection of nodal metastases, researchers reported at the AUA annual meeting here.

The analyses were based on a series of consecutive patients with clinical stage T1c-T3a prostate cancer who were operated on between January 1998 and 2002 at the Institute Mutualiste Montsouris, Paris, by Bertrand D. Guillonneau, MD, and at Memorial Sloan-Kettering Cancer Center, New York, by Dr. Guilloneau or Karim Touijer, MD. A total of 1,564 men underwent LRP during the study period.

Data were available for 1,422 patients (mean age, 61 years) to determine progression of disease, which was defined as a serum PSA of 0.1 ng/mL and rising or the introduction of adjuvant or salvage therapy. The overall 5-and 10-year progression-free probability rates were 80% and 77%, respectively.

Dr. Touijer noted that the definition used for disease progression in this analysis was relatively stringent. This feature must be considered by anyone attempting to make a cross-study comparison of the data from the LRP retrospective analysis.

"We will be providing a more definitive answer on the relative efficacy of LRP and open radical prostatectomy in the future, as a prospective study comparing the two procedures, each performed by two surgeons, was started at Memorial Sloan-Kettering in 2003," Dr. Touijer told Urology Times.

Data from the study were also analyzed with patients stratified according to different risk factors. Data were available to categorize 1,231 men into recurrence risk groups based on the predicted probability of disease progression using the Kattan pretreatment prostate cancer nomogram: 443 (36%) were in the low-risk group (≤10% risk), 642 were at intermediate risk (11% to 29%), and 146 (12%) were in the high-risk group (≥30%). For the low-, intermediate-, and high-risk groups, the 5-year progression-free probability rates were 92%, 77%, and 53%, respectively.

Surgical margin data were available for 1,384 men, and 173 (13%) had positive surgical margins. The 5-year progression-free probability was 49% for men with positive surgical margins and 89% for those with negative surgical margins.

Extended PLND favorable

Another analysis examined the potential influence of lymph node dissection technique on oncologic control. Dr. Touijer explained that prior to February 2005, a nomogram was used for LND decision-making. According to that nomogram, no LND was performed in men predicted to have a 1% or lower risk of lymph node invasion, while those with a higher risk underwent pelvic LND that was limited to the external iliac nodal group. Thereafter, the technique was changed so that an extended LND is performed in all patients.

Analyses of outcomes of the LND showed that the transition from the limited to an extended PLND technique was associated with an increase in the median number of lymph nodes removed from nine to 13. Importantly, the detection of lymph node metastases was increased more than threefold using the extended procedure compared with the limited dissection. Nodal metastases were detected in 10% of men who underwent the extended PLND compared with only 3% of men who had a limited PLND. Node-positive patients had a 46% 3-year probability of freedom from progression.

"Based on our experience, we believe the limited LND is inadequate for the surgical management of prostate cancer," Dr. Touijer said.