Robotic-assisted Radical Prostatectomy in Biopsy Proven High-grade Prostate Cancer: Experience From Two Tertiary Centres with Gleason Downgrading at Final Pathology Assessment
CUA Online Library. Al-Hathal N. 06/22/13; 31408; UP-29
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Abstract
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Introduction and Objectives: The use of radical prostatectomy as part of the treatment algorithm in high-grade prostate cancer (HGPCa) remains controversial. On the other hand, there are well-known limitations of conventional TRUS-guided biopsy such as insufficient tissue sampling, pathologist experience etc. Such limitations raise concerns about the accuracy of Gleason grading as a main predictor of PCa aggressiveness. Based on validation by the final pathology assessment of prostatectomized specimens, we searched a cohort of patients with Gleason downgrading regarding association with other pathology characteristics, oncological and functional outcomes.
Material and Methods: Among a total of 965 collective RARP consecutive cases, 59 (6.17%) patients with high-grade PCa underwent RARP at two, high-volume tertiary centers from October 2006 to August 2012. We assessed the rate of pathological Gleason downgrading, status of surgical margins, extarcapsular extension, seminal vesical invasion, lymph node involvement, biochemical recurrence (PSA ≥ 0.20ng/ml) and recovery of urine continence (0 pads usage). .
Results: Median follow-up was 12 months (range 1-24). Sixteen patients (27.1%) had positive surgical margins, majority (70%) where pT3-disease. Nineteen men (32.3%) had extra-capsular extension and eight (13.5%) had seminal vesicle invasion. Six patients (10.1%) did not reach undetectable PSA on initial post-op visit and were treated with ADT , 3 of which had positive lymph nodes. Overall biochemical recurrence was observed in a total of 7 patients (11.8%) with median time for recurrence 12 months. Only four men had PSA ≥ 0.20, the remaining had early salvage EBRT with PSA <0.20. Nine patients (15.2%) underwent adjuvant/salvage EBRT +/- ADT. In total, 34 patients (57.6%) were downgraded to Gleason 7 on final surgical pathology, and yet another two patients downgraded to Gleason 5 and 6. Finally, pad-free urine continence at 3 and 12 months were 64.5% and 82.9%, respectively.
Conclusion: In spite of advances in prostate biopsy diagnosis of HGPCa, we observed a significant likelihood for disease downgrading on final pathology. Most patients had organ/ specimen confined disease, adequately served by RARP and avoided ADT, while maintaining known advantages of RARP. Therefore, it should be taken into consideration by robotic surgeons that not necessarily all biopsy proven HGPCa will have these features at final pathology.
Material and Methods: Among a total of 965 collective RARP consecutive cases, 59 (6.17%) patients with high-grade PCa underwent RARP at two, high-volume tertiary centers from October 2006 to August 2012. We assessed the rate of pathological Gleason downgrading, status of surgical margins, extarcapsular extension, seminal vesical invasion, lymph node involvement, biochemical recurrence (PSA ≥ 0.20ng/ml) and recovery of urine continence (0 pads usage). .
Results: Median follow-up was 12 months (range 1-24). Sixteen patients (27.1%) had positive surgical margins, majority (70%) where pT3-disease. Nineteen men (32.3%) had extra-capsular extension and eight (13.5%) had seminal vesicle invasion. Six patients (10.1%) did not reach undetectable PSA on initial post-op visit and were treated with ADT , 3 of which had positive lymph nodes. Overall biochemical recurrence was observed in a total of 7 patients (11.8%) with median time for recurrence 12 months. Only four men had PSA ≥ 0.20, the remaining had early salvage EBRT with PSA <0.20. Nine patients (15.2%) underwent adjuvant/salvage EBRT +/- ADT. In total, 34 patients (57.6%) were downgraded to Gleason 7 on final surgical pathology, and yet another two patients downgraded to Gleason 5 and 6. Finally, pad-free urine continence at 3 and 12 months were 64.5% and 82.9%, respectively.
Conclusion: In spite of advances in prostate biopsy diagnosis of HGPCa, we observed a significant likelihood for disease downgrading on final pathology. Most patients had organ/ specimen confined disease, adequately served by RARP and avoided ADT, while maintaining known advantages of RARP. Therefore, it should be taken into consideration by robotic surgeons that not necessarily all biopsy proven HGPCa will have these features at final pathology.
Introduction and Objectives: The use of radical prostatectomy as part of the treatment algorithm in high-grade prostate cancer (HGPCa) remains controversial. On the other hand, there are well-known limitations of conventional TRUS-guided biopsy such as insufficient tissue sampling, pathologist experience etc. Such limitations raise concerns about the accuracy of Gleason grading as a main predictor of PCa aggressiveness. Based on validation by the final pathology assessment of prostatectomized specimens, we searched a cohort of patients with Gleason downgrading regarding association with other pathology characteristics, oncological and functional outcomes.
Material and Methods: Among a total of 965 collective RARP consecutive cases, 59 (6.17%) patients with high-grade PCa underwent RARP at two, high-volume tertiary centers from October 2006 to August 2012. We assessed the rate of pathological Gleason downgrading, status of surgical margins, extarcapsular extension, seminal vesical invasion, lymph node involvement, biochemical recurrence (PSA ≥ 0.20ng/ml) and recovery of urine continence (0 pads usage). .
Results: Median follow-up was 12 months (range 1-24). Sixteen patients (27.1%) had positive surgical margins, majority (70%) where pT3-disease. Nineteen men (32.3%) had extra-capsular extension and eight (13.5%) had seminal vesicle invasion. Six patients (10.1%) did not reach undetectable PSA on initial post-op visit and were treated with ADT , 3 of which had positive lymph nodes. Overall biochemical recurrence was observed in a total of 7 patients (11.8%) with median time for recurrence 12 months. Only four men had PSA ≥ 0.20, the remaining had early salvage EBRT with PSA <0.20. Nine patients (15.2%) underwent adjuvant/salvage EBRT +/- ADT. In total, 34 patients (57.6%) were downgraded to Gleason 7 on final surgical pathology, and yet another two patients downgraded to Gleason 5 and 6. Finally, pad-free urine continence at 3 and 12 months were 64.5% and 82.9%, respectively.
Conclusion: In spite of advances in prostate biopsy diagnosis of HGPCa, we observed a significant likelihood for disease downgrading on final pathology. Most patients had organ/ specimen confined disease, adequately served by RARP and avoided ADT, while maintaining known advantages of RARP. Therefore, it should be taken into consideration by robotic surgeons that not necessarily all biopsy proven HGPCa will have these features at final pathology.
Material and Methods: Among a total of 965 collective RARP consecutive cases, 59 (6.17%) patients with high-grade PCa underwent RARP at two, high-volume tertiary centers from October 2006 to August 2012. We assessed the rate of pathological Gleason downgrading, status of surgical margins, extarcapsular extension, seminal vesical invasion, lymph node involvement, biochemical recurrence (PSA ≥ 0.20ng/ml) and recovery of urine continence (0 pads usage). .
Results: Median follow-up was 12 months (range 1-24). Sixteen patients (27.1%) had positive surgical margins, majority (70%) where pT3-disease. Nineteen men (32.3%) had extra-capsular extension and eight (13.5%) had seminal vesicle invasion. Six patients (10.1%) did not reach undetectable PSA on initial post-op visit and were treated with ADT , 3 of which had positive lymph nodes. Overall biochemical recurrence was observed in a total of 7 patients (11.8%) with median time for recurrence 12 months. Only four men had PSA ≥ 0.20, the remaining had early salvage EBRT with PSA <0.20. Nine patients (15.2%) underwent adjuvant/salvage EBRT +/- ADT. In total, 34 patients (57.6%) were downgraded to Gleason 7 on final surgical pathology, and yet another two patients downgraded to Gleason 5 and 6. Finally, pad-free urine continence at 3 and 12 months were 64.5% and 82.9%, respectively.
Conclusion: In spite of advances in prostate biopsy diagnosis of HGPCa, we observed a significant likelihood for disease downgrading on final pathology. Most patients had organ/ specimen confined disease, adequately served by RARP and avoided ADT, while maintaining known advantages of RARP. Therefore, it should be taken into consideration by robotic surgeons that not necessarily all biopsy proven HGPCa will have these features at final pathology.
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