Robot-Assisted Laparoscopic Radical Prostatectomy In Patients With High-Risk Prostate Cancer

BackgroundsProstate cancer(PCa) is one of the most commonly diagnosed malignancy in UnitedStates and European countries. With more than240,000new cases estimated to occur inthe United States during2011, it continues to be the most frequent solid tumor in men. Theincidence of prostate cancer in most Asian countries is lower than the one in westerncountries. However, with the improvement of living conditions, aged tendency ofpopulation and popularity of PSA screening, morbidity of PCa is continuingly raising inChinese population in recent years. Although most of PCa patients could achieve earlydiagnosis in PSA era,15-38%of them still undertake therapy with high-risk disease, whichis more likely to metastasis and death than those without high-risk conditions. Thus,treatment for high-risk PCa remains a really challenging problem nowadays.Despite the fact that surgical treatment has traditionally been reserved for low-stage,low-risk PCa, the optimal management for high-risk PCa is still controversial.Radiotherapy, especially external-beam radiotherapy (ERBT) with androgen-deprivationtherapy(ADT) is considered the most common and a essential component of therapy forhigh-risk PCa. Adversely, the role of prostatectomy for high-risk PCa is also confirmed byprevious studies. High-risk patients undertake surgical treatment could achieve a more than50%5-year cancer-specific survival. Therefore, prostatectomy is proved to be a optimaltreatment for high-risk PCa patients. Additionally, with improved survival outcomes forhigh-risk PCa patients, post treatment health related quality of life (HRQOL) becomes animportant consideration.During the past decade, Robotic-assisted radical prostatectomy (RARP) has becomethe preferred surgical approach for radical prostatectomy in the United States, with anestimate that4out of5prostatectomies are robotically assisted. This minimally invasivetechnique is increasingly adopted to treat high-risk PCa patients. Nevertheless, withdisputable results, further assess for RARP for high-risk PCa is necessary. Due to thelack of haptic feedback on the robotic console, questions have arisen regarding theoncologic safety of nerve sparing in high-risk setting. Evaluation of functional andoncologic outcomes after RARP could lead to the selection of management for high-riskPCa patients.Meanwhile, aquracy of Gleason diagnosis is one issue which may infulencethe outcomes after RARP in high-risk Pca patients. ObjectivesThis study is designed to compare the results between different risk stratification ofPCa, to evaluate the feasibility of RARP and nerve sparing for high-risk status, todetermine the impact of outcomes by high-risk factors. Another aim of this study is toevaluate the disaccord rate between biopsy and pathologic Gleason, to demostrate theaquracy of Gleason diagnosis and the impact factors.MethodsAn institutional database of2888RARP was queried for patients according withinclude and exclude criteria. All patients was divided into three groups according toD'Amico risk stratification for PCa. Patients with routine RARP were selectivelyundertaking nerve sparing. Patients demography, perioperative outcomes, pathologic datawere collected and evaluated, as well as postoperative oncologic outcomes. Functionaloutcomes and quality of life after RARP were followed up by interview and UCLA-PCIquestionnaires. Continuous variables were compared by ANOVA, as categorical variableswere compared by χ2analysis. The Kaplan-Meier method was used to report biochemicalrecurrence (BCR) after surgery. Cox proportional hazards method analysis was performedto determin predictive factors for early functional recovery. Multivariate logistic regressionanalysis was conducted of risk factors in the prediction of surgical margin status.ResultsA total of1648RARP patients were included in this study,190of which were inhigh-risk status, as well as765and693of which were in low-risk and intermediate-riskdisease. The total average age and medial follow-up time were59.5year and18.7months.The total (BCR) rate, continence and potency rate was6.1%,87.7%and62.0%.Statistically significant was considered between the three risk groups in BCR, continenceand potency rate (p<0.001), while no statistically significant was found in mean surgicaltime, mean estimate blood loss, mean hospital stay, complication rate, positive surgicalmargin(PSM) rate and PSM position. Factors independently predictive of PSM wereclinical stage cT2c or above, extra-capsular extension (ECE) and tumor volume. Regardingcontinence in the patient with preoperative SHIM21or above, and/or with nerve sparingduring surgery, different risk groups demonstrated similar recovery except the6monthUrinary Function(UF). Age, preoperative Gleason score8or above and prostate volume were independent factors predicting continence recovery. Compared the sexually outcomesin patients with preoperative SHIM21or above, and/or with nerve sparing,3month and12month SHIM score,3month and6month potency recovery occurred more lower inhigh-risk group than the other two stratifications, as well as the1,3,6month sexualfunctional(SF) and3,12month sexual bother(SB)(p<0.05). Age, preoperative Gleasonscore8or above, preoperative SHIM score and nerving sparing demonstrated statisticalsignificance as independent prognostic factors for potency recovery.A total of188high-risk patients were included in the study for nerve sparing, amongwhich31(16.5%) were none nerve sparing,87(46.3%) undertook unilateral nerve sparing,and70(37.2%) were treated by bilateral nerve sparing. Total PSM rate was21.3%, while38.7%,21.8%and12.9%in none, unilateral and bilateral group (p=0.014). Total BCR ratewas15.5%. Statistical significance for BCR was revealed between none, unilateral andbilateral nerve sparing groups (25.8%vs20.7%vs4.3%, p=0.004), as well as for6,12monthSHIM score, potency rate, sexual function, and12month sexual bother(p<0.05).A total of309high-risk patients were included in the study for Gleason upgrading anddowngrading. Disaccord between biopsy and pathologic Gleason happened in166cases(53.7%), including43cases (13.9%) with upgrading and123cases (39.8%) withdowngrading. Primary and secondly biopsy Gleason score are both the predictive factorsfor Gleason upgrading and downgrading. Preoperative PSA lever, maximum cancerpercentage per core(Max%cancer/core) are also the predictive factors for downgrading.ConclusionsRARP is a feasible treatment option for high-risk PCa patients. Higher BCR rate andworse function recovery are associated with high-risk factors. Nerve sparing during RARPcan be safely performed in high-risk PCa patients by experienced robotic surgeon. Forovercoming the lack of haptic feedback in robot system, evaluation basing onintraoperative findings with the exception of previous characteristics is the key for PSMcontrol in high-risk PCa disease. Up to53.7%of the high-risk Pca patients undertakingRARP are with disaccord between biopsy and pathologic Gleason. Gleason upgrading anddowngrading remain an improtant issue for high-risk PCa patients.