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European UrologyVolume 59, issue 3, pages e5-e14, March 2011
Words of Wisdom
Re: Five Year Biochemical Recurrence Free Survival for Intermediate Risk Prostate Cancer After Radical Prostatectomy, External Beam Radiation Therapy or Permanent Seed Implantation
Published online 28 January 2011, page 467
Vassil AD, Murphy ES, Reddy CA, et al
This study investigates the biochemical recurrence-free survival (bRFS) of patients with intermediate-risk prostate cancer treated by either retropubic radical prostatectomy (RRP; 354 patients), laparoscopic radical prostatectomy (LRP; 64 patients), external-beam radiation therapy (RT; 305 patients), or permanent seed implantation (PI; 256 patients). The median follow-up was 65 mo. In conclusion, the authors state that the patients who underwent LRP had worse biochemical control than those who chose the other treatment modalities.
Because this study is retrospective, the treatment groups are not equally distributed and differ in several parameters such as number of patients per group, initial Gleason score, initial prostate-specific antigen (PSA) level, and local stage. The definition of treatment failure differs according to the treatment modalities (PSA cut point of ≥0.4 ng/ml after surgery; nadir +2 definition of biochemical failure for RT and PI patients). There were 53% and 31% of patients who received androgen deprivation therapy in addition to RT and PI, respectively; therefore, bRFS is difficult to compare in between the four groups. However, because the two surgical groups are more homogenous, a direct comparison may be still of interest.
The 5-year bRFS rate was 79.9% for RRP and 60.2% for LRP. This difference of 19.7% is substantial (p < 0.0001) and contravenes the current literature in which the two methods are considered equally efficient with regard to oncologic outcome. The higher rate of extracapsular tumour extension (47% vs 39%) and Gleason score 7 (79.7% vs 64.7%) in the LRP population may be indicative for more aggressive tumours in this subgroup. However, other possible factors have to be discussed.
Initially, when laparoscopy was introduced into oncologic surgery, there was great fear with regard to possible tumour spillage. The experience of many years has shown that tumour spillage due to laparoscopy is a very rare event that is most commonly related to the removal of high-grade transitional cell cancer and deviation from surgical principles . Tumour spillage after laparoscopic surgery for prostate cancer has only been described in a few case reports and certainly is not a factor that can be responsible for the observed difference in the bRFS rate .
The problem of the learning curve, which is also discussed by the authors, has been investigated by Vickers et al. . Experience with 250 RRPs is required to achieve an optimal bRFS rate; to achieve the same results with LRP, experience with 900 cases has to be collected. Thereafter, the bRFS rate improves further with laparoscopy but stagnates with open surgery. The experience of the surgeons participating in this study comprised median numbers of 246 RRPs and 126 LRPs. Therefore, it can be concluded that the results of this study were negatively influenced by the missing experience of the laparoscopic surgeons. To some extent, this is reflected by the high rate of positive margins (LRP: 44%; RRP: 27%). As mentioned, there were also higher stages in the laparoscopic group.
Another aspect is frequently neglected: the impact of lymph node metastases. Until recently, limited pelvic lymph node dissection (PLND) was routine, and extended PLND the exception. Several studies have clearly demonstrated that about 50% of lymph node metastases are overlooked when performing limited PLND . These overlooked metastases will certainly result in a biochemical relapse. There is no consensus about the indications for PLND. However, there are good arguments for performing PLND in intermediate and high-risk patients. In fact, 75% of patients undergoing RRP had a PLND, and this rate was 61% for LRP. There is no comment on the extent of PLND, but the quality of the PLND can be estimated by the rate of detected lymph node metastases, which was 2% for RRP and 0% for LRP. A poor-quality PLND is not an inherent problem of laparoscopy. Several authors have shown that laparoscopic PLND is equivalent to open PLND when using an appropriate technique, and one essential aspect is the transperitoneal approach . In this context, it has to be stated that there is a trend towards the extraperitoneal approach for LRP, and that will be a problem when considering extended PLND.
It may be concluded that the observed low bRFS rate after LRP is due to several factors, namely, a bias with regard to staging and grading, the learning curve, and an insufficient PLND, but it is obviously not due to an inherent problem of laparoscopy.
Conflicts of interest
The author has nothing to disclose.
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Department of Urology, Paracelsus Medical University, Salzburg, Austria
© 2010 Published by Elsevier B.V.
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