UROLOGICAL ONCOLOGY

Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results
Roehl KA, Han M, Ramos CG, Antenor JA, Catalona WJ
Department of Psychiatry, School of Medicine, Washington University, St. Louis, Missouri, USA
J Urol. 2004; 172: 910-4

• Purpose: We updated a long-term cancer control outcome in a large anatomical radical retropubic prostatectomy (RRP) series. We also evaluated the perioperative parameters that predict cancer specific outcomes following surgery.
• Materials and Methods: From May 1983 to February 2003, 1 surgeon (WJC) performed RRP in 3,478 consecutive men. Patients were followed with semiannual serum prostate specific antigen (PSA) tests and annual digital rectal examinations. We used Kaplan-Meier product limit estimates to calculate actuarial 10-year probabilities of biochemical progression-free survival, cancer specific survival and overall survival. Multivariate Cox proportional hazards models were used to determine independent perioperative predictors of cancer progression.
• Results: At a mean followup of 65 months (range 0 to 233) actuarial 10-year biochemical progression-free, cancer specific and overall survival probabilities were 68%, 97% and 83%, respectively. On multivariate analysis biochemical progression-free survival probability was significantly associated with preoperative PSA, clinical tumor stage, Gleason sum, pathological stage and treatment era. Cancer specific survival and overall survival rates were also significantly associated with clinicopathological parameters.
• Conclusions: RRP can be performed with excellent survival outcomes. Favorable clinicopathological parameters and treatment in the PSA era are associated with improved cancer control.
  
  
• Editorial Comment
  This paper is very valid as it describes the long-term outcome of a very large cohort of patients after radical prostatectomy. Notably, all patients have been operated by a single surgeon (W. Catalona), thus certifying best results by a high-volume urologist. The most interesting results are given as PSA progression-free survival data (defined as detectable PSA > 0.2 ng/mL) and are therefore comparable to other, especially nonsurgical data (see following comment). Biochemical progression was 20% at 5 and 32% at 10 years. A closer look into the Kaplan Meier curves reveals more truth: in very low-risk patients with PSA < 2.6 ng/mL around 10% showed PSA progression after 150 months, for PSA 2.6 - 4 ng/mL roughly 20% and PSA 4 -10 ng/mL roughly 25% had biochemical progression after 150 months. Notably, these patients are considered low risk. With PSA > 10 less than 50% of patients remained progression free after 150 months. Another look is worthwhile on the curve showing Gleason grades and biochemical progression. In Gleason 2-6 around 20% of patients have failed after 100 months of follow-up, with a continuously decreasing curve. Altogether these data give a clear view on the advantages and especially, the limits of radical prostatectomy and should be considered if this procedure is advocated to men with prostate cancer.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany