Adverse effect of transurethral resection on disease-free survival in locally advanced prostatic cancer treated with irradiation

Transurethral Prostatectomy Before or After External Beam Radiotherapy: Complications and Reoperation Rates

Purpose

Patients treated by external beam radiotherapy (EBRT) for localized carcinoma of the prostate (CAP) often suffer from urinary obstruction. While most patients can be treated medically, some require transurethral prostatectomy (TURP) for alleviation of obstruction. The consequences of combing EBRT and TURP are controversial. The objective of this study was to evaluate the success and complication rates of TURP combined with EBRT.

Patients and Methods

Between 2001 and 2017, 3501 patients underwent TURP. Sixty-six of them were treated with EBRT for CAP. Surgical complications according to the Clavien–Dindo (CD) scale and the need for secondary interventions were compared to 66 randomly selected patients operated on for benign prostatic hyperplasia (BPH).

Results

Patients who underwent TURP for BPH were significantly older compared to the patients with CAP with an average of 76.4 (SD 4.3) vs 71 (SD 8.2) years, p<0.0001. Substantial post-operative complications were rare in both groups with only a single case of CD grade 3 in each group. However, patients with CAP required significantly more secondary surgeries (21% vs 6%, p=0.02) and significantly more additional interventions (37.9% vs 13.6%, p=0.0025). There was no difference in complication rate, in the need for additional interventions or in the oncological outcome when comparing patients operated before or after EBRT.

Conclusion

The complication rate of TURP done before or after EBRT is low and comparable to surgery for BPH. However, the rates of secondary surgeries and additional interventions in these patients are high (40%). TURP before or after EBRT provides similar results.

The relationship of palliative transurethral resection of the prostate with disease progression in patients with prostate cancer

OBJECTIVES

To test, in a prostate-cancer population-based database, the validity of the finding that in single-institution series, palliative transurethral resection of prostate (TURP) is associated with an increased risk of progression.

PATIENTS AND METHODS

Using the Surveillance Epidemiology and END Results Registry, we identified men who had a TURP subsequent to their diagnosis of prostate cancer, from 1998 or 1999. The outcome of interest was disease progression, as defined by the initiation of androgen-deprivation therapy or procedures indicating progressive urinary obstruction. Multivariable logistic regression analysis was used to assess the adjusted odds of signal events related to disease progression adjusting for the concurrent effect of the covariates.

RESULTS

There were 29,361 men with prostate cancer and 2742 (9.3%) had a TURP after the diagnosis. These men had a mean age of 75 years and were unlikely to undergo definitive primary treatment. Men receiving TURP were more likely to undergo orchidectomy than men who did not have a TURP (odds ratio 1.64; 95% confidence interval 1.03-2.60) even after adjusting for differences in cancer-directed treatment, tumour stage and grade, prostate-specific antigen level, race, and age at diagnosis. These men were also more likely to have malignant urinary obstruction (ureteric and bladder outlet) than were men who did not have TURP.

CONCLUSION

The requirement for TURP is an adverse prognostic marker even when this is adjusted for classical tumour characteristics. Although the exact reasons for this finding are unclear, consideration should be given to adjuvant treatment in patients undergoing TURP.

Palliative transurethral resection of the prostate: functional outcome and impact on survival

OBJECTIVE

To assess the long-term functional and oncological outcome in a consecutive series of patients undergoing palliative transurethral resection of the prostate (pTURP).

PATIENTS AND METHODS

We retrospectively assessed all patients who had a pTURP between 1992 and 2004 at our institution. Patients with incidental prostate cancer (pT1a/pT1b) were excluded. In all, 89 patients (mean age 75.9 years, sd 0.9, at diagnosis) entered the study.

RESULTS

The median (range) prostate-specific antigen level at diagnosis was 25.7 (0.7-5000) ng/mL and the mean Gleason score was 7. The mean (sd, range) interval between the diagnosis of prostate cancer and pTURP was 1.5 (0.3, 0.5-10.9) years. The indications for pTURP were refractory urinary retention in 30%, severe bladder outlet obstruction with a postvoid residual urine volume of > 100 mL in 43%, and bladder stones, haematuria and hydronephrosis in 9% each. The mean (sd, range) follow-up after pTURP was 2.6 (0.2, 0.1-7.3) years. The peri-operative mortality (<30 days) was 2%, and 22 patients (25%) died during the follow-up. As estimated by Kaplan-Meier analysis, the 1-, 2- and 5-year survival rates were 83%, 70% and 61%, respectively. Patients with prostate cancer in the pTURP specimen had a shorter 3-year survival (52%) than those with a negative histology (89%, P = 0.03). At the last follow-up, 79% of men voided spontaneously and were continent. A repeat pTURP was necessary in 25% of patients, 11% required permanent catheterization and 10% were incontinent.

CONCLUSION

Despite greater peri-operative mortality and morbidity than conventional TURP, pTURP is a fairly safe and effective procedure. Although a potential negative impact of pTURP on survival cannot be excluded, the estimated 5-year survival of 61% in this series seems to justify this intervention.

Predicting the outcome of radiotherapy for prostate carcinoma: a model-building strategy

BACKGROUND

Clinical research of prostate carcinoma could be enhanced by models that allow early and reliable prediction of outcome. In this study, the authors describe a model-building strategy and compare different models.

METHODS

The sample population was comprised of 158 patients treated definitively with radiotherapy. Univariate and multivariate logistic regression analyses were conducted to identify prognostic factors and select the best predictive model. Variables included age, race, method of diagnosis (needle biopsy vs. transurethral resection of the prostate), stage, grade, pretreatment prostate specific antigen (PSA), in-treatment PSA (PSA(tx)), posttreatment PSA (PSA(post)), and nadir PSA. The following indices were used to compare discriminatory power: log-likelihood function, Akaike information criterion, the generalized coefficient of determination, and the area under the receiver operating characteristic curve.

RESULTS

At last follow-up, 49 patients (31%) had recurrence of carcinoma. By univariate analysis, the failure rate was significantly higher in patients with advanced stage, higher grade, higher pretherapy PSA, and nadir PSA > 1 ng/mL (P < 0.0001). Pretherapy PSA was associated significantly with stage, age, and nadir PSA (P = 0.001, P = 0.001, and P = 0.001, respectively). All PSA measurements were significantly interrelated. Nadir PSA was the most predictive variable. Significant gains (P = 0.01) in predictive power were derived from inclusion of PSA(tx), but not PSA (post). Age, race, stage, grade, and method of diagnosis contributed predictive power in addition to that derived from PSA levels (P = 0.01, log-likelihood test). The authors' model of choice predicts outcome with an overall correctness, sensitivity, specificity, and false-negative rate of 81.8%, 87.2%, 79.6%, and 12.8%, respectively.

CONCLUSIONS

Applying the strategy described, a model was selected that allowed accurate prediction of failure shortly after the completion of therapy.

Prognostic impact of transurethral resection on patients irradiated for localized prostate cancer

The prognosis for irradiated patients with localized prostatic carcinoma following transurethral resection of the prostate (TURP) has been debated. Controversy centers upon whether or not TURP has an adverse effect on the outcome. A retrospective analysis of 264 patients treated during 1974-1991 with radical external beam radiotherapy was performed. Ten patients who were irradiated postoperatively were excluded. One hundred and nine patients with urinary obstruction underwent TURP. In another 155 patients, pathological diagnosis was made by needle aspiration or tru-cut biopsies. One hundred and one patients received endocrine manipulation, 58 (40%) in the needle biopsy group, and 43 (39.5%) in the TURP group. Lymph node staging by pelvic lymphadenectomy (20 cases), lymphangiography (15 cases), and CAT and/or NMR (113 cases) was performed in 148 patients. Nodal metastases were found in 38 patients, 19 in the needle biopsy group, and 19 in the TURP group. Disease-related, disease-free and metastasis-free survivals were calculated for all stages and within each tumor stage and histological grade for both groups. Correlation of pretreatment factors with clinical outcome was evaluated by multivariate analysis. Overall, disease-related survival was significantly higher (P = 0.05) in patients undergoing needle biopsy than in those who had TURP (58% vs. 38% at 10 years). This difference was more significant in the subset of patients with well differentiated tumors (P < 0.01). However, no difference could be observed between the two groups in histological grade 2 and 3 tumors or by stage comparison.(ABSTRACT TRUNCATED AT 250 WORDS)