Risk of complications and urinary incontinence following cytoreductive prostatectomy: a multi-institutional study

A systematic review of cytoreductive prostatectomy outcomes and complications in oligometastatic disease

Objective

To analyze outcomes and complications of cytoreductive prostatectomy (CRP) for oligometastatic prostate cancer (PCa) in order to elucidate its role in this space.

Methods

We performed a systematic literature search using three databases (Medline, Scopus, and Web of Science). The primary endpoints were oncologic outcomes. The secondary endpoints were complication rates and functional results.

Results

In all studies, overall survival was better or at least comparable variable in the groups with CRP compared to no local treatment. The greatest benefit from CRP in 5-year overall survival in one study was 67.4% for CRP versus 22.5% for no local treatment. Cancer-specific survival (CSS) showed the same trend. Several authors found significant benefits from CSS in the CRP group: from 79% vs. 46% to 100% vs. 61%. CRP was a predictor of better CSS (hazard ratio 0.264, p=0.004). Positive surgical margin rates differed widely from 28.6% to 100.0%. Urinary continence in CRP versus RP for localized PCa was significantly lower (57.4% vs. 90.8%, p<0.0001). Severe incontinence occurred seldom (2.5%-18.6%). Total complication rates after CRP differed widely, from 7.0% to 43.6%. Rates of grades 1 and 2 events prevailed. Patients on ADT alone also showed a considerable number of complications varying from 5.9% to 57.7%.

Conclusion

CRP improves medium-term cancer control in patients with oligometastatic PCa. The morbidity and complication rates of this surgery are comparable with other approaches, but postoperative incontinence rate is higher compared with RP for localized disease.

Current Controversy and Developments Regarding the Cytoreductive Prostatectomy for Oligometastatic Prostate Cancer

Oligometastatic prostate cancer is a term that is most often used to refer to limited sites of disseminated tumor growth following primary radical prostatectomy (RP) or radiotherapy (RT), while de novo oligometastatic is a term that is used to refer to prostate tumors that have disseminated to limited sites before definitive treatment. In patients with de novo oligometastatic prostate cancer, treatment planning must thus consider the need to manage the primary tumor and the associated distant lesions. Traditionally, resectioning primary metastatic tumors is not thought to offer significant benefits to affected patients while increasing their risk of surgery-related complications. Recent clinical evidence indicates that patients undergoing cytoreductive prostatectomy (CRP) may observe substantial enhancements in overall survival rates while not experiencing a noticeable decline in their quality of life. Nevertheless, based on the current body of evidence, it is deemed inadequate to justify revising clinical guidelines. Consequently, it is not advisable to propose CRP for patients with oligometastatic prostate cancer. The present review was compiled to summarize available data regarding the indications, functional outcomes, and oncological outcomes associated with cytoreductive radical prostatectomy to provide a robust and objective foundation that can be used to better assess the value of this interventional strategy from a clinical perspective.

Influence of a continuous nursing model based on network cloud platforms for urinary control, urination function and quality of life of patients after radical prostatectomy

OBJECTIVE

To investigate the effect of a continuous nursing mode on urinary control, urinary function and quality of life of patients after radical prostatectomy under the network cloud platform.

METHOD

A total of 100 prostate cancer patients admitted to our hospital from January 2017 to January 2019 were enrolled. According to different care modes, they were divided into the experimental group and the control group, 50 patients in each group. Patients in the experimental group received the continuous care model under the network cloud platform, and the control group patients received the conventional care model. Urinary control, urination, self-care ability, incidence of complications, quality of life and nursing satisfaction of the two groups were compared.

RESULTS

In terms of urination, urinary control, quality of life, self-care ability, the incidence of complications and nursing satisfaction, the experimental group was better than the control group (P<0.05).

CONCLUSION

The continuous nursing model under the network cloud platform has a positive impact on patient's urinary control, urination function and quality of life after radical prostatectomy. It is worthy of being widely promoted and used in clinical treatment.

Oncological Outcome of Combining Cytoreductive Prostatectomy and Metastasis-Directed Radiotherapy in Patients with Prostate Cancer and Bone Oligometastases: A Retrospective Cohort Study

Background

The current standard of care for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without anti-androgen and chemotherapy. The aim of this study was to evaluate the efficacy and safety of a multimodal approach including local primary tumor therapy, metastasis-directed therapy (MDT), and hormonal therapy in patients with oligometastatic prostate cancer (PCa).

Methods

We reviewed data of patients with PCa and bone oligometastases at diagnosis treated in three institutions with ADT followed by cytoreductive surgery with or without metastases-directed radiotherapy. Oligometastases were defined as the presence of five or fewer metastatic lesions with the absence of visceral metastases. In this retrospective cohort study, 58 patients underwent cytoreductive radical prostatectomy and ADT. Of these, 26 patients (45%) received stereotactic body radiation therapy (SBRT) to all metastatic sites as a MDT. Oncological outcomes were analyzed using the Kaplan–Meier method.

Results

The median follow-up period was 46.2 months. Of the 58 patients, the 3-year castration-resistant prostate cancer (CRPC)-free survival and cancer-specific survival was 75.9% and 91.4%, respectively. Pre- or post-treatment predictive factors for progression to CRPC, including prostate-specific antigen (PSA) level at diagnosis ≥20 ng/mL, Gleason grade groups 5, clinical T stage cT3b-4, PSA nadir level of ≥0.05 ng/mL, and no MDT with SBRT, were significantly associated with progression to CRPC. Subgroup analysis showed that the MDT group had significantly better CRPC-free survival than the non-MDT group with Gleason grade groups 1–4 (HR=0.228; 95% CI= 0.056–0.926). A total of 3.4% of the patients had grade 2 acute genitourinary toxicities and 5.2% had grade 2 acute gastrointestinal toxicities. No late grade >2 adverse events were observed.

Conclusion

This multi-center, retrospective cohort study revealed the feasibility of combining cytoreductive prostatectomy and metastasis-directed radiotherapy for newly-diagnosed oligometastatic PCa. This treatment strategy has the potential to delay the progression to CRPC.

Oncological Outcome of Cytoreductive Radical Prostatectomy in Prostate Cancer Patients With Bone Oligometastases

OBJECTIVE

To explore the role of cytoreductive radical prostatectomy (CRP) for locally resectable and distant oligometastatic prostate cancer (CaP).

PATIENTS AND METHODS

Oligometastases were defined as the presence of 5 or fewer metastatic lesions detected on 99mTc bone scan and no suspicious visceral involvement at pretreatment imaging. Clinical data on 111 consecutive patients who were diagnosed as oligometastatic CaP in our center from 2005 to 2016 was retrospectively collected. In this retrospective cohort study, 35 patients underwent CRP and androgen deprivation therapy, and 76 patients underwent androgen deprivation therapy alone. Oncological outcomes were analyzed by employing Kaplan-Meier method.

RESULTS

The median follow-up of both groups was 35 months. In whole cohort analyses, prostate-specific antigen (PSA) decrease velocity (P = .167), PSA half-time (P = .263), and PSA nadir (P = .196) were not significantly different between 2 groups. Meanwhile, the differences in oncological outcomes between 2 groups did not reach statistical significance with regard to PSA relapse-free survival (P = .184), clinical progression-free survival (P = .118), and cancer-specific survival (P = .773). In addition, similar results were also observed in prespecified subgroup analyses (lower PSA group [0-100 ng/mL, P = .543], lower Gleason score group [6-7, P = .266], lower clinical T stage group [2-3 stage, P = .962], lower radiological N stage group [0 stage, P = .364]).

CONCLUSION

In our study, significant benefit from CRP has not been detected in patients with oligometastatic CaP. Facing current trend, it demands deliberate consideration to select candidates for cytoreductive surgery, and the selection criteria should be further refined by incorporating additional prognostic factors.

Results of Phase 1 study on cytoreductive radical prostatectomy in men with newly diagnosed metastatic prostate cancer

Background

Preclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery.

Methods

From four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery.

Results

The mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm.

Conclusion

Therefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available.

Cytoreductive Radical Prostatectomy in Men with Prostate Cancer and Skeletal Metastases

BACKGROUND

Androgen deprivation therapy (ADT) represents the standard treatment for hormone-naïve prostate cancer with systemic metastases (mPCA). The role of radical prostatectomy (RP) in this setting is unclear.

OBJECTIVE

To evaluate the oncological and functional outcomes of men with mPCA who underwent cytoreductive RP (CRP).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, multi-institutional study of 113 patients with biopsy-proven mPCA who fulfilled the following selection criteria: (1) completely resectable PCA; (2) osseous metastases; (3) absence of gross retroperitoneal lymph node metastases; (4) absence of bulky pelvic lymph node metastases >3cm; (5) no or minimal visceral metastases; (6) Eastern Cooperative Oncology Group performance status of 0-1; and (7) written informed consent.

INTERVENTION

CRP with extended pelvic lymphadenectomy. Eighty patients (70.8%) received neoadjuvant ADT and 91 (86.5%) adjuvant ADT and/or radiation therapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cancer-specific survival, overall survival (OS), biochemical relapse-free survival (BRFS), and clinical relapse-free survival (CRFS) were evaluated using descriptive statistical analyses, the Kaplan-Meier method, and univariate and multivariate analyses. Treatment-associated complications were analysed according to the Clavien-Dindo classification.

RESULTS AND LIMITATIONS

The mean patient age was 61 yr (range 42-69). The mean follow-up was 53.6 mo (range 13-96, median 45.7). The 3-yr and 5-yr OS was 99 (87.6%) and 90 (79.6%), respectively, and the mean CRFS was 72.3 mo. Preoperative prostate-specific antigen (PSA)<1.0ng/ml and PSA below the median of 8.0ng/ml were significantly associated with BRFS (p<0.0004). Pathohistology revealed viable PCA in all cases: 16 (14.2%) had pT4a, 21 (18.6%) had pT2a-c, and 76 (67.3%) had pT3a/b PCA. Positive lymph nodes were identified in 61.6% and positive surgical margins in 36.8% of the patients. Eleven men (9.7%) experienced Clavien Dindo grade IIIa-b complications. Low-volume disease, neoadjuvant ADT, and preoperative PSA were significantly associated with a lower risk of surgery-related complications (p<0.05). No, mild (1-2 pads/d), and severe incontinence (>2 pads/d) was observed in 68.1%, 17.7%, and 14.1%, respectively. Limitations of the study are the retrospective nature and potential patient selection bias.

CONCLUSIONS

CRP results in 5-yr OS of 80%, a low rate of significant complications, and good functional outcome in well-selected patients. CRP might be an individualised treatment option in the multimodal management of mPCA.

PATIENT SUMMARY

We assessed oncological and functional outcomes associated with cytoreductive radical prostatectomy (CRP) in select men with prostate cancer and osseous metastases. We found that CRP might be associated with long overall and relapse-free survival in well-selected patients. CRP could become an additional treatment option in the multimodal therapy of metastatic prostate cancer; it should be performed in a clinical protocol setting and does not represent a standard therapeutic option.

Radical Prostatectomy in Metastatic Castration-resistant Prostate Cancer: Feasibility, Safety, and Quality of Life Outcomes

Ongoing prospective studies are evaluating treatment of the primary tumor in men with de novo metastatic prostate cancer (PCa). One potential benefit is prevention of morbidity from local progression. Thus, local therapy may be best applied selectively to men with local progression once resistance to first-line therapies has occurred. Here, we gather support for the hypothesis that radical prostatectomy (RP) is safe and preserves quality of life (QOL) when applied in men with metastatic castration-resistant PCa (mCRPC). We analyzed 14 patients who underwent RP in the setting of mCRPC from 2008 to 2016. Median time from mCRPC to RP was 5.1 mo (interquartile range [IQR] 1.4-12.0). Median preoperative and <3 mo postoperative Expanded Prostate Cancer Index Composite urinary function QOL scores were 84 (IQR 70-95) and 78 (IQR 62-81), respectively. There were one Clavien Grade III, three Grade II, and one Grade I complications postoperatively. In these patients with mCRPC, RP was feasible with limited minor complications.

PATIENT SUMMARY

We report on a select group of men with metastatic castration-resistant prostate cancer who had prostatectomy. Prostatectomy is highly investigational in this setting and should not be used outside of a clinical trial other than for symptom relief.