RADICAL PROSTATECTOMY AND LYMPHADENECTOMY IN CLINICALLY LOCALLY ADVANCED

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RADICAL PROSTATECTOMY AND LYMPHADENECTOMY IN CLINICALLY LOCALLY ADVANCED PROSTATE CANCER PATIENTS Professor Guram Karazanashvili

RADICAL PROSTATECTOMY AND LYMPHADENECTOMY IN CLINICALLY LOCALLY ADVANCED PROSTATE CANCER PATIENTS Professor Guram Karazanashvili MD, KMSc, DMSc MMT Hospital

When diagnosis of clinically locally advanced prostate cancer is established, patient selection and preparation

When diagnosis of clinically locally advanced prostate cancer is established, patient selection and preparation for the surgery is critically important

Patient examination • Experienced surgeon does DRE and TRUS • DRE and TRUS are

Patient examination • Experienced surgeon does DRE and TRUS • DRE and TRUS are essential for estimation of resectability: Prostate consistence Prostate apex Lateral margins Adherence to rectum Seminal vesicles

Patient consultation • How looks the patient? • How motivated is he? • Has

Patient consultation • How looks the patient? • How motivated is he? • Has the patient voiding problems? • Take a time to explain the patient: -Different treatment modalities in context of quality of life and effectiveness -Necessity in adjuvant treatments -Speak with patient together with close relatives -Give patient a time for consideration

Patient selection Good performance status 10 year survival should be expected Patient motivated for

Patient selection Good performance status 10 year survival should be expected Patient motivated for aggressive cancer management Patients ready for increased risk of incontinence and impotence

Preoperative evaluation and preparation • Standardized preparation of patients for the surgery reduces the

Preoperative evaluation and preparation • Standardized preparation of patients for the surgery reduces the risks of intra and postoperative complications • Special team is advisable for routine preoperative check up: Cardiologists, Anesthesiologist and urologist • Send the patient for coronarography in any doubtful case • Coronary stenting or bypass before surgery reduces the risks • Hospitalization 1 day before the surgery • Bowel preparation is needed, especially in locally advanced cases • Anticoagulants night before surgery • Gloves before surgery

Patients Surgery from 2011 to 2014, by single surgeon 48 Patients with clinically locally

Patients Surgery from 2011 to 2014, by single surgeon 48 Patients with clinically locally advanced Prostate cancer were selected for the surgery T 3 a - 21 patients T 3 b – 17 patients T 4 – 8 patients

Patients • DRE detected extra capsular spread • Extra capsular spread was confirmed by

Patients • DRE detected extra capsular spread • Extra capsular spread was confirmed by TRUS, CT/MRI • No balky lymph nodes by CT/MRI • Bone scan was negative • Patient age: 50 -60 years – 6 cases 60 -70 years – 21 cases 70 -75 years – 19 cases

Preoperative data PSA < 30 ng/ml Gl. 5 -6 12 cases Gl. 7 (3+4)

Preoperative data PSA < 30 ng/ml Gl. 5 -6 12 cases Gl. 7 (3+4) 5 cases Gl. 7 (4+3) 16 cases Gl. 8 6 cases Gl. 9 3 cases

Tipe of Surgery • Radical prostatectomy with extended lymphadenectomy (along internal and external iliac

Tipe of Surgery • Radical prostatectomy with extended lymphadenectomy (along internal and external iliac vessels) – 38 cases • Radical prostatectomy with bladder neck wide excision, and extended lymphadenectomy (along internal and external iliac vessels) – 4 cases • Radical cystoprostatectomy, extended lymphadenectomy, sigma-rectum pouch – 1 case • Radical cystoprostatectomy, extended lymphadenectomy, ileal conduit (Briker’s operation) - 3 cases • Monolateral or bilateral Nerve sparing – 24 cases

Surgical margins were positive in 15 (of 46) patients: Apex 3 cases Neurovascular bundle

Surgical margins were positive in 15 (of 46) patients: Apex 3 cases Neurovascular bundle 1 case Bladder neck 7 case Other locations 4 case Relatively high incidence of positive margins at bladder neck was determined by preoperative downstaging and absence of macroscopic alterations intraoperatively

Stage migration • Preoperative T stage migration occurred in 39% of cases: Downstaging 14

Stage migration • Preoperative T stage migration occurred in 39% of cases: Downstaging 14 cases Overstaging 5 cases • Preoperative N stage migration occurred in 43% of cases: Downstaging 20 cases

Stage migration • In 7 (of 12) downstaged men local spread reached T 4

Stage migration • In 7 (of 12) downstaged men local spread reached T 4 stage. These men need wide excision of bladder neck, beyond macroscopic alterations. • 3 (of 5) T overstaged cases were node free. Thus surgery was curative • 20 N downstaged men might benefit from lymphadenectomy

PSA > 0. 2 ng/ml at 3 monthes N+ and positive surgical margins 5

PSA > 0. 2 ng/ml at 3 monthes N+ and positive surgical margins 5 cases N+ 4 cases Positive surgical margins 2 cases N- and negative surgical margins 2 cases Overall in 28% of cases PSA>0. 2 ng/ml at 3 months, most of these patients are N+. Only 7 (of 15) patients with positive surgical margins had PSA nadir above 0. 2 ng/ml. Thus despite residual tumor, prognosis can be favorable

Adjuvant therapies Antiandrogens 4 cases Medical or surgical castration 4 cases Radiation therapy+medical castration

Adjuvant therapies Antiandrogens 4 cases Medical or surgical castration 4 cases Radiation therapy+medical castration 3 cases No adjuvant therapies 35 cases

76% of patients with clinically locally advanced cases have got no adjuvant therapies!

76% of patients with clinically locally advanced cases have got no adjuvant therapies!

Bone metastasis Currently 0 (of 46) patients have bone metastasis after surgery for clinically

Bone metastasis Currently 0 (of 46) patients have bone metastasis after surgery for clinically locally advanced prostate cancer

Incontinence • At 3 monthes: Total incontinence Stress incontinence Continent • Currently: Total incontinence

Incontinence • At 3 monthes: Total incontinence Stress incontinence Continent • Currently: Total incontinence Stress incontinence Continent 0 of (42) cases 12 (of 42) cases 30 (of 42) cases 4 (of 42) cases 38 (of 42) cases

Conclusions Radical surgery is feasible in men with clinically locally advanced prostate cancer and

Conclusions Radical surgery is feasible in men with clinically locally advanced prostate cancer and should be applied in selected patients Significant number of patients can be saved from adjuvant therapies Surgical excision has potential to delay development of bone metastasis Functional outcomes are excellent

Conclusions • Node status downstaging, is common in cases of clinically locally advance prostate

Conclusions • Node status downstaging, is common in cases of clinically locally advance prostate cancer patients • Extended lymphadenectomy is recommended in all cases, this might have therapeutic results • Bladder neck invasion is not rare, wide excision of bladder neck is recommended, even in case of absence of macroscopic alterations