UroToday - AUA 2008 - Society of Urologic Oncology Meeting - Whitmore Lecture: Radical Prostatectomy - Where We Were and Where We are Going

[Guest guest]

Sunday, 18 May 2008

ORLANDO, FL

(UroToday.com) - Dr. Walsh presented the Whitmore Lecture. He discussed the

past history of radical prostatectomy (RP). The first RP was performed in 1904

in a perineal approach. The retropubic operation was introduced in 1947. During

the Whitmore era, many men did not need to be cured, as they had more

comorbidities and died of other causes. Presently, cancer is the leading cause

of death in the US.

In Whitmore's era, cure was often not possible due to advanced disease and

complications for lower risk disease were too high.

In the

present era, anatomy, surgical technique and quality of life have made

significant advances. The dorsal vein complex was not charted and resulted in

bleed, the sphincter and neurovascular anatomy was not understood and resulted

in incontinence and impotence. With advances in these areas, surgery increased

form 7-15% in 1983 up to 70% 15 years later. Men under the age of 65 had a

significant cancer specific survival benefit compared to watchful waiting in a

Scandinavian study. It also reduced the number of patients with metastasis and

compounded, there will be a potential 30% decrease. He addressed the issue of

robotic RP and that time to full recovery is relatively similar. He discussed

the veil of Aphrodite and whether its release resulted in improved potency.

Early release of the levator fascia during open RP results in better potency

according to his data at this meeting. SHIM scores were significantly better at

one year with this approach, increasing from 77% to 93%. The major impact is on

less traction on the neurovascular bundle.

Dr. Walsh

stated that more accurate imaging of tumor within the prostate and molecular

markers would be more important than nomograms. Regarding positive surgical

margins, extensive positive margins go down but focal positive margins remain

unchanged according to data he showed. His positive surgical margin rate is

1.8%, compared to 23% for open RPs in recently published data. This is due to

experience, and for this there is no substitute.

Regarding

QOL, a cohort study comparing RP to radiotherapy and brachytherapy was recently

in the NEJM. He applauded this type of study, as randomized treatment trials

for localized prostate cancer have not succeeded. He pointed out the inadequate

definitions used to evaluate success in patients undergoing radiotherapy.

Objective, comparable criteria are needed. For focal therapies, he stated that

they should be judged by the same biochemical freedom from disease criteria. He

cited the ASCO guidelines on hormonal therapy that stated that there is a

15-17% cancer specific survival, but is no overall survival benefit.

The

challenges of the future include accurate imaging, cohort studies, and adjuvant

trials for those men who are not cured by surgery alone.

Presented

by Walsh, MD, at the Annual

Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County

Convention Center - Orlando, Florida, USA.