5-year outcomes of patients treated with RALP at a high-volume, specialty center

There has been much discussion of whether surgical outcomes following robot-assisted laparoscopic prostatectomy (RALP) are comparable to those observed after open surgery. The 5-year outcome data from the Vattikuti Urology Institute at Henry Ford Hospital in Detroit may help us to make such a determination.

Menon et al. have published data from their cohort of 1,384 consecutive patients with localized prostate cancer who were treated using RALP between September 2001 and May 2005. The full text of this article is available on line. No patient received any type of second-line treatment until biochemical recurrence was clearly documented, and biochemical recurrence in these patients was defined as a two serum PSA levels ≥ 0.2 ng/ml.

The top-line data from this patient cohort are reported as follows:

  • Overall, these patients had moderately aggressive, localized forms of prostate cancer.
    • 49.0 percent had D’Amico intermediate- or high-risk disease at the time of biopsy.
    • 60.9 percent had a Gleason score of 7 or higher.
    • 25.5 percent had pathologic T3 disease based on post-surgical pathology.
  • Median follow-up was 60.2 months (interquartile range, 37.2 to 69.7 months).
  • Biochemical recurrence occurred in 189/1,384 patients (13.7 percent).
  • Median time to biochemical recurrence was 20.4 months.
  • 65 percent of biochemical recurrences occurred within 3 years.
  • 86.2 percent of biochemical recurrences occurred within 5 years.
  • Actuarial biochemical recurrence-free survival was 
    • 95.1 percent at 1 year
    • 90.6 percent at 3 years
    • 86.6 percent at 5 years
    • 81.0 percent at 7 years
  • The strongest predictors of biochemical recurrence were
    • A pathologic Gleason grade of 8-10 (hazard ratio [HR] = 5.37)
    • A pathologic stage of T3b/T4 (HR = 2.71)

The authors conclude that, in this contemporary cohort of patients with localized prostate cancer, RALP “confers effective 5-yr biochemical control” of the patients’ disease. A media release from Henry Ford Hospital is also available.

As is widely appreciated, 5-year outcome data after treatment of localized prostate cancer is interesting, but 10-year follow-up data are usually considered to be more accurate, and patients may continue to demonstrate recurrence for 15 years and more. These data from Menon and his colleagues are therefore helpful in understanding the long-term outcomes after RALP, but longer-term data will be needed.

It is informative to note the relatively high risk of the patients in this cohort. The full published version of this paper includes outcomes over time broken out by D’Amico risk categories (see Figure 2) and by Gleason score for patients with organ-confined and non-organ-confined status (see Figure 3). Clearly, these risk factors have a significant impact on biochemical recurrence over time. For example, about half of the patients with non-organ-confined disease and a Gleason score of 8 or higher had biochemical recurrence within 2 years and about 75 percent of these patients had biochemical recurrence at 5 years. It would have been interesting to know how well these 5-year outcomes correlated with those predicted by the Kattan nomograms (which were developed on the basis of open surgical data).

4 Responses

  1. It would be nice to have also a report on the side effects (quality of life) results.

    We had two new members coming to our support group. Both received recommendations for surgery from their doctors and both are concerned about possible side effects. As one guy put it: “being dead from the belt downwards.”

    Is there any new study that provides information based on a large population sample that would have strong statistical validity?

  2. Reuven:

    I am not aware of a comparable 1,000+ patient QoL study that has followed patients for 3 to 5 years.

    There was a study by Patel et al. reported in 2007 that encompassed 500 patients and that incuded data for up to 18 months on incontinence and erectile function post-surgery. At the end of the day, however, the skill of the surgeon is the defining factor, not whether the procedure is open or robot-assisted.

  3. One of the interesting things I noticed about this study is that the mean age was 60 (+/- 7.1) years. This is one of the youngest mean ages I have seen in a study.

    I am also not understanding the graph when it says “the number at risk” on the x-axis. The numbers get smaller as time goes on. Does this mean that fewer people were at risk for BCR as time goes on? If so, why is this? If the risk never goes to zero I would think that everyone is at risk for as long as they are alive.

  4. Chris:

    The reason that the “number at risk” declines with time is that this is the time for which individual have been followed since their surgery. The smallest numbers of patients (on the right) represent those who were treated earliest in the study and have therefore been followed for the longest period of time. Conversely, the largest numbers of patients appear at the left-hand end of this axis because all the patients were followed for at least a brief period of time.

    My suspicion as to why the average age of the patients is so low is simply that it was younger patients who were those most willing to be “guinea pigs” for robot-assisted surgery early on.

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