Different types of surgery for high-risk disease … outcomes at Johns Hopkins

In the context of the current question about “problems” with the da Vinci robot (previously addressed today), we have some new data from Johns Hopkins on the outcomes of men with high-risk, localized prostate cancer, treated using open, retropubic (ORP), non-robot-assisted laparoscopic (LRP), and robot-assisted laparoscopic (RALP) forms of radical prostatectomy.

Now Johns Hopkins was not exactly an enthusiastic “early adopter” of either LRP or RALP. However, in a paper available on line in European Urology, Pierorazio et al. offer data suggesting that “open and minimally-invasive radical prostatectomy offer equivalent short-term outcomes for men with high-risk prostate cancer” at a highly experienced center.

In coming to this conclusion, the authors looked at the pathological and short-term oncological outcomes data from in men undergoing open (ORP) and minimally invasive forms (LRP/RALP) of radical prostatectomy for high-risk disease at Johns Hopkins between 2002 and 2011. The authors defined high-risk as meaning that the patient must have had any one (or more) of the following criteria at diagnosis: a PSA level > 20 ng/ml, a clinical stage ≥ T2c, a Gleason score of 8-10. In other words, these are patients who meet the D’Amico criteria for high risk.

Here is what the authors report:

  • 913 patients met the study eligibility criteria.
  • 743/913 (81.4 percent) were treated by ORP.
  • 170/913 (18.6 percent) were treated by one of the two forms of minimally invasive forms of surgery (LRP/RALP)
    • 65/913 (7.1 percent) were treated by LRP.
    • 105/913 (11.5 percent) were treated by RALP.
  • Age, race, body mass index (BMI), preoperative PSA level, clinical stage, number of positive cores, and Gleason score at final pathology were similar between ORRP and LRP/RALP.
  • On average, men undergoing LRP/RALP had smaller prostates and more organ-confined (pT2) disease (P = 0.02).
  • The number of surgeons and surgeon experience were greatest for the ORRP cohort.
  • Postoperative surgical margin rates were:
    • 29.4 percent for all men treated with ORP
    • 27.7 percent for all men treated with LRP
    • 34.3 percent for all men treated with RALP
    • 1.9 percent for men with pT2 disease treated with ORP
    • 6.2 percent for men with pT2 disease treated with LRP
    • 2.9 percent for men with pT2 disease treated with RALP
    • None of these differences is statistically significant.
  • At a median 3 years of follow-up, rates of biochemical recurrence-free survival were:
    • 56.3 percent for all men treated with ORP
    • 41.1 percent for all men treated with LRP
    • 67.8 percent for all men treated with RALP
    • Again, none of these differences was statistically significant.
    • The technical approach employed did not predict biochemical recurrence.

Now even though Johns Hopkins may not have been an enthusiastic “early adopter” of minimally invasive way to carry out a radical prostatectomy (in any type of surgical candidate for prostate cancer), the one thing that we can be pretty certain about is that when they did adopt such methods, they would have been carried out at the highest possible standards. (Johns Hopkins has a reputation for excellence that they would want to protect at all costs!) The “New” Prostate Cancer InfoLink therefore finds the above data to be of some relevance to the debate about the relative merits of ORP, LRP, and RALP.

5 Responses

  1. Given that the “curative” results were about the same, what about continence and sexual function?

  2. As if those of us who have had prostate cancer don’t already have enough to worry about. … It would be nice for once if the information we have would remain constant over time instead of changing over and over again. Sorry, I’ll go have a little cheese with my whine. Oh wait, cheese is bad for you. …

  3. Doug: I can only tell you what the studies tell me! :O)

    Gary: If you think the pace of change is fast now, just wait another 20 years … or add some serious liquor to the whine! :O)

  4. Thanks for the info. Every little bit helps. I’m at treatment 29 of 39 here at M. D. Anderson. I’m becoming the de-facto, go-to guy in my social circle on prostate cancer. Good to know this.

  5. This shows that if you have high-risk, organ-confined prostate cancer, you should be making sure your prospective surgeon has a similarly low 2.9% rate of positive margins. In my opinion, this is one of the most important questions you can ask when shopping for the best urologist. Good luck on finding one this good.

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