1. Prostate Cancer Local treatment: Surgery Prof. Dr. med. Tullio SulserDivision of UrologyUniversity Hospital ZürichSwitzerland

2. Radical Prostatectomy: History 1867

3. Radical Prostatectomy: History Christian Albert Theodor Billroth (1829-1894)

4. Radical Prostatectomy: History Carcinom der Prostata sah ich überhaupt nur 2 Mal. Der eine Fall ist im Züricher Bericht beschrieben; ich wagte die Sectiolateralis zu machen und das Carcinom auszukratzen. Pat. überstand die Operation, die Wunde heilte; er ging 1 2/12 Jahre nach der Operation an Recidiv zu Grunde. – Einen gleichen Fall sah ich hier in Wien auf meiner Klinik im Jahre 1873 bei einem 56jährigen Mann. Die Sache lief aber nicht so gut ab; der Operierte starb am 4. Tag an retroperitonealer septischer Phlegmone.

6. Radical Prostatectomy: Why? Low-risk: cT1-T2a, Gleason score 2-6, PSA < 10 T1a: - 50% disease progression after 10-13y1 T1b: - Significantly higher disease progression after 5y1 T1c: - 30% locally advanced2 - 11-16% insignificant3, 4  Active surveillance T2a: - Disease progression after 5y: 35-55% 1. Lowe BA et al. J Urol 1988 Dec;140(6):1340-4. 2. Elgamal AA, et al. J Urol 1997 Jan;157(1):244-50. 3. Oesterling JE, et al. Urol Clin North Am 1993 Nov;20(4):687-93 4. Epstein JI, et al. J Urol 1994 Nov;152(5 Pt 2):1721-9.

7. Radical Prostatectomy: Why? Low-risk: cT1-T2a, Gleason score 2-6, PSA < 10 T1a: - 50% disease progression after 10-13y1 T1b: - Significantly higher disease progression after 5y1 T1c: - 30% locally advanced2 - 11-16% insignificant3, 4  Active surveillance T2a: - Disease progression after 5y: 35-55% 1. Lowe BA et al. J Urol 1988 Dec;140(6):1340-4. 2. Elgamal AA, et al. J Urol 1997 Jan;157(1):244-50. 3. Oesterling JE, et al. Urol Clin North Am 1993 Nov;20(4):687-93 4. Epstein JI, et al. J Urol 1994 Nov;152(5 Pt 2):1721-9.

8. Radical Prostatectomy: Why? 5 /10 year BCR-free survival: 92 % / 87% No difference between T1a and T1b Predictors for BCR - PSA after BPH surgery - BPH specimen Gleason score PSA < 1 after BPH surgery and Gleason score < 6:  low risk of BCR after RPVE

9. Radical Prostatectomy: Why? Low-risk: cT1-T2a, Gleason score 2-6, PSA < 10 T1a: - 50% disease progression after 10-13y1 T1b: - Significantly higher disease progression after 5y1 T1c: - 30% locally advanced2 - 11-16% insignificant3, 4  Active surveillance T2a: - Disease progression after 5y: 35-55% 1. Lowe BA et al. J Urol 1988 Dec;140(6):1340-4. 2. Elgamal AA, et al. J Urol 1997 Jan;157(1):244-50. 3. Oesterling JE, et al. Urol Clin North Am 1993 Nov;20(4):687-93 4. Epstein JI, et al. J Urol 1994 Nov;152(5 Pt 2):1721-9.

10. Radical Prostatectomy: Why? Low-risk: cT1-T2a, Gleason score 2-6, PSA < 10 T1a: - 50% disease progression after 10-13y1 T1b: - Significantly higher disease progression after 5y1 T1c: - 30% locally advanced2 - 11-16% insignificant3, 4  Active surveillance T2a: - Disease progression after 5y: 35-55% 1. Lowe BA et al. J Urol 1988 Dec;140(6):1340-4. 2. Elgamal AA, et al. J Urol 1997 Jan;157(1):244-50. 3. Oesterling JE, et al. Urol Clin North Am 1993 Nov;20(4):687-93 4. Epstein JI, et al. J Urol 1994 Nov;152(5 Pt 2):1721-9.

11. Radical Prostatectomy: Why? Intermediate-risk - cT2b-c or Gleason score = 7 or PSA 10-20 T2: Time to progression: 6-10y1 T2b: Disease progression after 5y: >70%2 Bill-Axelson A. J Natl Cancer Inst 2008 Aug;100(16):1144-54. 1. Johansson JE, et al. Acta Oncol 1991;30(2):221-3. 2. Graversen PH, et al. Urology 1990 Dec;36(6):493-8.

12. Radical Prostatectomy: Why? Oncological results of low- and Intermediate-risk PCA

13. Radical Prostatectomy: Why?

14. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 Still 20-35% of all Patients Role of RP controverisial RT + ADT has been proven to be superior to RT alone1 RT + ADT has not been proven to be superior to: RP + adj. RT RP alone 1. Bolla M, et al. Lancet 2002 Jul:360(9327):103-6.

15. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 High risk patients: - Extracapsular extension: 35-71 % - Seminal vesicle invasion: 10-33 % - Lymph node metastasis: 7-23 % - PSA relapse 1,8 - 4,8-fold However: - Organ confined: 22-61 % - Progression free: 41-74 %

16. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 Pre-operative risk evaluation: MRI, CT, Nomograms

17. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 cT3 - Over-Staging 13-27% - Equal PFS for pT2 and pT3R0 - 56-78% require adjuvant therapy - Published OS- and CS-rates not different to RT+ADT

18. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 cT3

19. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 cT3

20. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 Gleason score 8-10 - Organ confined: 26-31% - Downgrading: = 45%

21. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20 PSA >20 - 5y BCR-free: 44-65% 1-3 PSA >50 - RP + multimodal adjuvant therapy  10y BCR-free: 43 %  10y CS-survival: 87%4 1. D’Amico AV, et al. J Clin Oncol 1999 Jan;17(1):168-72. 2. Tiguert LL, et al Urol 1997 Jan;157(1):244-50. 3. Yossepowitch O, J Urol 2007 Aug;178(2):493-9; 4. Inman BA, et al. Cancer 2008 Oct;113(7):1544-51.

22. Radical Prostatectomy: Why? Very high-risk: cT3b-T4 N0 or any T, N1

23. Radical Prostatectomy: When? Salvage Prostatectomy 2% of all RP Technical challenging High potential for complications High recurrence rates Difficult patient selection Improved results in more contemporary series1-3 1. Vaidya A, et al J Urol 2000 Dec;164(6):1998-2001. 2. Stephenson AJ, et al. J Urol 2004 Dec;172(6 Pt 1):2239-43. 3. Heidenreich A, et al. Eur Urol 2010 Mar;57(3):437-43.

24. Radical Prostatectomy: When?

25. Radical Prostatectomy: When?

26. Radical Prostatectomy: When?

27. Trifecta: Cancer control Continence Erectile function Pentafecta: + Neg. margins + No post-op complications Radical Prostatectomy: Why?

28. Radical Prostatectomy: Why?

29. Radical Prostatectomy: Why?

30. Complications after RP: Radical Prostatectomy: Why?

31. Radical Prostatectomy: Who?

32. Radical Prostatectomy: Who?

33. Radical Prostatectomy: Who?

34. Radical Prostatectomy: Who?

35. Radical Prostatectomy: Who?

36. Radical Prostatectomy: How? Open vs. Minimal invasive Open RP - Retropubic - Perineal Minimal invasive - Laparoscopic - Roboter-assisted

37. Radical Prostatectomy: How?

40. Radical Prostatectomy: How? Open RP vs. Lap. RP Operation time Complication rate Transfusion rate

41. Radical Prostatectomy: How? Open RP vs. Lap. RP Continence Pos. Margins

42. Radical Prostatectomy: How? Open vs. Minimal-invasive RP

43. Radical Prostatectomy: How? Lymphadenectomy Provides important information for prognosis - Decision making for adjuvant treatment No clear evidence: - When to perform LA - Influence on prognosis Partin Tables1 - PSA >10 and Bx-Gleason <7  Low risk - From series with limited LA 1. Partin AW et.al. Urology 2001 Dec;58(6):843-8.

44. Radical Prostatectomy: How? Lymphadenectomy Classic: obturatory and ext. iliac LN - mean: 8-10 LN Extended: + presacral & int. Iliac LN - mean: 20 LN - exlusively 19-35% pos LK Gleason score >7, PSA<10: - 25% pos LK

45. Radical Prostatectomy: How? Recommendation EAU Low Risk: - < 7% pos LN  no eLND Intermediate risk: - risk for pos. LN <7%  no eLND - risk for pos. LN >7%  eLND High risk: - eLND Limited LND  not recomended anymore

46. Radical Prostatectomy: How? Median Number of LN: 19 (8-53)

47. Radical Prostatectomy: How? Nerve Sparing RP Contraindications - cT2c / cT3 PCA - Gleason score >7 - more then one Bx > 6 ipsilateral Unilateral - cT2a PCA

48. ED (%) Age 2.3 30-39 9.5 40-49 15.7 50-59 34.4 60-69 53.4 70-79 Radical Prostatectomy: How? Erectile Dysfuncion: Prevalence total: 19%1 und 52%2 Age-dependend: Altersabhängiger Anstieg der ED 1 Braun M et al. Int J Impot Res. 2000 Dec;12(6):305-11 2 Feldman HA et al, J Urol 1994; 151:54-61

49. Radical Prostatectomy: How? Open vs. Minimal-invasive RP

50. Radical Prostatectomy: Why? High-risk: cT3a or Gleason score 8-10 or PSA > 20