Prostate cancer surgery

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Prostate Cancer Surgery: Insights and Outcomes

Introduction to Prostate Cancer Surgery

Prostate cancer is a prevalent malignancy among men worldwide, and radical prostatectomy (RP) is a common surgical treatment for localized prostate cancer. This procedure can be performed using various approaches, including open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robotic-assisted radical prostatectomy (RARP) .

Comparing Surgical Approaches: Open vs. Minimally Invasive

Laparoscopic and Robotic-Assisted Radical Prostatectomy

Minimally invasive techniques such as LRP and RARP have emerged as alternatives to the traditional ORP. These techniques offer potential benefits, including reduced postoperative pain, shorter hospital stays, and fewer blood transfusions. However, studies indicate that there is little to no difference in urinary and sexual quality of life between RARP and ORP. Additionally, overall and serious postoperative complication rates appear similar across these surgical methods.

Long-Term Outcomes and Cancer Control

Long-term cancer control following RP is generally favorable, with less than 10% of men experiencing death from prostate cancer 15 years post-surgery. For high-risk patients, RP provides pathologic staging that can guide the selective application of secondary therapies, potentially reducing mortality risk compared to radiation therapy . However, the use of robot-assisted techniques has not shown superiority in terms of functional or oncologic outcomes compared to other approaches.

Functional Outcomes: Urinary Continence and Erectile Dysfunction

Functional outcomes post-RP, particularly urinary continence and erectile dysfunction, vary significantly. These variations are often due to nonstandardized reporting methodologies. Despite advancements in surgical techniques, all aggressive treatments for prostate cancer, including RP, negatively impact erectile function and urinary continence.

Salvage Surgery for Radiorecurrent Prostate Cancer

Salvage surgery is an option for patients with persistent prostate cancer following definitive radiotherapy. This approach has shown significant progression-free survival (PFS) and cancer-specific survival (CSS) rates, although it comes with notable surgical risks and complications, such as urinary extravasation and bladder neck contracture.

Radical Prostatectomy vs. Observation

The Prostate Cancer Intervention Versus Observation Trial (PIVOT) provides insights into the long-term effects of RP versus observation. The study found that RP is associated with small reductions in all-cause mortality and increases in years of life gained, particularly in men with intermediate-risk disease. However, the benefits are less pronounced in men with low-risk disease.

Radical Prostatectomy vs. Radiotherapy

A systematic review and meta-analysis comparing RP with external beam radiotherapy (RT) for high-risk prostate cancer found that RP is associated with improved overall survival (OS) and prostate cancer-specific mortality (PCSM) compared to RT. Surgery also showed a 50% decreased risk of non-PCSM compared to RT.

Conclusion

Radical prostatectomy remains a cornerstone in the management of localized prostate cancer, offering excellent long-term cancer control and survival benefits, particularly for high-risk patients. While minimally invasive techniques like LRP and RARP provide certain perioperative advantages, their long-term functional and oncologic outcomes are comparable to traditional ORP. The choice of surgical approach should be tailored to individual patient characteristics, cancer risk, and preferences, emphasizing the importance of shared decision-making in prostate cancer care.