Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.
BJU Int. 2012 Mar;109(5):752-9. doi: 10.1111/j.1464-410X.2011.10548.x. Epub 2011 Oct 12.
• To report the outcome of robotic-assisted laparoscopic radical prostatectomy (RALP) for men with localised high-risk prostate cancer at diagnosis. • Although commonly managed by radiotherapy (RT) with prolonged androgen-deprivation therapy (ADT), we hypothesize that initiation of multimodal therapy with RALP is oncologically efficacious and may allow many men to avoid ADT.
• Between December 2003 and September 2010, 1480 men underwent RALP of whom 160 fulfilled the National Comprehensive Control Network criteria for high-risk disease (prostate-specific antigen (PSA) > 20 ng/mL and/or clinical stage, cT ≥ 3 and/or biopsy Gleason score ≥ 8). • Biochemical recurrence (postoperative PSA ≥ 0.2) was used to assess outcome after RALP monotherapy. • Treatment failure was defined as either a rising PSA level after salvage RT or the initiation of ADT.
• The mean age ± standard deviation was 63.1 ± 6.3 years. Median PSA level was 9.95 ng/mL (interquartile range 6.0-21.4). • Analysis of prostatectomy specimen showed Gleason 8-10 cancers in 65 (41%), and extracapsular disease, pT ≥ 3, in 96 (60%) of which seminal vesicle invasion was evident in 36 (23%). Downgrading by prostatectomy occurred in 64 (40% of total group) and five (3%) were downstaged to pT2 disease. By contrast, any upgrading occurred in 29 (18% of total group) and upstaging occurred in 68 (43%). The overall positive surgical margin rate was 38%, correlating with stage pT2 (15%) or pT3 (53%). • With median follow-up of 26.2 months (interquartile range 5.5-37.3), two non-cancer-related deaths have occurred (overall survival 98.8%; cancer-specific survival 100%), and biochemical recurrence has occurred in 53 men (33%). RALP surgery has served as monotherapy (n= 117, 73%), or has been followed by salvage RT (n= 24, 15%) and/or ADT (n= 43, 27%). Overall 2-year and 3-year treatment failure was 31 and 41%, respectively. • Serum PSA level was the only independent predictor of overall treatment failure (hazard ratio [HR] 1.02, P= 0.001) although a strong trend was observed for both clinical stage (HR 1.22, P= 0.058) and the number of positive biopsy cores on transrectal biopsy (HR 1.06, P= 0.057).
• RALP incorporating the use of postoperative RT is a good multimodal management strategy for men with this aggressive variant of prostate cancer. • At median follow-up in excess of 2 years, we found low rates of treatment failure enabling a high proportion of men to remain free of ADT.
• 报告诊断为局部高危前列腺癌男性接受机器人辅助腹腔镜根治性前列腺切除术（RALP）的结果。• 虽然通常通过放疗（RT）联合长期雄激素剥夺治疗（ADT）进行治疗，但我们假设RALP 起始的多模式治疗在肿瘤学上是有效的，并且可以使许多男性避免 ADT。
• 2003 年 12 月至 2010 年 9 月，1480 名男性接受了 RALP，其中 160 名符合国家综合控制网络的高危疾病标准（前列腺特异性抗原（PSA）>20ng/mL 和/或临床分期，cT≥3 和/或活检 Gleason 评分≥8）。• 生化复发（术后 PSA≥0.2）用于评估 RALP 单一疗法的结果。• 治疗失败定义为挽救性 RT 后 PSA 水平升高或开始 ADT。
• 平均年龄±标准差为 63.1±6.3 岁。中位 PSA 水平为 9.95ng/mL（四分位距 6.0-21.4）。• 前列腺切除术标本分析显示，65 例（41%）为 Gleason 8-10 级癌症，96 例（60%）为包膜外疾病，pT≥3，其中 36 例（23%）可见精囊侵犯。64 例（总组的 40%）发生前列腺癌降级，5 例（3%）降为 pT2 疾病。相比之下，29 例（总组的 18%）发生任何升级，68 例（43%）发生升级。总的阳性切缘率为 38%，与 pT2（15%）或 pT3（53%）相关。• 在中位随访 26.2 个月（四分位距 5.5-37.3）时，发生了 2 例非癌症相关死亡（总生存率 98.8%；癌症特异性生存率 100%），53 例患者（33%）发生生化复发。RALP 手术作为单一疗法（n=117，73%），或随后进行挽救性 RT（n=24，15%）和/或 ADT（n=43，27%）。总的 2 年和 3 年治疗失败率分别为 31%和 41%。• 血清 PSA 水平是总治疗失败的唯一独立预测因素（风险比[HR]1.02，P=0.001），尽管临床分期（HR 1.22，P=0.058）和经直肠活检阳性活检核心数（HR 1.06，P=0.057）有强烈的趋势。
• RALP 联合术后 RT 是治疗这种侵袭性前列腺癌的一种良好的多模式管理策略。• 在超过 2 年的中位随访中，我们发现治疗失败的发生率较低，使大多数男性能够避免 ADT。
