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Heidenreich A, Bach C, Pfister D. [Palliative surgery for metastatic prostate cancer]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:241-253. [PMID: 38418597 DOI: 10.1007/s00120-024-02285-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 03/01/2024]
Abstract
Androgen deprivation in combination with novel hormonal agents, docetaxel, or in combination with abiraterone/prednisone plus docetaxel or darolutamid plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favorable response rates, basically all patients will develop castration resistant prostate cancer (CRPC) within 2.5 to 4 years. In addition to systemic chemotherapy, second-line hormonal treatment of systemic application of radionuclides such as radium223 or 177Lu-PSMA represent salvage management options. However, nowadays about 50-65% of patients will develop symptoms due to local progression of prostate cancer which is the result of improved oncological outcomes with significantly prolonged survival times due to the new medical treatment options. Management of such symptomatic local progression will become more important in upcoming years so that all uro-oncologists need to be aware of the various surgical management options. Complications of the lower urogenital tract such as recurrent gross hematuria ± bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction and acute urinary retention, rectourethral or rectovesical fistulas might be managed by palliative surgery such as palliative transurethral resection of the prostate (TURP), radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract might be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of the Detour® system (Coloplast GmbH, Hamburg, Germany).
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Affiliation(s)
- Axel Heidenreich
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
- Klinik für Urologie, Medizinische Universität Wien, Wien, Österreich.
| | - Christian Bach
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - David Pfister
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Kanzelmeyer S, Bludau M, Pfister DJKP, Heidenreich A. [Pelvic exenteration in patients with locally advanced, symptomatic castration-resistant prostate cancer]. Urologe A 2021; 61:167-172. [PMID: 34424358 PMCID: PMC8831235 DOI: 10.1007/s00120-021-01619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 10/24/2022]
Abstract
GOAL The retrospective evaluation of clinical outcomes after palliative pelvic exenteration (PPE) in patients with subvesical and supravesical complications due to symptomatic locally advanced castration-resistant prostate cancer (CRPC). PATIENTS AND METHODS In all, 84 patients with locally advanced and symptomatic CRPC underwent radical cystoprostatectomy (n = 71, 83.3%) or anterior and posterior exenteration (n = 13, 16.7%). Local staging was done via pelvic MRI (magnetic resonance imaging), cystoscopy, and rectoscopy. Systemic staging was performed by computed tomography of the thorax, abdomen pelvis, and skeletal scintigraphy. Perioperative complications were evaluated using the Clavien-Dindo classification. The primary study objective was symptom-free survival defined as absence of lower or upper urinary tract symptoms and absence of endoluminal or percutaneous intervention. RESULTS After a median follow-up of 43.5 (3-139) months, symptom-free survival at 1 and 3 years was 95.2% and 86.7%, respectively. In all, 86.7% of patients remained symptom-free for their remaining lifetime with respect to local symptoms. Overall survival at 1 and 3 years was 92.9% and 54.7%, respectively. Clavien-Dindo grade 2, 3, and 4 complications occurred in 19 (22.6%), 7 (8.3%), and 3 (3.6%) patients, respectively. CONCLUSION With adequate patient selection, PPE is possible with a low complication rate and results in significant symptom relief in the lower or upper genitourinary tract in about 90% of patients, of whom more than 80% remain symptom-free for the remainder of their lives. Prerequisites for favorable surgical outcomes are patient selection, an interdisciplinary approach, and appropriate surgical expertise.
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Affiliation(s)
- Saskia Kanzelmeyer
- Klinik und Poliklinik für Urologie, Uro-Onkologie, spezielle urologische und roboter-assistierte Chirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Mark Bludau
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - David Johannes Karl Paul Pfister
- Klinik und Poliklinik für Urologie, Uro-Onkologie, spezielle urologische und roboter-assistierte Chirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Axel Heidenreich
- Klinik und Poliklinik für Urologie, Uro-Onkologie, spezielle urologische und roboter-assistierte Chirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik für Urologie, Medizinische Universität Wien, Wien, Österreich.
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Bhanvadia RR, Khouri RK, Ashbrook C, Woldu SL, Margulis V, Raj GV, Bagrodia A. Safety, Efficacy, and Impact on Quality of Life of Palliative Robotic Cystectomy for Advanced Prostate Cancer. Clin Genitourin Cancer 2020; 19:e129-e134. [PMID: 33246846 DOI: 10.1016/j.clgc.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/13/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Raj R Bhanvadia
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Roger K Khouri
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Caleb Ashbrook
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Ganesh V Raj
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern, Dallas, TX.
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Heidenreich A, Bludau M, Bruns C, Nestler T, Porres D, Pfister DJKP. Pelvic exenteration surgery in patients with locally advanced castration-naïve and castration-resistant, symptomatic prostate cancer. BJU Int 2020; 126:342-349. [PMID: 32320130 DOI: 10.1111/bju.15088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate retrospectively the surgical, symptomatic and oncological outcomes of pelvic exenteration surgery (PES) in men with significant intrapelvic complications of locally advanced castration-sensitive (CSPC) and castration-resistant prostate cancer (CRPC). PATIENTS AND METHODS A total of 103 patients with locally advanced progressive and symptomatic CSPC or CRPC underwent PES (radical cystoprostatectomy, n = 71 [68.9%]; radical prostatectomy with continent vesicostomy, n = 9 [8.7%]; total exenteration, n = 23 [22.3%]). All patients underwent local staging via magnetic resonance imaging, cystoscopy and rectoscopy. Systemic staging was carried out with chest, abdominal and pelvic computed tomography scans and bone scans. Peri-operative complications were assessed according to Clavien-Dindo classification. Symptom-free and overall survival were evaluated using the Kaplan-Meier method. Statistical tests were two-tailed with a P value <0.05 taken to indicate statistical significance. RESULTS After a median (range) follow-up of 36.5 (3-123) months, the symptom-free survival rate at 1 and 3 years was 89.2% (n = 89) and 64.1% (n = 66), respectively. The median symptom-free survival was 27.9 months. A total of 78.6% of the patients were symptom-free during their remaining lifetime. The overall survival rate at 1 and 3 years was 92.2% and 43.7%, respectively, and the median overall survival was 33.6 months. Clavien-Dindo grades 2, 3 and 4 complications developed in 31 (30.6%), 12 (11.6%) and eight patients (8.1%), respectively. CONCLUSION Pelvic exenteration surgery is technically feasible in well-selected patients, resulting in symptom relief in >90% of patients, covering 80% of their remaining lifetime.
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Affiliation(s)
- Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urological Surgery, University Hospital Cologne, Cologne, Germany.,Department of Urology, Medical University Vienna, Vienna, Austria
| | - Mark Bludau
- Department of Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christiane Bruns
- Department of Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tim Nestler
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urological Surgery, University Hospital Cologne, Cologne, Germany
| | - Daniel Porres
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urological Surgery, University Hospital Cologne, Cologne, Germany
| | - David Johannes Karl Paul Pfister
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urological Surgery, University Hospital Cologne, Cologne, Germany
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Radical cytoreductive prostatectomy in men with prostate cancer and oligometastatic disease. Curr Opin Urol 2020; 30:90-97. [DOI: 10.1097/mou.0000000000000691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Knipper S, Graefen M. Palliative Radical Prostatectomy in Men with Metastatic Castration-resistant Prostate Cancer: Only When Your Back Is Against the Wall! Eur Urol 2018; 74:144-145. [DOI: 10.1016/j.eururo.2018.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 01/30/2023]
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Heidenreich A. [Limits of surgery in uro-oncology]. Urologe A 2018; 57:1058-1068. [PMID: 30043291 DOI: 10.1007/s00120-018-0735-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The limits of cancer surgery in uro-oncology are characterized by a carefully weighed risk of surgical feasibility and oncological necessity. The limits of uro-oncological cancer surgery do not represent fixed dogmas but ideally these more or less cognitive boundaries move based on new scientific findings, improved imaging modalities, optimized surgical techniques and perioperative care. The limits of cancer surgery are defined by patient-specific parameters, the biological aggressiveness of the tumor itself, the skills and expertise of the surgeon, and adequate perioperative care of the patient. Dependent on the origin of the cancers of the upper and lower urogenital tract, the specific particularities of each individual cancer in terms of prognosis need to be known, taking into consideration the newest molecular insights and modern multimodality treatment regimes. Only the consideration of the above mentioned basics will allow the best decision to be made with the patient concerning the optimal individual treatment. The current article highlights general parameters of the patient, tumor and surgeon which might define the limits of cancer surgery in uro-oncology. In addition, specific clinical scenarios are discussed with regard to surgery limits in cancer of the kidney, the prostate and the testis.
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Affiliation(s)
- A Heidenreich
- Klinik für Urologie, Uro-Onkologie, roboter-assistierte und spezielle urologische Chirurgie, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland. .,Klinik für Urologie, Medizinische Universität Wien, Wien, Österreich.
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