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Heidenreich A. Surgery Remains an Integral Part of Multimodal Treatment for High-risk Prostate Cancer. Eur Urol Oncol 2024:S2588-9311(24)00157-3. [PMID: 39019710 DOI: 10.1016/j.euo.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/20/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital Cologne, Germany; Department of Urology, Medical University Vienna, Austria.
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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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Heidenreich A, Bach C, Pfister D. [Palliative urologic surgery for metastatic prostate cancer: what needs to be considered in the future?]. Aktuelle Urol 2024. [PMID: 38232756 DOI: 10.1055/a-2226-9243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Androgen deprivation in combination with novel hormonal agents, docetaxel or the combination of abiraterone/prednisone plus docetaxel or darolutamide 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 favourable response rates, basically all patients will develop castration-resistant prostate cancer (CRPC) within 2.5 to 4 years. Systemic chemotherapy, second-line hormonal treatment or systemic application of radionuclides such as Radium-223 or 177Lu-PSMA represent salvage management options. As the new medical treatment options have led to an improved oncological outcome with significantly prolonged survival times, about 50% to 65% of patients will develop symptoms due to local progression of prostate cancer. The management of such symptomatic local progression will become more important in upcoming years, which means that all uro-oncologists need to be aware of the various surgical management options. If complications of the lower urogenital tract occur, for example repetitive gross haematuria with or without bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction, acute urinary retention or rectourethral or rectovesical fistulas, these may be managed by palliative surgery such as palliative TURP, radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract can be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of a Detour system. However, an individualised and risk-adapted treatment strategy needs to be developed for each single patient to achieve an optimal therapeutic outcome with improvement of both symptoms and quality of life. In specific clinical situations, best supportive care may be an adequate option.
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Affiliation(s)
- Axel Heidenreich
- Klinik für Urologie, Uro-Onkologie, spezielle urologische und Roboter-assistierte Chirurgie, Universitätsklinikum Köln, Köln, Germany
| | - Christian Bach
- Klinik für Urologie, Uro-Onkologie, spezielle urologische und Roboter-assistierte Chirurgie, Universitätsklinikum Köln, Köln, Germany
| | - David Pfister
- Klinik für Urologie, Uro-Onkologie, spezielle urologische und Roboter-assistierte Chirurgie, Universitätsklinikum Köln, Köln, Germany
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The role of surgery for loco-regional and advanced urological cancers. Curr Opin Urol 2022; 32:634-642. [PMID: 36101519 DOI: 10.1097/mou.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a general misconception that surgery is the antithesis of palliation. However, symptom mitigation, the basic tenet of palliative interventions, can be achieved by invasive procedures. Surgical care, thus, plays an important role in palliative oncology, alongside radiation and systemic therapy. There is global movement to improve palliation in oncology, and thus it is timely to evaluate the role of surgical interventions can play in this setting. RECENT FINDINGS Many of the surgical interventions done with palliative intent were first established as curative options. Most studies looked at interventions for local control of primary tumour including extirpative surgeries, while some studies studied pain relief for bone metastases. Results show that patients have an acceptable survival outcome and complication rate comparable to those done in the curative setting. However, not all studies report functional outcomes and symptom-relief consistently, highlighting an unmet need. SUMMARY More studies are needed to further define the role of surgery in palliative care. Randomized controlled trials studying surgical intervention in the palliative setting will be challenging because of lack of equipoise, inherent bias in patient and disease characteristics in those who undergo surgery. Nonetheless, studies should endeavour to study symptom-free survival and PROMs as meaningful endpoints of interventions performed in a palliative setting rather than solely focus on hard oncological endpoints of survival.
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Sun X, Liu M, Zhao Y, Leng K, Zhang H. Evaluation of cystoprostatectomy on patients with prostate cancer extending to bladder: a retrospective study from single center. BMC Urol 2022; 22:118. [PMID: 35902854 PMCID: PMC9330683 DOI: 10.1186/s12894-022-01068-7] [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] [Received: 04/07/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background This is an exploratory research of cystoprostatectomy (CP) in treating prostate cancer (PCa) extending to the bladder, which aimed to evaluate the effects of CP on survival outcomes and improving quality of life (QoL) in these patients. Methods A total of 27 PCa patients extending to the bladder were subjected to CP and followed up at regular intervals in our center. Prostate cancer-specific survival (PCSS) and prostate-specific antigen recurrence-free survival (PFS) were assessed by Kaplan–Meier analysis. Multivariate Cox regression was performed to evaluate clinical characteristics predicting survivals. QoL and pelvic symptoms were also evaluated. Results Median PCSS was not reached over the period of follow-up. 5-year PCSS rate was 82.1%. Median PFS was 66.0 months. 5-year PFS rate was 58.5%. Multivariate analysis showed Gleason score (≥ 8) (hazard ratio (HR) 2.55, 95% confidence interval (CI) 1.28–4.04, p = 0.033), positive local lymph node status (HR 3.52, 95% CI 1.57–7.38, p = 0.006) and bladder muscle-invasion (HR 4.75, 95% CI 1.37–7.53, p < 0.001) were independent predictors of worse PCSS. The number of patients suffering pelvic symptoms was significantly decreased, and QoL scores were significantly down-regulated after surgeries. Conclusion CP offered effective and durable palliation in patients of locally advanced prostate cancer with invasion of the bladder, providing better QoL and relieving local symptoms.
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Affiliation(s)
- Xiaoliang Sun
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Min Liu
- Department of Oncologic Chemotherapy, Shandong Second Provincial General Hospital, Jinan, 250022, Shandong, China
| | - Yong Zhao
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Kang Leng
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Haiyang Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China. .,Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, 94143, USA.
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Abstract
PURPOSE OF REVIEW Salvage surgeries are rarely offered and performed in prostate cancer except for isolated lymph node metastases. Meanwhile, data are sufficient that salvage radical prostatectomy is recommended by the guidelines. In the following review, we focus on different treatment strategies comparing open and DaVinci laparoscopic approach with regard to functional and oncologic outcome. Of further interest are palliative surgeries. RECENT FINDINGS Salvage radical prostatectomy is mainly performed in high volume centres. Data are increasing on minimal invasive surgery, although data on functional outcome are conflicting. As patients with prostate cancer have longer life expectancy even in metastasized disease, the possibility of developing symptomatic progression increases as well. We need to be aware that the confrontation with symptomatic prostate cancer patients will be more frequent in the future and that there are surgical approaches to palliate these patients sufficiently. SUMMARY Data on minimal invasive salvage radical prostatectomy are getting more valid and are an option in experienced centres. Salvage radical prostatectomy is a definitive curative option for the patients. To avoid local progression, palliative local surgeries need to be discussed with the patients.
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Surcel C, Mirvald C, Tsaur I, Borgmann H, Heidegger I, Labanaris AP, Sinescu I, Tilki D, Ploussard G, Briganti A, Montorsi F, Mathieu R, Valerio M, Jinga V, Badescu D, Radavoi D, van den Bergh RCN, Gandaglia G, Kretschmer A. Contemporary role of palliative cystoprostatectomy or pelvic exenteration in advanced symptomatic prostate cancer. World J Urol 2020; 39:2483-2490. [PMID: 33135127 DOI: 10.1007/s00345-020-03493-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To access the feasibility of palliative cystoprostatectomy/pelvic exenteration in patients with bladder/rectal invasion due to prostate cancer (PC). PATIENTS AND METHODS Twenty-five men with cT4 PC were retrospectively identified in the institutional databases of six tertiary referral centers in the last decade. Local invasion was documented by CT or MRI scans and was confirmed by urethrocystoscopy. Oncological therapies, local symptoms, previous local treatments, time from diagnosis to intervention and type of surgical procedure were recorded. Patients were divided into groups: ADT group (12 pts) and 13 pts without any history of previous local/systemic treatments for PCa (nonADT groups). Perioperative complications were classified using the Clavien-Dindo system. Overall survival (OS) was defined as the time from surgery to death from any cause. A Cox regression analysis, stratified for ISUP score and previous hormonal treatment (ADT) was also performed for survival analysis. RESULTS Ileal conduit was the main urinary diversion in both cohorts. For the entire cohort, complication rate was 44%. No significant differences regarding perioperative complications and complication severity between both subgroups were observed (p = 0.2). Median follow-up was 15 months (range 3-41) for the entire cohort with a median survival of 15 months (95% CI 10.1-19.9). In Cox regression analysis stratified for ISUP score, no statistically significant differences in OS in patients with and without previous ADT before cystectomy or exenteration were observed (HR 3.26, 95% CI 0.62-17.23, p = 0.164). CONCLUSION Palliative cystoprostatectomy and pelvic exenteration represent viable treatment options associated with acceptable morbidity and good short-term survival outcome.
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Affiliation(s)
- C Surcel
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
| | - C Mirvald
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania. .,Department of Urology, Fundeni Clinical Institute, Bucharest, Romania.
| | - I Tsaur
- Department of Urology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - H Borgmann
- Department of Urology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Isabel Heidegger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - A P Labanaris
- Department of Urology, Interbalkan Medical Center, Thessaloniki, Greece
| | - I Sinescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - G Ploussard
- Department of Urology, La Croix du Sud Hospital, Toulouse, France
| | - A Briganti
- Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - F Montorsi
- Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - R Mathieu
- Department of Urology, CHU Rennes, Rennes, France
| | - M Valerio
- Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - V Jinga
- Urology Department, 'Prof. Dr. Th. Burghele' Clinical Hospital, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - D Badescu
- Urology Department, 'Prof. Dr. Th. Burghele' Clinical Hospital, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - D Radavoi
- Urology Department, 'Prof. Dr. Th. Burghele' Clinical Hospital, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - R C N van den Bergh
- Unit of Urology/Division of Oncology, St Antonius Hospital, Utrecht, Netherlands
| | - G Gandaglia
- Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - A Kretschmer
- Department of Urology, Ludwig-Maximilians University of Munich, Munich, Germany
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