Laparoscopic radical prostatectomy is feasible and effective in ‘fit’ senior men with localized prostate cancer

Abstract

Study Type – Therapy (case series) Level of Evidence 4OBJECTIVE To assess the effect of age and comorbidity on short‐term complications, long‐term continence and oncological outcome after laparoscopic radical prostatectomy (LRP) for localized prostate cancer.PATIENTS AND METHODS In all, 2048 consecutive men underwent LRP for localized prostate cancer in one institution. Comorbidity was assessed using the Charlson index. Short‐term postoperative complications, transfusion rate, duration of hospital stay, long‐term continence and oncological outcome were analysed by age and comorbidity classes.RESULTS Of the 2048 men, 297 were aged ≥70 years and 281 had a Charlson index of >0 (mainly diabetes 31%, chronic pulmonary disease 26%, prior other nonmetastatic cancer 16%, prior myocardial infarction 12%). Compared with younger men, senior men had significantly higher pathological stages and tumor grades. Of those 297 men aged ≥70 years, 90 (30.3%) developed biochemical relapse, none died from prostate cancer and five (1.7%) died from another cause over a median follow‐up of 5 years. The occurrence and severity of short‐term postoperative complications were more strongly related to comorbidity than chronological age. Multivariate analysis with stepwise regression confirmed that most important predictors of short‐term postoperative complications were a Charlson index of ≥2, prostate weight of >80 g, obesity and age of ≥70 years. Postoperative continence significantly declined with age (ranging from 87% in men aged <60 years to 67.5% in men aged ≥70 years). Predictors of long‐term incontinence were age of ≥70 years, obesity and need for perioperative transfusion.CONCLUSIONS LRP is feasible and effective in fit senior men (aged ≥70 years) with localized prostate cancer, including those at high risk of dying from it.

Challenges of managing elderly men with prostate cancer

“…17,18 However, there is an increased incidence of post- operative impotence and urinary incontinence that is particularly high in men older than 70 years (24% versus 18% for the age group 66–69 years, P <0.001). 19,20 The 10-year cancer- specific survival rate after radical prostatectomy for patients aged ≥70 years with low-risk, intermediate-risk, and high-risk disease is 99.5%, 97.5%, and 94%, respectively. 21 The risk of biochemical failure observed from a database of 15,899 radical prostatec tomies for patients aged ≥70 years was 12.6% at a mean follow-up of 5.1 years.…”

Is Radical Prostatectomy a Useful Therapeutic Option for High-Risk Prostate Cancer in Older Men?

“…Similarly, among 11,522 men who underwent radical prostatectomy, the Charlson index was also identified as a significant predictor of surgery-related death, postoperative complications, and late urinary complications [29]. In addition, analysis of the effect of age and comorbidity on treatment outcomes in 2,048 men treated by laparoscopic radical prostatectomy also concluded that the occurrence and severity of short-term postoperative complications were more strongly related to comorbidity than to chronological age [2]. In centers of excellence for the treatment of prostate cancer, patients with high-risk disease do not have an increased risk of postsurgery incontinence compared with other risk groups [30].…”

“…In an autopsy study of men with no diagnosed history of prostate cancer, prostate cancer was identified in 45% of the men aged 70 years or over, and they were more likely to have higher stage and more poorly differentiated tumors than younger men [1]. In a retrospective analysis of 2,048 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer in a single institution, men Ն70 years of age showed significantly higher pathologic stages (T3-T4, 30%) and tumor grades (Gleason Ն7, 67%) than younger men (21% and 54%, respectively) [2]. Higher pathologic stages and tumor grades, as well as a higher risk of upgrading, in patients aged 70 or older were also reported by other institutions [3,4].…”

Optimizing the Management of Prostate Cancer in Senior Adults: Call to Action

“…However, there is increasing evidence that men over the age of 70 years are more likely to have higher-risk prostate cancer-with higher clinical stage, Gleason score, and tumor volume-than younger men [10]. Without curative treatment, these aggressive tumors may lead to prostate cancer death in a significant number of men [11], which helps to explain the high rate of prostate cancer death at an advanced age. In a 20-year follow-up of a population-based cohort with localized prostate cancer between 1971 and 1984, men diagnosed after the age of 70 years of age with Gleason score 8 -10 and managed conservatively (watchful waiting or androgen-deprivation therapy) had a 64% chance of dying of prostate cancer (Table 1) [12].…”

“…The Charlson index, which rates exclusively potentially lethal comorbid conditions [15], has been identified as a much more powerful predictor of nonprostate cancer death than chronological age [16]. Complications of curative therapies such as radical prostatectomy [11,17] and brachytherapy [18] are also more related to Charlson index than age. Nevertheless, both the functional and the nutritional status of the patient are also important parameters to consider in health status evaluation because the degree of dependence in daily living activities and malnutrition have been shown to significantly influence survival [19,20].…”