RALP May Be Better than Active Surveillance

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BARCELONA—Prostate cancer patients who are eligible for active surveillance may actually benefit from robotic-assisted laparoscopic prostatectomy (RALP), according to data announced at the 25th Anniversary European Association of Urology Congress. 

David Samadi, MD, and colleagues at Mount Sinai Medical Center in New York City, reported final histopathologic and functional outcomes in 368 men who qualified for active surveillance under conventional criteria but elected to undergo RALP instead.

“Active surveillance is growing in popularity as a treatment option for men with localized prostate cancer who are classified as low-risk patients,” said Dr. Samadi, Chief of the Division of Robotics and Minimally Invasive Surgery. “While active surveillance has been shown to be a useful option for patients with low-risk disease, clinically low-risk prostate cancer does not necessarily mean that disease will be indolent or insignificant disease on final pathology. Given the difficulties of accurate preoperative staging and grading of prostate cancer, upgrading and upstaging are extremely common at the time of prostatectomy.”

 “Our final analysis of functional and histopathologic data after RALP shows a 44% rate of upgrading in those patients whom we thought had slow-growing disease and were considered suitable for an active surveillance strategy using standard criteria for active surveillance,” Dr. Samadi said.

These criteria include a PSA level below 10 ng/mL, clinical stage T2a or less, and a biopsy Gleason score of 6 or less in one or two cores with 50% tumor volume in a single core. 

Overall, 147 (40%) patients were upgraded from a biopsy Gleason score of 6 to a score of 7. One patient was upgraded to Gleason 8. Upstaging to pT3 or pT4 disease occurred in 17 (4.6%) patients. Given the low rate of upstaging, nerve-sparing could be “confidently” performed, with 97% of the study cohort undergoing a bilateral nerve-sparing procedure, Dr. Samadi said.

Oncologic outcomes were good, with an 8% positive margin rate and a 1.6%

biochemical recurrence rate at 14 months' follow-up, he said. In addition, at 12 months, 95% of patients were continent and 88% had recovered potency.

Robotic prostatectomy provides men with another option, Dr. Samadi said. It can cure their cancer and preserve their quality of life in terms of sexual function and continence. However, the learning curve is steep and surgeons need to perform a high volume of cases to become proficient. “Robotic prostate surgery is a challenging and complex procedure and should be done only in the hands of experienced surgeons,” he said. So patients need to choose the right surgeon, not just the technology, he said.

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