Onkologische Langzeitergebnisse nach radikaler Prostatektomie

Backround: The radical prostatectomy (RPE) is one of the recommended therapies for prostate cancer (PCa) according to German S3-guidelines, concerning all risk groups based on d‘Amico classification. Even in the case of an advanced PCa, RPE can prolong the overall survival and provide good long-term oncological outcomes as part of a multimodal therapy. Objectives: The aim of the present monocentric retrospective study was to evaluate the long-term oncological outcomes of patients undergoing open RPE performed in a large teaching hospital for urologic surgeons in Germany. In the context of a quality control of the PCa-center, we compared our oncological outcomes with those of other PCa-centres in Europe and worldwide. In addition, the current study tried to identify the prognostic factors, which affect the oncological outcomes after RPE and to determine if RPE is able to provide satisfactory oncological outcomes as a standard therapy for advanced PCa as a part of a multimodal therapy. Methods: Between January 2008 and December 2016, 1.373 patients were treated with RPE due to a PCa in our centre, 1.161 of whom were included in the study. The median follow-up was 75 months. In order to minimize the selection bias, the patients were divided into two modified risk groups (low and high-risk). A stratification of the patients according to the d'Amico classification was avoided, due to the fact that 28% of patients with a clinical stage cT1c were diagnosed with a locally advanced PCa and 27.7% had an upgrading of the Gleason score in RPE-specimens. The low-risk group consisted of patients with a localised PCa (pT2-Stage), prostate-specific antigen (PSA) ≤ 20ng/ml and Gleason score between 6-7b without lymph node metastasis (N0). The high-risk group consisted of patients with a locally advanced tumour (≥pT3a) and/or PSA >20ng/ml and/or Gleason score ≥8 and/or lymphogenic metastatic spread (N1). Results: The 2-, 5- and 10-year biochemical recurrence (BCR)-free survival was overall 86,9%, 68,6% and 58,2%; in the low-risk group 90%, 77,7% and 68,4% and in the high-risk group 84,3%, 58,7% and,47,0%. The Gleason-score was the most important prognostic factor, followed by pT- stage. The positive surgical margins were only in the low-risk group statistically associated with BCR-free survival. The 2-, 5-, and 10-year metastasis-free survival after BCR was overall 93,0%, 84,8% and 76,1%; in the low-risk group 95,9%, 92,9% and 87,7% and in the high-risk group 90,7%, 78,4% and 66,5%. The Gleason-score was in accordance to the multivariate Cox regression analysis the only statistically significant prognostic factor for metastasis-free survival after BCR. The 2-, 5-, and 10-year cancer-specific survival was overall 99,7%, 98,0% and 94,2 and in the high-risk group 99,4%, 95,6% and 87,4%. The 10-year cancer-specific survival was 100% in the low-risk group. The Gleason score and the pN1-stage played the most important role. Finally, the 2-, 5- and 10-year overall survival rate was overall 99,0%, 94,9% and 82,1%; 99,1%, 96,6% and 89,0% in the low risk and 98,7%, 92,8% and 73,9% in the high-risk group. Age was the most important prognostic factor for overall survival in both groups of patients. An elevated prostate-specific antigen (PSA) after RPE was associated with a clinical progression and a very high cancer specific mortality rate (87,5%). Four patients with an oligometastatic prostate cancer had a poor prognosis after RPE, with a mortality rate of 75% at the end of follow-up. Conclusions: The technique of RPE does not affect the incidence of positive surgical margins (R1) nor the long-term oncological outcomes after RPE. Instead, the surgeon's experience and ability seem to play the most important role. RPE is a curative therapy in early stages of PCa and a very good therapy option for high-risk PCa, as the age of patients at the time of the surgery was the most important prognostic factor for overall survival in our study, regardless of the tumor risk profile. Even in case of a BCR, patients have a good prognosis; a systemic progression after BCR is rare. Here, the Gleason score is the most important prognostic factor. The persistent PSA after RPE is a very unfavourable prognostic factor associated with clinical progress and increased mortality. Finally, cytoreductive RPE in oligometastatic PCa can prolong symptom-free and overall survival in selected cases. Further prospective studies are required to evaluate the long-term oncological outcomes. The oncological outcomes of our PCa-center are comparable to other centres in Europe and USA.