MDT (multi-disciplinary team) guidance for managing prostate cancer

Radical treatments
Radical prostatectomy
There are now four approaches to performing a radical prostatectomy: retropubic, perineal, laparoscopic
and robotic. The procedure involves removal of the whole prostate and the seminal vesicles. The most
commonly used approaches are retropubic and perineal, but laparoscopic and robotic techniques are
becoming more frequently adopted. The newer approaches have the advantage of reduced blood loss
and shorter inpatient stays.
Overview
• In 1997, Selley et al. reviewed a total of 17 studies (two randomised controlled trials [RCTs] and
15 observational studies involving a total of 5410 patients) to investigate the efficacy of radical
prostatectomy for men with localised prostate cancer. Cancer-specific survival after 10 years of followup
ranged from 86% to 91%, with clinical disease-free survival (DFS) ranging from 57% to 83%. 38
Patient selection
• Anaesthetic fitness
• At least 10 years’ life expectancy
• Complications increase and benefits decrease in patients aged >70 years
Side-effects of treatment
• Based on the systematic review by Selley et al., the following side-effects should be considered: 38
o Operative and post-operative mortality: 0.2−1.2%
o Sexual dysfunction: 51−61%
o Incontinence (mild stress): 4−21%
o Incontinence (total): 0−7%
Clinical evidence
• One randomised trial has compared radical prostatectomy with watchful waiting in localised
prostate cancer. 39
o The trial randomised 695 men with localised disease between radical prostatectomy and
watchful waiting.
o At a median follow-up of 8.2 years, randomisation to radical prostatectomy was associated with
a benefit both in terms of disease-specific mortality (hazard ratio [HR] 0.56; 95% confidence
interval [CI]: 0.36−0.88; p=0.01) and overall mortality (HR 0.74; 95%CI: 0.56−0.99; p=0.04).
o This translated into 10-year OS of 73% versus 68% (p=0.04) for radical prostatectomy versus
watchful waiting.
o In terms of 10-year freedom from distant metastases, the absolute benefit of surgery versus
watchful waiting was 10% (84.8% versus 74.6%; p=0.004).
o However, patients need to weigh these benefits against the risk of adverse consequences of
treatment. The 5% absolute improvement in 10-year survival was achieved at the expense of a
35% absolute increase in the risk of erectile dysfunction and a 28% absolute increase in the risk
of urinary leakage.
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