Radical prostatectomy for localized prostate cancer provides durable cancer control with excellent quality of life: a structured debate.
OBJECTIVE
To cure localized prostate cancer, the entire prostate must be eliminated, which is what all forms of treatment must achieve. Although there is no better way to cure localized disease than total surgical removal, the challenge is whether this can be accomplished with acceptable morbidity.


METHODS
To evaluate quality of life following radical retropubic prostatectomy, patient reported outcomes of 62 men who underwent radical retropubic prostatectomy at this institution were recorded during the first 18 months of followup. By 18 months 93% of the patients were dry (wearing no pads) and 93% to 98% characterized urinary bothersomeness as none or small. Potency, defined as the ability to achieve unassisted intercourse with or without the use of sildenafil, improved gradually and by 18 months 86% of the patients were potent and 84% considered sexual bothersomeness as none or small. In an effort to improve the outcome of radical prostatectomy, the surgical procedures on these 62 patients were videotaped prospectively. The videotapes were reviewed 18 months after the study was initiated and 4 specific steps in the surgical procedure were correlated with patient reported outcomes. Surgeons who wish to improve their outcomes should consider using this technique to identify in their own hands other important arbitrary variations that may improve results.


RESULTS
The probability of maintaining an undetectable prostate specific antigen was evaluated in men with similar pathological stages of disease who were or were not potent following surgery. Men who were potent had the same outcome as those who were impotent, supporting the premise that preservation of sexual function does not compromise cancer control. Cancer control and quality of life following brachytherapy were analyzed and the following conclusions were made: 1) high dose intensification is necessary if radiation therapy is expected to cure prostate cancer but I doubt that any form of radiotherapy will produce durable cancer control for 20 to 30 years; 2) although brachytherapy is rarely adequate as monotherapy, I am not certain that brachytherapy combined with external beam radiotherapy is any better than 3-dimensional conformal therapy alone and the side effects are uncertain, and 3) I believe that a prostate specific antigen nadir of less than 0.2 ng./ml. is necessary to confirm an adequate response to radiation.


CONCLUSIONS
I believe that there is no better way to cure organ confined cancer than total surgical removal. Today continence and potency rates should be high. If not, a review of intraoperative videotapes of successful and unsuccessful cases can improve results. In men treated with radiotherapy stringent criteria for treatment response and quality of life outcomes are needed.
Walsh
P C
PC
James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
D000230:Adenocarcinoma / Q000601:surgery*; D001918:Brachytherapy; D007172:Erectile Dysfunction / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D008297:Male; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000601:surgery*; D011788:Quality of Life; D013997:Time Factors; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000209:etiology