Propensity Score Vergleich der verschiedenen radikalen Operationstechniken beim high risk Prostatakarzinom

Zusammenfassung

Einleitung: Die Behandlung von Patienten mit einem high risk Prostatakarzinom (PCa) bleibt hinsichtlich der Wahl des geeigneten operative Verfahrens der radikalen Prostatektomie (RP) kontrovers: offene retropubisch RP (RRP), laparoskopisch RP (LRP) oder Roboter-assistiert (RARP). Ziel dieser Arbeit war es, den Einfluss der unterschiedlichen Techniken auf das histopathologische Ergebnis sowie auf die biochemischen Rezidivraten zu untersuchen.

Patienten und Methoden: Insgesamt wurden 805 Patienten mit einem high risk PCa (PSA >20 ng/mL, Gleason Score ≥8, oder klinisches Stadium ≥cT2c) identifiziert. Der Vergleich von 407 RRP Patienten mit 398 Fällen, die minimal invasiv operiert wurden (LRP+RARP) ergab deutliche Störgrößen. Dementsprechend wurden alle 110 RARP Fälle mit dem Propensity Score (PS) 1:1 gegen LRP und RRP Fälle gematched. Der PS beinhaltete Alter, klinisches Tumorstadium, präoperativer PSA, Gleason Score der Biopsie, die Erfahrung des Operateurs sowie die Anwendung einer nerverhaltenden Operationstechnik. Die Patientencharakteristika wurden mit geeigneten Testverfahren verglichen. Vergleich von Gesamtüberleben (OS) und Rezidiv-freiem Überleben (RFS) mit dem log rank Test. Die RFS Prädiktoranalyse erfolgte mithilfe von Cox Regressionsmodellen.

Ergebnisse: Innerhalb der post-matching Kohorte von 330 Patienten lag der Anteil an Patienten mit einem pathologischen Gleason Score < 7, = 7 und > 7 bei 1,8, 55,5 und 42,7% für RARP, 8,2, 36,4, 55,5% für LRP sowie 0, 60,9 und 39,1% für RRP (p=0,004 für RARP vs. LRP und p=0,398 für RARP vs. RRP). Unterschiede bei den histopathologischen Stadien waren statistisch nicht signifikant. Die Gesamtrate an positiven Schnitträndern (PSM) sowie die PSM Rate für ≥pT3 waren nicht unterschiedlich. PSM bei pT2 betrug 15,7, 14,0 und 20,0% für RARP, LRP und RRP (statistisch nicht signifikant). Das mittlere 3-Jahres RFS lag bei jeweils 41,4, 77,9, 54,1% (p<0,0001 für RARP vs. LRP und p=0,686 für RARP vs. RRP). Das mittlere 3-Jahres OS wurde jeweils mit 95,4, 98,1 und 100% berechnet (statistisch nicht unterschiedlich).

Schlussfolgerung: RARP kann bei high risk PCa Patienten mit der LRP und RRP vergleichbaren pathologischen sowie onkologischen Ergebnissen angewendet werden.

Abstract

Introduction: The optimal surgical treatment of patients with a high risk prostate cancer (PCa) in terms of radical prostatectomy (RP) is still controversial: open retropubic RP (RRP), laparoscopic RP (LRP), or robot-assisted (RARP). We aimed to investigate the influence of the different surgical techniques on pathologic outcome and biochemical recurrence.

Patients and Methods: A total of 805 patients with a high risk PCa (PSA >20 ng/mL, Gleason Score ≥8, or clinical stage ≥cT2c) were included. A comparison of 407 RRP patients with 398 minimally invasive cases (LRP+RARP) revealed significant confounders. Therefore all 110 RARP cases were propensity score (PS) matched 1:1 with LRP and RRP patients. PS included age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon’s experience and application of a nerve sparing technique. Comparison of overall survival (OS) and recurrence-free survival (RFS) was done with the log rank test. Predictors of RFS were analyzed by means of Cox regression models.

Results: Within the post-matching cohort of 330 patients a pathologic Gleason score < 7, = 7 and > 7 was found in 1.8, 55.5 and 42.7% for RARP, in 8.2, 36.4, 55.5% for LRP and in 0, 60.9 and 39.1% for RRP (p=0.004 for RARP vs. LRP and p=0.398 for RARP vs. RRP). Differences in histopathologic stages were not statistically significant. The overall positive surgical margin rate (PSM) as well as PSM for ≥ pT3 were not different. PSM among patients with pT2 was found in 15.7, 14.0 and 20.0% for RARP, LRP and RRP (statistically not significant). The respective mean 3-year RFS rates were 41.4, 77.9, 54.1% (p<0.0001 for RARP vs. LRP and p=0.686 for RARP vs. RRP). The mean 3-year OS was calculated as 95.4, 98.1 and 100% respectively (statistically not significant).

Conclusion: RARP for patients with a high risk PCa reveals similar pathologic and oncologic outcomes compared with LRP and RRP.

Schlüsselwörter

Prostatakarzinom - Prostatektomie - Laparoskopie - Roboterchirugie - onkologisches Outcome - Propensity Score Matching - High Risk

Key words

prostate cancer - prostatectomy - laparoscopy - robotic surgery - oncologic outcome - propensity score matching - high risk

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