Zusammenfassung
Wir berichten über unsere Erfahrungen mit der radikalen perinealen Prostatektomie
(RPP) an einem Kollektiv von 1242 Patienten mit klinisch organbegrenztem Prostatakarzinom
(Stadien T1 - T2 N0 M0). In diesem Patientenkollektiv betrug der durchschnittliche
Zeitraum bis zum Eintreten eines nicht tumorassoziierten Todes 19,3 Jahre. Bei Patienten
mit kapselbegrenztem und kapselüberschreitendem Prostatakarzinom, das jedoch vollständig
(mit negativen Absetzungsrändern) entfernt werden konnte, wurde die mittlere tumorassoziierte
Überlebenszeit nicht erreicht. Patienten mit positiven Absetzungsrändern hatten hingegen
eine mittlere tumorassoziierte Überlebenszeit von 12,7 Jahre. Ein PSA-Anstieg als
Zeichen eines Rezidivs ging dem tumorassoziierten Tod des Patienten in Abhängigkeit
von Gleason Grad und Summe als Ausdruck der biologischen Tumoraggressivität um durchschnittlich
5 bis 12 Jahre voraus. Gleason Grad und Summe waren entscheidende prognostische Faktoren
für die Länge des Zeitraums zwischen RPP und tumorassoziiertem Tod. Zusammenfassend
läßt sich sagen, daß die RPP bei Patienten mit organbegrenztem Prostatakarzinom eine
effektive Tumorkontrolle leistet und der Mehrzahl der Patienten ein langes tumorfreies
Überleben ermöglicht.
Abstract
Purpose: We present our experience with the radical perineal prostatectomy (RPP) in the treatment
of clinically confined prostate cancer in a large series of consecutive patients.
The importance of the biology of the primary tumor in regards to disease recurrence
and progression, as well as the role of prostate specific antigen (PSA) as a surrogate
endpoint for defining disease control were investigated.Material and Methods: A total of 1,242 men with clinical stage T1 - T2 N0 M0 disease underwent radical
perineal prostatectomy (RPP) in a 24 year period from 1972 to 1996. Prostatectomy
specimens were characterized histopathologically by Gleason grade and score, and the
extent of disease (organ-confined, specimen-confined or margin positive). Patients
were routinely followed at 2 months and then at 6-months intervals for biochemical,
physical and radiographic evidence of recurrence.Results: No patient received adjuvant postoperative therapy unless there was documented evidence
of recurrence. As endpoints of clinical outcome we analyzed the time to biochemical
failure (PSA 0.5 ng/ml or greater) and cancer associated death, which was defined
as patient death of any cause with a biologically active malignancy. The median time
to noncancer death was 19.3 years. The median time to cancer associated death was
not reached by patients with organ and specimen confined disease during the period
of follow-up, while patients with margin positive disease had a median cancer associated
time to death of 12.7 years. PSA failure preceded cancer associated death by 5 to
12 years depending on the biological aggressiveness predicted by Gleason grade and
score. Overall PSA failure rate at 5 years follow-up of patients with organ confined,
specimen confined and margin positive disease were 8 %, 35 % and 65 % respectively.
Organ confined, high grade disease was associated with a high percentage of disease-free
survival.Conclusions: RPP provides a substantial disease control benefit in men with clinically confined
prostate cancer. PSA is an excellent surrogate endpoint for defining disease control
in these patients. The biology of the cancer as predicted by the Gleason grade and
score is an important predictor of the interval between surgical intervention and
death from recurrence.
Key words:
perineal prostatectomy - Gleason score - PSA
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Prof. Dr. med. David F. Paulson
Chief, Division of Urology, Department of Surgery Duke University Medical Center
Box 2977
Durham, NC 27710, USA
