Introduction

Long-term data on the outcomes of aggressive loco-regional surgical resection in prostate cancer (PCa) with nodal involvement are lacking. The present study reports on the impact of adding radical retropubic prostatectomy (RRP) to surgical castration on long-term cancer-specific (CSS) and overall survival (OS) outcomes in men with pathological node-positive (pN+) PCa.

Methods

Men with pN+ PCa who underwent pelvic lymphadenectomy and early bilateral orchiectomy (within 90 days of surgery), with (n=382) or without (n=79) RRP, were identified (1966-1995). Men who underwent RRP + orchiectomy and men who underwent orchiectomy alone were matched 1:1 on age, year of surgery, clinical grade, clinical stage, number of positive nodes, and pre-operative serum PSA level (after 1987). Kaplan-Meier and Cox regression analyses were used to compare CSS and OS between groups.

Results

The cohort included 158 men (79 in each group) with a mean age of 66 years (SD=6), of whom 146 (92%) were followed until death. Groups were balanced on all matched parameters. Among men undergoing orchiectomy alone, 76 died, with 60 dying from PCa. Among patients undergoing RRP + orchiectomy, 70 died, with 28 dying from PCa. On Kaplan-Meier analyses, RRP + orchiectomy versus orchiectomy alone was associated with significantly improved CSS at 10 years (79% vs. 35%) and 20 years (59% vs. 18%) (log-rank p<0.001). Likewise, RRP + orchiectomy versus orchiectomy alone was also associated with prolonged OS at 10 years (66% vs 27%) and 20 years (22% vs. 9%)(log-rank p<0.001). In Cox models, RRP + orchiectomy versus orchiectomy alone was associated with significantly improved CSS (HR=0.28, 95%CI=0.17-0.46, p<0.001) and OS (HR=0.48, 95%CI=0.34-0.66, p<0.001). Findings were similar in the subset with available pre-operative PSA (CSS: HR=0.31, 95%CI=0.16-0.61, p<0.001; OS: HR=0.45, 95%CI=0.26-0.77, p=0.004).

Conclusions

With nearly the entire cohort having lifelong follow up, this analysis demonstrates that the addition of RRP to surgical castration for pN+ PCa is associated with improved CSS and OS. When technically feasible in well-selected patients, aggressive loco-regional resection should be considered in node-positive PCa as a part of a multi-modal approach.

Funding

None