Radical perineal prostatectomy: Oncological outcome during a 20-year period

Purpose: We examined 4 postulates: 1) radical perineal prostatectomy provid es a substantial disease control benefit in men with clinically confined pr ostate cancer, 2) postoperative prostate specific antigen (PSA) levels are an excellent surrogate end point for defining disease control, 3) the biolo gy of primary malignancy defines the interval to death after recurrence and 4) the interval from intervention to death from recurrence is so long that current series of alternative curative therapies have insufficient duratio n of observation to permit a comparison with the results of surgery. Materials and Methods: A total of 1,242 men with a median age of 65.2 years who had stage cT1 to 2 N0M0 disease underwent radical perineal prostatecto my. The final pathology specimen was characterized in regard to disease ext ent, and Gleason grade and score. Patients were followed at 2 weeks, at 2 m onths and then at 6-month intervals for biochemical, physical and radiograp hic evidence of disease recurrence. Outcome was evaluated by determining ti me to biochemical failure (PSA 0.5 ng./ml. or greater) and cancer associate d death. Results: Median time to noncancer death was 19.3 years. Median cancer assoc iated death end point was not reached by patients with organ and specimen c onfined disease, while it was 12.7 years for margin positive disease. At 5 years 8, 35 and 65% of the patients with organ confined, specimen confined and margin positive disease, respectively, had PSA failure. This served as an excellent surrogate end point, preceding cancer associated death by 5 to 12 years depending on the biological aggressiveness predicted by Gleason g rade or score. Biologically aggressive organ confined disease that had been surgically removed was associated with a high percentage of disease-free s urvival. Conclusions: Our study con-firms our postulates. It also provides guideline s for comparing therapies among institutions and emphasizes that enthusiasm for new treatments may be based on insufficient followup. Patient selectio n may severely bias outcome independent of treatment when death is used as the end point. Our study establishes the value of PSA as a surrogate end po int.