RADICAL PROSTATECTOMY IN LYMPH-NODE POSIT IVE DISEASE

Lymph-node metastases of prostate carcinoma are indicative of a system ic disease, thus a local treatment like radical prostatectomy is consi dered inadequate. However, due to the good results of surgery despite node-positive disease at the Mayo Clinic and as reported by Frohmuller et al. (1995), the value of radical prostatectomy is still under disc ussion. Retrospectively, 111 patients who were candidates for radical prostatectomy between 1976 and 1990 were studied. 67 patients had the operation, but in 44 patients the operation was discontinued after pos itive pelvic lymph-nodes were found. Following radical surgery 70.1% r eceived an adjuvant therapy (androgen deprivation 39, irradiation 6, c ombination 2), the remaining patients received androgen deprivation at the time of progression. In the lymphadenectomy-only group the patien ts received hormonal therapy (33), irradiation (4) era combination (7) . After a mean follow-up of 4.8 years, 108/111 patients were re-examin ed. In the radical prostatectomy group 40.3% had stage pN(1) and 56.7% stage pN(2), however, in the lymphadenectomy group only 11.4% had sta ge pN(1) versus 79.5% stage pN(2). There were no postoperative deaths. Severe complications were significantly more common in the radical pr ostatectomy group. In the latter group, the median time of hospitaliza tion was 30 days versus 18 days in the ether group. Cancer-specific su rvival following radical prostatectomy was at 5 years 87.5%, at 10 yea rs 60.7% versus 50.3% and 20% in the lymphadenectomy group. When compa ring the cancer specific survival rates for both groups in stage pN(2) , there was no statistically significant difference. The lower progres sion rates following radical prostatectomy in comparison to lymphadene ctomy-only almost equalized when a subgroup analysis for stage pN(2) w as carried out. Even the time-to-local-progression of patients with st age pN(2) was not statistically different in both groups. In a multiva riate analysis including measurable parameters this was confirmed. Inc ontinence and strictured anastomosis was a disadvantage following radi cal prostatectomy. In contrast, local progression was noticed mainly i n patients following lymphadenectomy-only. Accordingly, in the latter group, 1.57 rehospitalizations per patient were necessary in contrast to 0.7 per patient in the other group. In essence, the positive presel ection of patients subjected to radical prostatectomy despite lymph-no de metastases explains the presumably better results when the time-to- progression or the survival rates are measured. The shortened lead-tim e for patients with lymphadenectomy only plus conservative primary the rapy is probably responsible for the shorter time-to-progression. The favourable local progression rates after radical prostatectomy have to be weighed against the higher complication rate.