Outcome in radical perineal prostatectomy

Purpose: We present our experience with the radical perineal prostatectomy (RPP) in the treatment of clinically confined prostate cancer in a large se ries 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 di sease control were investigated. Material and Methods: A total of 1,242 men with clinical stage T1-T2 NO MO disease underwent radical perineal prostatectomy (RPP) in a 24 year period from 1972 to 1996. Prostatectomy specimens were characterized histopatholog ically by Gleason grade and score, and the extent of disease (organ-confine d, specimen-confined or margin positive). Patients were routinely followed at 2 months and then at 6-months intervals for biochemical, physical and ra diographic evidence of recurrence. Results: No patient received adjuvant postoperative therapy unless there wa s documented evidence of recurrence. As endpoints of clinical outcome we an alyzed the time to biochemical failure (PSA 0.5 ng/ml or greater) and cance r 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 patie nts with organ and specimen confined disease during the period of follow-up , while patients with margin positive disease had a median cancer associate d time to death of 12.7 years. PSA failure preceded cancer associated death by 5 to 72 years depending on the biological aggressiveness ness 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 dise ase were 8%, 35% and 65% respectively. Organ confined, high grade disease w as 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 endpoin t 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 t he interval between surgical intervention and death from recurrence.