RE: AN EVALUATION OF THE DECREASING INCIDENCE OF POSITIVE SURGICAL MARGINS IN A LARGE RETROPUBIC
PROSTATECTOMY SERIES
M. Han, A. W. Partin, D. Y. Chan and P. C. Walsh J Urol, 171: 23–26, 2004
To the Editor. The term “organ confined disease” means cancer con-tained within the prostate gland. “Specimen confined disease” means prostate cancer contained within the anatomical (nerve sparing) radical retropubic prostatectomy specimen of the prostate, pros-tate capsule and seminal vesicles. By definition radical retropubic prostatectomy specimens that are “pathological T3” are not “organ confined,” as there is capsule invasion in these specimens.
The data presented in table 2 in this article confuse “organ con-fined disease” and “specimen concon-fined disease” or “clinically localized disease.” The prostate develops from the confluence of wolffian and mullerian elements in the urogenital sinus and becomes the postero-lateral area (peripheral zone) of the prostate when the urogenital septum separates the prostate from the rectum. More than 90% of prostate cancer develops from prostate epithelial cells in the postero-lateral area (peripheral zone) of the prostate, where the prostate epithelial cells are compressed against the prostate capsule by be-nign prostatic hyperplasia, an area easily biopsied by digitally di-rected transrectal biopsy. This embryonic origin of the prostate ex-plains the “organ confined” rate of only 50% in most larger series of radical prostatectomies.1 – 4
Local microscopic capsule invasion occurs early in prostatic cancer. Prostate cancer is frequently a systemic disease at the time of diag-nosis. A recent study showed that early radical prostatectomy did not extend life expectancy (survival) over expectant treatment, and the prostate cancer death rate was decreased from 8.9% to 4.6% by radical prostatectomy.5 Less than 3% of the men with recurrent
prostate cancer had local recurrence without systemic recurrence. Local disease was not the cause of prostatic cancer death.
As Willet Whitmore asked, “When cure is possible, is it necessary? When cure is necessary, is it possible?”4A critical assessment of the
articles on radical prostatectomy would have saved urologists from explaining to oncologists that an operation with 50% pathological “nonorgan confined disease” is helpful in the cure of prostate cancer and has little or no effect on long-term survival.
Respectfully, W. Reid Pitts
New York Presbyterian Hospital/Weill Cornell Medical College 115 E. 61st St.
11th Floor
New York, New York 10021
1. Pitts, W. R., Jr.: Outcome research after radical retropubic pros-tatectomy for prostate cancer. J Natl Cancer Inst, 90: 1107, 1998
2. Garnick, M. B. and Fair, W. R.: Prostate cancer: emerging con-cepts. Part I. Ann Intern Med, 125: 118, 1996
3. Morton, H. M., Steiner, P. L. and Walsh, P. C.: Cancer control following anatomical radical prostatectomy: an interval re-port. J Urol, 145: 1197, 1991
4. Pitts, W. R., Jr.: Re: Editorial: The prostate puzzle. J Urol, 160: 1441, 1998
5. Holmberg, L., Bill-Axelson, A., Helgesen, F., Salo, J. O., Folmerz, P., Haggman, M. et al: A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med, 347: 781, 2002
To the Editor. The huge series documented by Han et al demon-strates that early detection programs result in a downward stage migration, increased cases of organ confined disease and decreased cases with positive surgical margins. However, it is widely accepted that autopsy series have shown a prevalence of prostate cancer in more than 60% of men in their eighties, whereas data from the Surveillance, Epidemiology and End Results program of the Na-tional Cancer Institute indicate that the lifetime probability of dying of prostate cancer is 3% and of symptoms developing is 8%.1The
threshold used to distinguish between significant and insignificant cancer was 0.5 cm3excluding any poorly differentiated Gleason 4 or
5 cancers.2It would be interesting to assess, with a morphometric
measurement of prostate cancer volume, whether the stage
migra-tion related to early detecmigra-tion programs is also related to an increase in clinically insignificant prostate cancer, considering that more than 65% of patients treated with radical prostatectomy between 1997 and 2001 by Han et al presented with Gleason score 6 or less and more than 70% had organ confined disease.
Respectfully,
Bernardo Rocco, Ottavio de Cobelli and Francesco Rocco Urology Department
European Institute of Oncology and Clinica Urologica I
Ospedale policlinico Milan, Italy
1. Hautmann, S. H., Conrad, S., Henke, R. P., Erbersdobler, A., Simon, J., Straub, M. et al: Detection rate of histologically insignificant prostate cancer with systematic sextant biopsies and fine needle aspiration cytology. J Urol, 163: 1734, 2000 2. Stamey, T. A., Freiha, F. S., McNeal, J. E., Redwine, E. A.,
Whittemore, A. S. and Schmid, H. P.: Localized prostate can-cer. Relationship of tumor volume to clinical significance for treatment of prostate cancer. Cancer, 71: 933, 1993
DOI: 10.1097/01.ju.0000133181.94746.b5
RE: SUCCESSFUL TRANSFER OF OPEN SURGICAL SKILLS TO A LAPAROSCOPIC ENVIRONMENT USING A ROBOTIC INTERFACE: INITIAL EXPERIENCE WITH LAPAROSCOPIC
RADICAL PROSTATECTOMY
T. E. Ahlering, D. Skarecky, D. Lee and R. V. Clayman J Urol, 170: 1738 –1741, 2003
To the Editor. We read this article with interest and are much encouraged. The authors noted the learning curve to 4-hour profi-ciency to be 12 cases. This finding is of significant bearing in our setting, the first center in Asia to use the da Vinci robot primarily for urology. We have a predominantly Chinese population of 4 million with a low age standardized incidence of prostate cancer at 13.0 per 100,000 per year. The team of 3 surgeons has moderate experience in open prostatectomy but modest experience in laparoscopy. The spe-cific laparoscopic skill for prostatectomy was acquired via overseas training, while the robot handling skills were acquired by attendance at a robotic surgery symposium, site visits and laboratory training. Most significantly, we found that on-site expert advice was pivotal in the introduction of the program (cases 1to 3) and the modification of the Montsouris1technique to the Vattikuti Institute2prostatectomy
(cases 9 and 10). The current da Vinci technology was difficult for telesurgery/telementoring per se, and the physical presence of the expert may be required for a number of moderate volume centers, at least in the beginning. On the other hand, this study demonstrates the beauty of working in a console where surgical assistance can be offered selectively and in a leisurely manner.
During a period of 8 months we successfully performed 17 robot assisted laparoscopic radical prostatectomies (Montsouris technique for the first 8 patients, and Vattikuti Institute prostatectomy for the next 9), where our annual average number of open retropubic prostatectomies is only 25. We found that our perioperative statistics improved significantly after the first 8 cases. The first 8 patients had a mean preparation time of 47 minutes and dissection time of 284 minutes, while the subsequent 9 patients had a mean preparation time of 23 minutes and dissection time of 215 minutes. Intraoperative estimated blood loss decreased from a median of 650 cc to 400 cc. As a result, length of stay after surgery improved from a mean of 3.8 days to 1.8 days.
Currently, we offer robotic assisted surgery as the preferred sur-gical option (over open surgery) to our patients with clinically local-ized prostate cancer. Thus, we concur with the authors that the robotic interface can decrease the learning curve tremendously to make it feasible even in a lower volume setting.
Respectfully,
H. G. Sim, S. K. Yip and W. S. Cheng Department of Urology
Singapore General Hospital Singapore 169608
LETTERS TO THE EDITOR
