Patient Selection Robotic Prostatectomy

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HalO'Thane

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Do urologists have any specific criteria for selecting suitable candidates for robotic prostatectomies based on age and/or co-morbidities? My understanding is that the 10 year survival rate for patients with non-metastatic prostate cancer undergoing robotic prostatectomies are very high (greater than 95%). However, I wasn't sure if the patients who presented for these surgeries were already pre screened and were healthier and/or younger than the overall population of patients diagnosed with prostate cancer. If a patient is > 75 y.o., for example, would they still be considered a candidate for a robotic prostatectomy or would they be referred for radiation therapy or observation/serial biopsies? If they are referred for surgery, would the risks of surgery (anesthesia, post op complications, etc.) be considered greater than the risks of the untreated cancer?

I apologize in advance if this topic has already been covered or if this not the appropriate forum for this question.

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Do urologists have any specific criteria for selecting suitable candidates for robotic prostatectomies based on age and/or co-morbidities? My understanding is that the 10 year survival rate for patients with non-metastatic prostate cancer undergoing robotic prostatectomies are very high (greater than 95%). However, I wasn't sure if the patients who presented for these surgeries were already pre screened and were healthier and/or younger than the overall population of patients diagnosed with prostate cancer. If a patient is > 75 y.o., for example, would they still be considered a candidate for a robotic prostatectomy or would they be referred for radiation therapy or observation/serial biopsies? If they are referred for surgery, would the risks of surgery (anesthesia, post op complications, etc.) be considered greater than the risks of the untreated cancer?

I apologize in advance if this topic has already been covered or if this not the appropriate forum for this question.

Read the nccn guidelines:

www.nccn.org

In brief the 10-year survival for all patients undergoing prostatectomies is significantly less than 95%. Prostatectomies should really only be completed for young patients with low-risk prostate cancers (and possibly a select group of intermediate risk prostate cancers). Any higher risk group should be treated with radiotherapy with androgen deprivation therapy due to the very high risk of extraprostatic disease. Unfortunately economics play a huge factor (especially in non-academic settings) where the private practice urologist would operate despite the lack of evidence for any benefit in surgery just to make more dough.
 
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Read the nccn guidelines:

www.nccn.org

In brief the 10-year survival for all patients undergoing prostatectomies is significantly less than 95%. Prostatectomies should really only be completed for young patients with low-risk prostate cancers (and possibly a select group of intermediate risk prostate cancers). Any higher risk group should be treated with radiotherapy with androgen deprivation therapy due to the very high risk of extraprostatic disease. Unfortunately economics play a huge factor (especially in non-academic settings) where the private practice urologist would operate despite the lack of evidence for any benefit in surgery just to make more dough.

I'm noticing a pattern with you mp which is make blanket statements and link to the NCCN guidelines as if your statements are supported to these guidelines (when they are not). In general, I agree that older patients (<10 year life expectancy) should be managed with active surveillance (preferred) or EBRT + ADT for higher risk disease. RP remains an option for select patients in both high and very high risk groups -- typically younger/healthier patients. It says this right in the guidelines.

In answer to the original question: decision making for prostate cancer is usually quite complex. Competing risks for the patient need to be assessed and there are usually multiple valid treatment options. Use of the NCCN guidelines and multiple available risk stratification tools are helpful. The reason RP is usually not offered in older patients, is because they are unlikely to realize the benefits of therapy in their remaining life. Traditionally, urologists were taught that RP shouldn't be done in patients over 70, but I think a 10 year life expectancy is a more appropriate metric. There are some 70 year olds who may have 20+ years left, and there are some 50 year olds who are extremely unhealthy and don't have 5 years left. Ultimately, after an honest discussion of the competing risks the patient has to decide what is best for him.

Be wary of people who say you always have to do X or Y for a certain disease. Medical decision making is usually more complex. This is particularly true in prostate cancer.
 
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I'm noticing a pattern with you mp which is make blanket statements and link to the NCCN guidelines as if your statements are supported to these guidelines (when they are not). In general, I agree that older patients (<10 year life expectancy) should be managed with active surveillance (preferred) or EBRT + ADT for higher risk disease. RP remains an option for select patients in both high and very high risk groups -- typically younger/healthier patients. It says this right in the guidelines.

.

Only if you want to butcher the patient. It's a low-category recommendation in the guidelines (ie you shouldn't do it as a category 3 recommendation is against the standard of care and NCCN clearly states that the category 1 recommendation is radiotherapy and ADT for high-risk prostate cancer). Be more wary of people trying to profit off of patients with cancer.
 
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It's not category 3. It's category 2A. I don't expect you to understand the difference. Just because there isn't an RCT, doesn't mean a treatment is malpractice.

FYI it's more lucrative to spend 4 hours in my office than to do an RP. If I was profit-driven I'd give everyone radiation or AS.
 
It's not category 3. It's category 2A. I don't expect you to understand the difference. Just because there isn't an RCT, doesn't mean a treatment is malpractice.

FYI it's more lucrative to spend 4 hours in my office than to do an RP. If I was profit-driven I'd give everyone radiation or AS.

I was teaching you what the categories of NCCN guidelines mean, not stating that prostatectomy is category 3 (again, you really should read something before you argue for or against it). NCCN clearly states that radiotherapy is category 1 (ie supported by randomized trials) for high and very-high risk prostate cancers and it's sad to know that you would pick a lower category recommendation instead. BTW the lawyer of the patient whose suing my local urologist would disagree that it's not malpractice :p
 
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