A trend towards surgical treatment of more aggressive prostate cancer (PCa) was reported at high volume centers due to better patient selection. However, whether such inverse stage migration is paralleled also by improvement in functional outcomes over time has not been fully assessed yet. We analysed the patterns of clinical and pathological tumour characteristics and patient-related mid-term functional outcomes over the last decade at two high-volume centers.
The study included 2,205 PCa patients who received robot-assisted radical prostatectomy (RARP) at two European tertiary referral centers between 2008 and 2017. Only men with at least 12 months of follow-up and complete data on functional outcomes, namely urinary continence (UC) and erectile function (EF), were included. EF recovery was defined as IIEF-EF score ≥22, while UC recovery was defined as being completely pad-free over the 24 hours. Lowess functions graphically represented temporal trends in clinical and pathological characteristics and functional outcomes at 12 months. Estimated annual percentage changes (EAPCs) were calculated. Multivariable logistic regression analyses (MVA) assessed the relationship between year of surgery (2008-2012 [historical] vs. 2012-2017 [contemporary]) and functional outcomes. Covariates consisted of age, body mass index (BMI), D’Amico risk groups, nerve sparing technique, pathological stage, prostate volume and adjuvant therapies. The same analyses were repeated using year of surgery as a continuous variable.
Overall, 1602 (82%) and 376 (18%) achieved complete UC and EF recovery at 12 months, respectively. During the study period, UC recovery remained stable (EAPC -1.0%, p=0.08), with the highest rate recorded in 2008 (91%). Similarly, EF recovery rates did not vary over the study period (EAPC -1.4%, p=0.6). We observed a considerable decrease in the rate of low risk patients treated with RARP (from 49 to 18%; p<0.001), while the rates of intermediate (from 49 to 59%, p=0.02) and high (from 2 to 23%, p<0.001) risk patients sharply increased. Similar trend was reported after stratification for pathological stage, where we observed a sharp increase of pT3a (from 13 to 32%; p<0.001) and ≥pT3b (from 1 to 9%; p<0.001) tumours treated with RARP. At MVA, more recent years of surgery did not exhibit a protective effect on both UC (HR:1.12; p=0.4) and EF recovery at 12 months (HR:0.86; p=0.3), even when coded as a continuous variable.
Over the last decade, a stage migration towards more aggressive and locally advanced disease was observed in patients treated with RARP at two high-volume, tertiary referral centers. These findings may explain the stable rates of UC and EF recovery at 12 months observed over time despite refinements in surgical approach and improved skills.