european urology 51 (2007)

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1 european urology 51 (2007) available at journal homepage: Laparoscopy Laparoscopic Radical Prostatectomy in Men Older than 70 Years of Age with Localized Prostate Cancer: Comparison of Morbidity, Reconvalescence, and Short-Term Clinical Outcomes between Younger and Older Men Vassilis Poulakis *, Ulrich Witzsch, Rachelle de Vries, Wolfgang Dillenburg, Eduard Becht Department of Urology and Pediatric Urology, Northwest Hospital, Stiftung Hospital zum Heiligen Geist, Frankfurt am Main, Germany Article info Article history: Accepted December 6, 2006 Published online ahead of print on December 14, 2006 Keywords: Prostate Prostate neoplasms Laparoscopy Prostatectomy Elderly Abstract Objectives: To analyze the safety and efficacy of extraperitoneal laparoscopic radical prostatectomy (el-rpe) in elderly versus younger men with localized prostate cancer. Methods: Patients undergoing el-rpe were retrospectively subdivided into group el-rpe1 (72 men aged 71 yr and older) and group el-rpe2 (132 men aged 59 yr and younger). Group el-rpe1 was compared with a group of 70 contemporary, comparable patients aged 71 yr and older undergoing open retropubic radical prostatectomy (group OPEN-RPE). Results: Compared with group el-rpe2, patients of group el-rpe1 had a higher pathologic stage (45% vs. 32% stage pt3 or greater, p < 0.001) and higher Gleason score (median 7 vs. 6, p < 0.001). Prostate-specific antigen recurrence was significantly worse compared with age-matched controls for younger patients with high-stage or high-grade lesions ( p < 0.001). Importantly operative time, analgesic requirements, hospital stay, convalescence, and complication rates were comparable. Urinary continence rate was significantly better in group el-rpe2 at 6 mo (67% vs. 91%, respectively, p < 0.001). Group el-rpe1 and group OPEN-RPE patients had statistically similar pathologic stage and Gleason score (each p > 0.05), similar operative time ( p = 0.12), but less blood loss ( p < 0.001), shorter hospital stay ( p < 0.001), and more rapid convalescence ( p < 0.001) occurred in el-rpe1. Conclusions: el-rpe is feasible and efficacious even in elderly patients with unfavorable, large-volume disease. el-rpe offers the advantages of decreased blood loss, shorter hospital stay, and more rapid recovery over OPEN-RPE. However, the elderly patient must be informed preoperatively about the observed higher incontinence rate. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology and Pediatric Urology, Nordwest Hospital, Steinbacher Hohl 2-26, D Frankfurt am Main, Germany. Tel address: vpoulakis@aol.com, vpoulakis@hotmail.com (V. Poulakis) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 1342 european urology 51 (2007) Introduction Prostate cancer (pca) is one of the most common cancers in Western countries and a disease predominantly of the elderly [1]. This trend is expected to continue well into the new century because, with improvement in health care and medical technology, the population of these countries has aged progressively [1]. Therefore the issue of managing pca in the elderly is of increasing importance. In the guidelines of the European Association of Urology (EAU), no upper age limit is recommended for the performance of radical prostatectomy (RPE) in patients with clinically localized pca [2]. However, many physicians believe that men whose disease is diagnosed at ages >70 yr will not benefit from a RPE because in this patient group the morbidity of RPE is too high and these patients are likely to die of causes other than pca. Thus, other less invasive and potentially less effective forms of treatment for localized pca are proposed in the elderly. Conversely, others have shown that RPE can be performed safely in carefully selected elderly patients [3,4]. However, no study has examined the safety and the effectiveness of laparoscopic RPE in patients aged >70 yr. Believing in the advantages of the laparoscopic approach [5 10] and as our laparoscopic experience has grown [11,12] we extended the indications for extraperitoneal laparoscopic RPE (el-rpe) to include properly selected elderly patients with clinically localized pca. We report our experience with el-rpe in elderly patients and compare it with el-rpe in younger men and open RPE in a comparable elderly patient group. 2. Material and methods The medical records of patients, who underwent el-rpe and pelvic lymphadenectomy since January 2004 for clinically localized pca were retrospectively reviewed. Patients, who had follow-up shorter than 6 mo were excluded. Patients undergoing el-rpe were subdivided into group el-rpe1 (72 men aged 71 yr and older) and group el-rpe2 (132 men aged 59 yr and younger). Additionally, patients in group el-rpe1 were compared with a comparable cohort of 70 patients who had undergone open retropubic RPE (group OPEN-RPE) at our institution since July 2000 for clinically localized pca. The techniques used for the laparoscopic [11,12] and open surgical [13] approaches were standardized. No robotic-assisted technique was used. Groups el-rpe2 and OPEN-RPE were compared with the study group el-rpe1. The preoperative preparation and evaluation and the postoperative follow-up were similar for all patients, and were performed according to the EAU guidelines [2]. A single pathologist examined the specimens according to the Stanford protocol [14]. Positive surgical margin was defined as tumor cells at the ink site of surgical specimen. According to the degree of severity, complications were classified as major (life threatening or required stay of more than 24 h in the intensive care unit and reoperation), moderate (required reoperation or conversion or admission to the intensive care unit for less than 24 h), and minor (no requirement of admission to the intensive care unit, reoperation of conversion, or prolongation of hospitalization). The perioperative and the early postoperative (i.e., during the first 30 d after surgery) complications were registered. Late complications (i.e., occurred 30 d after surgery) were recorded by using follow-up examination according to the EUA guidelines [2]. Any detectable prostate-specific antigen (PSA) level (0.1 ng/ml) was considered as biochemical recurrence [15]. Medical comorbidity was assessed with a scoring algorithm, which placed patients in one of four groups: (1) no or asymptomatic disease, (2) controlled but mildly symptomatic disease, (3) uncontrolled and severely symptomatic disease, and (4) life-threatening comorbid disease [16]. This comorbidity scale was reliable and was validated in pca men [17]. Potency and urinary continence were evaluated by validated questionnaires, namely the International Index of Erectile Function [18] and the short form of the International Continence Society male questionnaire [19]. The use of no pads was defined as urinary continence. To measure the health-related quality of life (QoL), we used the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-30; version 3.0), which was validated in a normal German population [20] and used in German-speaking patients after retropubic RPE [21]. For pain assessment, the visual analogue scale (VAS) was used with ratings from 0 (no pain) to 10 (excruciating pain). For the QLQ-C30, norm-based and z scores were used to compare patients with age- and sex-matched normative data for the German general population. For comparison between the groups baseline functional and symptomatic data from the preoperative questionnaire for each subscale were normalized on a per-patient basis to 100%. Then, mean scores of QoL domains and subdomains at 3 and 6 mo after RPE were calculated, and the percentage of baseline function or symptom was interpreted. Because the baseline pretreatment QoL scores were collected before surgery, patients served as their own controls. We used logistic regression models to compare the return with baseline after treatment between the patients groups. A patient was considered to have returned to baseline when the score returned to actual pretreatment score on a particular subscale. For comparison of mean QoL scores at a single time between two different patient groups the Student t test was used. Postoperative QoL and VAS scores of each patient group during the whole follow-up period were compared with the use of analysis of covariance. Continuous variables were compared with the Mann- Whitney rank sum test, whereas categoric data were compared with the Fisher s exact and chi-square tests. Correlations between continuous variables were performed with the use of Spearman correlation coefficients. A p < 0.05 was considered statistically significant. Statistical analyses were performed with the use of commercially available software.

3 european urology 51 (2007) Table 1 Baseline (preoperative) characteristics in the three age groups of patients with clinically localized prostate cancer Preoperative baseline characteristics el-rpe1 (n = 72) el-rpe2 (n = 132) p value el-rpe2 vs. el-rpe1 OPEN-RPE (n = 70) p value OPEN-RPE Age (mean SD [yr]) < ns Median comorbidity (range) 2 (1 2) 1 (1 3) ns 2 (1 2) ns Prostate volume (mean SD [cm 3 ]) ns ns Body mass index (mean SD [kg/m 2 ]) ns 30 5 ns Previous operation(s) in lower 18 (35%) 41 (31%) ns 17 (32%) ns abdomen and pelvis (n [%]) PSA (mean SD [ng/ml]) < ns Clinical stage (n [%]) ct1c 6 (12%) 33 (25%) < (12%) ns ct2a/b 27 (53%) 64 (48%) 30 (56%) ct2c 18 (35%) 36 (27%) 17 (32%) Median Gleason score on biopsy (range) 7 (5 9) 6 (5 9) < (5 9) ns el-rpe1 = extraperitoneal laparoscopic radical prostatectomy in men aged 71 yr and older; el-rpe2 = extraperitoneal laparoscopic radical prostatectomy in men aged 59 yr and younger; OPEN-RPE = open retropubic radical prostatectomy in men aged 71 yr and older; SD = standard deviation; ns = nonsignificant. 3. Results The baseline and operative characteristics of the patient groups are illustrated in Tables 1 and 2. Patients aged 71 yr and older had pca in significantly higher clinical and pathologic stage with higher PSA and Gleason score (all p < 0.001) than patients aged <60 yr. Consecutively, in both older patient groups, positive surgical margins and PSA recurrence were significantly more frequent than in men aged <60 yr ( p < 0.001). All PSA recurrence patients had a Gleason score of 7 or higher. In groups Table 2 Perioperative and postoperative characteristics in the three age groups of patients with clinically localized prostate cancer Perioperative and postoperative characteristics el-rpe1 (n = 72) el-rpe2 (n = 132) p value el-rpe2 OPEN-RPE (n = 70) p value OPEN-RPE Final pathologic stage pt2a 3 (4%) 24 (18%) < (6%) ns pt2b 10 (14%) 28 (21%) 12 (17%) pt2c 27 (37%) 38 (29%) 24 (34%) pt3a 19 (27%) 26 (20%) 17 (25%) pt3b 13 (18%) 16 (12%) 13 (18%) Definite Gleason score in surgical specimen (median [range]) 7 (5 9) 6 (5 9) < (5 9) ns Operative time (mean SD [h]) ns ns Neurovascular preservation (n [%]) Unilateral 13 (18%) 41 (31%) < (16%) ns Bilateral 2 (3%) 30 (23%) 3 (4%) Positive surgical margins (total number [%]) 15 (21%) 14 (11%) (23%) ns pt2 (n [%]) 5 (12%) 6 (7%) ns 5 (12%) ns pt3 (n [%]) 10 (31%) 8 (19%) ns 11 (37%) ns PSA recurrence or persistent elevation (0.1 ng/ml) at 6-mo follow-up (n [%]) Intraoperative estimated blood loss (mean SD [ml]) Postoperative hemoglobin reduction in 24 h (mean SD [g/dl]) Intra- and postoperative banked blood transfusion (unit [%]) 10 (14%) 7 (5%) (16%) ns ns < ns < (3%) 3 (2%) ns 13 (24%) <0.001 el-rpe1 = extraperitoneal laparoscopic radical prostatectomy in men aged 71 yr and older; el-rpe2 = extraperitoneal laparoscopic radical prostatectomy in men aged 59 yr and younger; OPEN-RPE = open retropubic radical prostatectomy in men aged 71 yr and older; ns = nonsignificant; SD = standard deviation; PSA = prostate-specific antigen.

4 1344 european urology 51 (2007) el-rpe1, el-rpe2, and OPEN-RPE, the pathologic stage of PSA recurrence patients were pt3 in 9 patients and pt2c in 1, pt3 in 7, and pt3 in 10 and pt2c in 1, respectively. In el-rpe1 and OPEN-RPE men, neurovascular preservation was performed more infrequently than in el-rpe2 men. Patients who underwent el-rpe showed comparable intraoperative morbidity (measured as intraoperative estimated blood loss, postoperative hemoglobin reduction, and blood transfusion) independently from their age ( p > 0.05). Contrarily, in OPEN-RPE men, the intraoperative morbidity was significantly higher than that in men after el-rpe ( p < 0.001). Table 3 lists the outcomes relevant to convalescence and complication. Neither fistulae nor abscesses were observed. No patient death occurred. The complication rate was similar in both patient groups after el-rpe independent of the patients age. In OPEN-RPE men the minor and moderate complications were significantly more frequent than in group el-rpe1 (43% vs. 16%, respectively, p = 0.001). The major complications were statistically equal in the three groups. The incidence of respiratory insufficiency was greater in the elderly patients than in younger patients, but because of the low patient number this trend reached no statistical significance (two patients in el-rpe1 group, two in OPEN-RPE, and none in el-rpe2; p = for el-rpe1 vs. el-rpe2). Only the elderly patients (el-rpe1 and OPEN-RPE group) experienced delirium ( p = 0.002) and showed a significant delay in convalescence ( p < 0.05). OPEN- RPE men showed a longer catheterization time than the patients of a similar age class after an el-rpe ( p < 0.01). In both elderly groups the continence rate at 6-mo follow-up was similar and independent of the surgery art, that is, OPEN-RPE or el-rpe (70% vs. 67%, Table 3 Convalescence, perioperative, and late complications in the three age groups of patients with clinically localized prostate cancer Characteristics el-rpe1 (n = 72) el-rpe2 (n = 132) p value el-rpe2 OPEN-RPE (n = 70) p value OPEN-RPE Convalescence Duration of parenteral fluid administration ns <0.001 (mean SD [d]) Time to first oral intake (mean SD [d]) ns Time to full mobilization (mean SD [d]) ns Length of hospital stay (mean SD [d]) ns Total morphine equivalent requirement ns <0.001 (mean SD [mg]) Partial convalescence (mean SD [d]) <0.001 Full recovery (mean SD [d]) < <0.001 Duration of catheterization (mean SD [d]) ns 22 6 <0.001 Urinary continence (no pads) at 6 mo (n [%]) 34 (67%) 120 (91%) < (70%) ns Perioperative/early complications (during the first 30 d after surgery) Minor/moderate complications 12 (17%) 9 (7%) (43%) <0.001 (total number [%]) Dehiscence/rupture of wound 0 1 (1%) ns 7 (10%) Hematoma/hemorrhage 2 (3%) 2 (2%) ns 7 (10%) ns Urinary retention 0 2 (2%) ns 1 (1.5%) ns Prolonged urinary leakage (>2 wk) 1 (1.5%) 0 ns 3 (4%) ns Lymphocele 2 (3%) 2 (2%) ns 2 (3%) ns Gastrointestinal symptoms including 0 0 ns 7 (10%) peritonitis and ileus Delirium 6 (9%) (6%) ns Fever > 39 8C (urosepsis) 1 (1.5%) 1 (1%) ns 1 (1.5%) ns Major complications (total number [%]) 4 (6%) 2 (2%) ns 7 (10%) ns Respiratory insufficiency 2 (3%) 0 ns 2 (3%) ns Cardiovascular including arrhythmias and 1 (1.5%) 1 (1%) ns 3 (4%) ns myocardial infarction Thrombophlebitis/pulmonary emboli/stroke 1 (1.5%) 1 (1%) ns 2 (3%) ns Late complications (30 d after surgery) Bladder-neck contraction 0 0 ns 3 (4%) ns Wound hernia 0 1 (1%) ns 3 (4%) ns el-rpe1 = extraperitoneal laparoscopic radical prostatectomy in men aged 71 yr and older; el-rpe2 = extraperitoneal laparoscopic radical prostatectomy in men aged 59 yr and younger; OPEN-RPE = open retropubic radical prostatectomy in men aged 71 yr and older; ns = nonsignificant; SD = standard deviation.

5 Table 4 Patients (pts) achieving baseline quality of life (QoL) scores during follow-up after radical prostatectomy, stratified according to their age and operation technique QoL questionnaires and their subscales el-rpe1 (n = 72) el-rpe2 (n = 132) p value el-rpe2 % pts reaching Mean months % pts reaching Mean months baseline to baseline baseline to baseline at 6 mo % pts reaching baseline 3mo 6mo 3mo 6mo 3mo 6mo OPEN-RPE (n = 70) Mean months to baseline p value OPEN-RPE at 6 mo EORTC QLQ-C30 Physical functioning Social functioning ns Emotional functioning ns ns Cognitive functioning ns ns Role functioning ns Symptoms ns Financial impact ns ns Global quality of life Visual analogue pain score Overall bodily pain <0.01 Interference with work or <0.01 daily activities Overall disturbance by pain ns ICS male SF Voiding symptoms < ns Incontinence symptoms < ns IIEF < ns el-rpe1 = extraperitoneal laparoscopic radical prostatectomy in men aged 71 yr and older; el-rpe2 = extraperitoneal laparoscopic radical prostatectomy in men aged 59 yr and younger; OPEN-RPE = open retropubic radical prostatectomy in men aged 71 yr and older; ns = nonsignificant; EORTC QLQ-C30 = European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; ICS male SF = International Continence Society male short-form questionnaire; IIEF-5 = International Index of Erectile Function. european urology 51 (2007)

6 1346 european urology 51 (2007) respectively, p = 0.206). However, significantly more el-rpe1 men were continent 6 mo postoperative compared with men aged >70 yr who underwent either OPEN-RPE or el-rpe (91% vs. 70% and 67%, respectively, p < 0.001). In both patient groups the early convalescence (defined as duration of parenteral fluid administration, time to first oral intake, etc) was statistically similar after el-rpe. The time to partial and full recovery was significantly shorter for men aged <60 yr than for elderly men independent of the surgery art ( p < 0.01). Table 4 shows the proportion of patients who returned to baseline in each QoL subscale at each postoperative survey. In men who underwent el-rpe, at least 71% of the patients had attained baseline levels of all QLQ-C30 domains 6 mo after el- RPE independently of their age group. In el-rpe2 group, the recovery of only two subscales (i.e., physical functioning and global QoL) was most rapid ( p = 0.03 and p = 0.01, respectively) compared with el-rpe1 men. Contrarily, el-rpe1 men had postoperatively significantly more pain and more frequent incontinence and impotence than the el-rpe2 men. In the groups of elderly men, the majority of subscales of QLQ-C30 and all the domains of pain assessment became normal most rapidly in men who underwent an el-rpe versus OPEN-RPE. However, the postoperative continence and potency required similar time to return to baseline. The el-rpe1 patients show significantly higher QoL scores during each time period compared with OPEN-RPE men ( p < 0.05 at each time point). In the multivariable analysis, the difference between the two groups became more pronounced. This finding is also illustrated graphically (Fig. 1). Patients Fig. 1 Health-related quality of life (QoL) after extraperitoneal laparoscopic radical prostatectomy in men aged 71 yr and older (el-rpe1), and open retropubic radical prostatectomy in men aged 71 yr and older (OPEN-RPE). Repeated measures of analysis of covariance ( p < 0.001). after el-rpe demonstrated consistently higher postoperative QoL scores from hospital discharge to 1 yr postoperatively. However, the gap between the el-rpe1 and OPEN-RPE men began to narrow from 6 mo postoperatively onward ( p < 0.001). The nervesparing procedure had no influence on urinary continence or positive margin rate in each patient group (each p > 0.05). 4. Discussion Although some studies [22 25] have examined the differences in recovery of QoL following laparoscopic and open prostatectomy, no study has compared differences in convalescence, complications, and clinical outcomes associated with each approach in elderly patients. Our findings demonstrate that, in men aged over 70 yr, QoL is substantially greater after el-rpe than after OPEN- RRE. QoL scores return to baseline values more rapidly in laparoscopic patients and remain higher during every time period, even up to 1 yr postoperatively ( p = 0.031). In contrast, approximately 75% of el-rpe1 patients return to their baseline QoL scores within 6 mo of surgery, but approximately only 65% of OPEN-RPE patients achieve the same outcome (Table 4). Contrarily, patients after el-rpe show a comparable recovery in the majority of QoL subscales independently of their age. However, elderly patients seem to be more sensitive to pain perception and need postoperatively significantly more analgesics than the younger men. Elderly patients after el-rpe and OPEN-RPE reported equally delayed recovery of urinary function and voiding symptoms compared with the younger men. In concordance to others [3], this increased incontinence rate in the elderly seemed to affect the recovery of general QoL dramatically and was independent of the pathologic stage. It was postulated that the reason for this delayed recovery of continence was the different tissue resiliency of elderly men compared with that in men aged 59 yr and younger, which was probably also obvious from the significantly higher incidence of inguinal hernias in the older (10%) versus younger (2%) patients [3]. Because urinary incontinence is a patient s main concern, the shorter duration of bladder catheterization and the earlier recovery of continence in young men after el-rpe seemed to affect positively the recovery of their general health-related QoL. Importantly, others have shown that the decreased period of indwelling urethral catheter and hospital stay in L-RPE men was a source of a more favorable attitude toward surgery [22]. Consistent with our

7 european urology 51 (2007) observations, Hara [25] and Soderdahl et al [23], who performed a cross-sectional retrospective and a prospective longitudinal study, respectively, found no statistically significant differences regarding the recovery of urinary-related QoL between patients who underwent L-RPE or OPEN-RPE. Even in elderly patients, L-RPE is really a minimally invasive operation showing significantly lower intraoperative blood loss and shorter convalescence compared with OPE-RPE. Similar to other results [23], the morbidity, pain, and physical limitations measured by validated questionnaires were significantly lower in patients after el-rpe. The complication rates and the perioperative morbidity did not differ significantly between the young and old who underwent el-rpe. In concordance with others [3], the most common complications in the elderly in our series were respiratory insufficiency and delirium. In contrast to other series of RPE in the elderly [3,4], no perioperative deaths occurred. This result is probably a selection effect because all the older patients were well selected and were healthy men with a minimal comorbidity index comparable to those of the younger patients. These elderly patients do not reflect the average patient of their age, but represent a male group characterized by a significantly lower biologic age. Furthermore, the mean age of the elderly was 74 yr, indicating that approximately half of the men of this group are at least 4 yr over the lower age limit of 70 yr. All the patients underwent a detailed preoperative examination for exact evaluation of comorbidity and exclusion of those at moderate or high operative risk. The clinical advantage of laparoscopic surgery in the elderly over the traditional open approach is a well-known phenomenon in general surgery. Not only relatively simple laparoscopic operations for benign diseases [26] but also complicated ones for cancer [27] have been studied in the elderly, with the studies showing significantly lower morbidity and shorter convalescence compared with open surgery. In patients aged >70 yr, those who underwent laparoscopic colorectal cancer surgery had significantly lower complications and shorter postoperative recovery than those who underwent open surgery [27]. Young men seem to have more favorable oncologic outcome after RPE than older men [28]. Although the exact mechanism for this outcome remains unclear, like others [3], we found a trend for higher Gleason scores among older men suggesting a biologically more aggressive form of pca than in younger patients. Contrarily, a retrospective study of 5509 patients treated with RPE showed that, despite more favorable clinicopathologic features, younger patients undergoing RPE for pca have survival similar to that of older counterparts [29]. Whichever point of view is closer to the truth, even older men with clinically organ-confined (ct2) pca and without significant comorbidity will die of pca if they are not treated vigorously and early in the course of their disease. Taking in account that el-rpe is a minimally invasive procedure with significantly lower morbidity versus open surgery [5 12], there is no apparent excuse for excluding older men who are in healthy condition and have the optimal life expectancy time from having a potentially curative surgical therapy. Furthermore, because the 2002 life tables of the German population estimate a 12-yr overall life expectancy for men at age 71 yr and 10 yr for men aged 75 yr [30], an RPE with curative intention should not be denied on the basis of age alone in healthy patients with clinically localized pca. Our study has several limitations. Obviously there is a certain degree of selection bias in this study because only those elderly patients deemed in adequate condition were offered surgery. This study is not randomized; it reflects a partially prospective patient self-selection study having two groups of aged patients (el-rpe1 and OPEN-RPE) with similar clinicopathologic factors, which might predict outcome. Because these groups are well matched regarding the clinopathologic characteristics, the substantial differences in postoperative convalescence may be attributed mainly to the different surgical approach. Because all the PSA recurrence patients had a Gleason score of 7 or higher and the vast majority of these patients had a pathologic stage of pt3, the subgroups of PSA recurrence patients were comparable. Our study has relatively few patients with a short period of follow-up and therefore is better considered a feasibility study of longitudinal design. Our findings are also better considered as an initial assessment of convalescence and clinical outcome of el-rpe in the elderly; longterm assessment is still ongoing. Finally, a comparison of our results of improved convalescence and low complication rates after el-rpe in the elderly with other published series is almost impossible because no other series have been published on this topic. Furthermore, differences in health care system and cultural factors make this comparison complicated. 5. Conclusions el-rpe was a minimally invasive procedure showing a significantly lower morbidity and shorter convalescence in patients >70 yr compared with OPEN-RPE.

8 1348 european urology 51 (2007) The elderly undergoing el-rpe for localized pca had mortality and early complication rates equivalent to those in the younger men. Both techniques offer similar functional and oncologic results in the elderly. However, the observed higher incontinence rate in the elderly should be discussed preoperatively. It is safe and probably more reasonable to offer carefully selected elderly patients an el-rpe because chronologic age, per se, is not a contraindication for a laparoscopic approach in the setting of localized pca. Multicenter studies with longer follow-up comparing QoL after different forms of surgical treatment are necessary to increase our knowledge regarding this important aspect in elderly men with localized pca. Conflicts of interest No authors have any commercial relationship such as: consultancies, stock ownership or other equity interests, patents received and/or pending, or any commercial relationship. 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9 european urology 51 (2007) Editorial Comment Ramsey N. Chichakli, Marcus L. Quek, Department of Urology, Loyola University Stritch School of Medicine, Maywood, IL, United States Both laparoscopic and robotic-assisted laparoscopic approaches are being increasingly used in the surgical management of clinically localized prostate cancer. As the average life expectancy of men has increased, the age limits traditionally used to guide the decision for radical prostatectomy have come into question [1]. Coupled with the widespread use of prostate-specific antigen (PSA) screening, more men over age 70 yr will be diagnosed with and seek treatment for clinically localized disease. Several studies have demonstrated improvements in blood loss and convalescence with the laparoscopic compared to open approaches, though long-term equivalence of oncologic control remains to be determined [2,3]. The authors have nicely demonstrated that the advantages of minimally invasive surgery can apply to a select elderly population as well. Although the authors report on a pure laparoscopic series, it may be safe to extrapolate these benefits to robotic-assisted surgery as well. It should be emphasized, however, that the overall morbidity in this age group, regardless of technique, is significant. The 6-mo incontinence rate was found to be 33%. Other studies have confirmed that age is an independent risk factor for postoperative incontinence [4,5]. In addition, the oncologic outcomes were inferior, with a 6-mo biochemical recurrence rate of 14%, likely due to the higher stage, preoperative PSA level, and Gleason scores for this older cohort. This underscores the need to thoroughly counsel elderly patients who may be considering surgery. Although they should not be discouraged from seeking potentially curative therapies, all available options and their associated risks should be discussed. References [1] Thompson R, Lieber MM, et al. Radical prostatectomy for octogenarians: how old is too old? Urology 2006;68: [2] Menon M, Tewari A, et al. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology 2002;60: [3] Guillonneau B, Gupta R, et al. Laparoscopic radical prostatectomy: oncologic evaluation after 1,000 cases at Montsouris Institute. J Urol 2003;169: [4] Sacco E, Prayer-Galetti T, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int 2006;97: [5] Eastham JA, Scardino PT, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996;156: