1. Professor Guram Karazanashvili MD, KMSc, DMSc MMT Hospital

2. When diagnosis of clinically locally advanced prostate cancer is established, patient selection and preparation for the surgery is critically important

3. Patient examination Experienced surgeon does DRE and TRUS DRE and TRUS are essential for estimation of resectability: Prostate consistence Prostate apex Lateral margins Adherence to rectum Seminal vesicles

4. Patient consultation How looks the patient? How motivated is he? Has the patient voiding problems? Take a time to explain the patient: -Different treatment modalities in context of quality of life and effectiveness -Necessity in adjuvant treatments -Speak with patient together with close relatives -Give patient a time for consideration

5. Patient selection  Good performance status  10 year survival should be expected  Patient motivated for aggressive cancer management  Patients ready for increased risk of incontinence and impotence

6. Preoperative evaluation and preparation Standardized preparation of patients for the surgery reduces the risks of intra and postoperative complications Special team is advisable for routine preoperative check up: Cardiologists, Anesthesiologist and urologist Send the patient for coronarography in any doubtful case Coronary stenting or bypass before surgery reduces the risks Hospitalization 1 day before the surgery Bowel preparation is needed, especially in locally advanced cases Anticoagulants night before surgery Gloves before surgery

7. Patients  Surgery from 2011 to 2014, by single surgeon  48 Patients with clinically locally advanced Prostate cancer were selected for the surgery T3a - 21patients T3b – 17 patients T4 – 8 patients

8. Patients DRE detected extra capsular spread Extra capsular spread was confirmed by TRUS, CT/MRI No balky lymph nodes by CT/MRI Bone scan was negative Patient age: 50-60 years – 6 cases 60-70 years – 21 cases 70-75 years – 19 cases

9. Preoperative data  PSA < 30ng/ml  Gl. 5-6 12 cases  Gl. 7 (3+4) 5 cases  Gl. 7 (4+3) 16 cases  Gl. 8 6 cases  Gl.9 3 cases

10. Tipe of Surgery Radical prostatectomy with extended lymphadenectomy (along internal and external iliac vessels) – 38 cases Radical prostatectomy with bladder neck wide excision, and extended lymphadenectomy (along internal and external iliac vessels) – 4 cases Radical cystoprostatectomy, extended lymphadenectomy, sigma-rectum pouch – 1case Radical cystoprostatectomy, extended lymphadenectomy, ileal conduit (Briker’s operation) - 3 cases Monolateral or bilateral Nerve sparing – 24 cases

11. Surgical margins  Surgical margins were positive in 15 (of 46) patients: Apex 3 cases Neurovascular bundle 1 case Bladder neck 7 case Other locations 4 case  Relatively high incidence of positive margins at bladder neck was determined by preoperative downstaging and absence of macroscopic alterations intraoperatively

12. Stage migration Preoperative T stage migration occurred in 39% of cases: Downstaging 14 cases Overstaging5 cases Preoperative N stage migration occurred in 43% of cases: Downstaging 20 cases

13. Stage migration In 7 (of 12) downstaged men local spread reached T4 stage. These men need wide excision of bladder neck, beyond macroscopic alterations. 3 (of 5) T overstaged cases were node free. Thus surgery was curative 20 N downstaged men might benefit from lymphadenectomy

14. PSA > 0.2ng/ml at 3 monthes  N+ and positive surgical margins5 cases  N+4 cases  Positive surgical margins2 cases  N- and negative surgical margins2 cases  Overall in 28% of cases PSA>0.2ng/ml at 3 months, most of these patients are N+.  Only 7 (of 15) patients with positive surgical margins had PSA nadir above 0.2ng/ml. Thus despite residual tumor, prognosis can be favorable

15. Adjuvant therapies  Antiandrogens 4 cases  Medical or surgical castration 4 cases  Radiation therapy+medical castration 3 cases  No adjuvant therapies 35 cases

16. 76% of patients with clinically locally advanced cases have got no adjuvant therapies!

17. Bone metastasis Currently 0 (of 46) patients have bone metastasis after surgery for clinically locally advanced prostate cancer

18. Incontinence At 3 monthes: Total incontinence 0 of (42) cases Stress incontinence 12 (of 42) cases Continent 30 (of 42) cases Currently: Total incontinence 0 (of 42) cases Stress incontinence 4 (of 42) cases Continent 38 (of 42) cases

19. Conclusions  Radical surgery is feasible in men with clinically locally advanced prostate cancer and should be applied in selected patients  Significant number of patients can be saved from adjuvant therapies  Surgical excision has potential to delay development of bone metastasis  Functional outcomes are excellent

20. Conclusions Node status downstaging, is common in cases of clinically locally advance prostate cancer patients Extended lymphadenectomy is recommended in all cases, this might have therapeutic results Bladder neck invasion is not rare, wide excision of bladder neck is recommended, even in case of absence of macroscopic alterations