MP74-04: Radical prostatectomy for Gleason 3+3 prostate cancer; who, how and why? Analysis of the British Association of Urological Surgeons complex operations database.

Joseph B John, John Pascoe, Sarah Fowler, Thomas Walton, Mark Johnson, Jonathan Aning, Benjamin Challacombe, John S McGrath

Introduction: There is a risk of overtreating low-grade prostate cancer (PCa) with radical prostatectomy (RP). A preference for active surveillance for localised Gleason 3+3 disease was advocated in the 2018 UK National Prostate Cancer Audit. This reflects the peri-operative risks of major pelvic surgery and the common longer-term functional sequelae following RP.

Objectives:  - To understand modern RP practices in England for Gleason 3+3 PCa, describing the patient, indication, procedure, and outcomes.

Methods: BAUS manage the complex operations database for RP. Seventy data fields are uploaded by surgical departments, pertaining to patient, disease, surgical, pathological and outcome descriptors. Surgeons can review and amend their data before lockdown and data cleansing. Analysis of all 21,973 RPs recorded in England from 2016-18 was performed to identify 2,627 cases of Gleason 3+3 disease diagnosed pre-operatively.

Results: The BAUS RP dataset for England (2016-18) was deemed to be 91% complete, using Hospital episode statistics (HES) as the comparator. Gleason 3+3 patients accounted for 12% of RPs. Median patient age was 63 (IQR 57 – 68), and 89% of patients were ASA 1-2. Median PSA was 7.0 (IQR 5.1 – 10.4). Pre-operative clinical T-stages of 1, 2, 3 and 4 were recorded in 24%, 62%, 11% and 0.04% respectively. Intermediate-risk disease was present in 52% (pre-operative T stage =2b and/or PSA =10). Primary treatment of cancer was the indication in 70%, and 28% had previously been under active surveillance. RARP was the chosen surgical modality in 80%. Bilateral and unilateral nerve spare was performed in 53% and 19% respectively. Post-operative 3+3 disease was confirmed in 28%, whilst 52% had 3+4 disease and 7% had 4+3 disease. Post-operative histological upstaging occurred in 40%, and downstaging in 7%. Median LOS was 1 day, and transfusion rate was 0.3%. Clavien-Dindo 3-4 complications were reported in 0.8% of patients. In-hospital mortality was zero.

Conclusions: Decisions to proceed to RP for Gleason 3+3 PCa in England are commonly justified by pre-operative factors indicating intermediate or high-risk disease (PSA =10, =T2b), and by post-operative upstaging or upgrading. In addition to PSA and T stage, factors that might lead a surgeon to perform RP for a patient with locally-confined Gleason 3+3 disease include, but are not limited to, patient preference, high disease volume, MRI suggesting a higher-grade lesion, and prostate capsule proximity. Peri-operative outcome data indicate that RP in this cohort is safe. Source of

Funding: None