Prospective evaluation of combined oncological and functional outcomes after laparoscopic radical prostatectomy: trifecta rate of achieving continence, potency and cancer control at 2 years

What's known on the subject? and What does the study add? The first objective of radical prostatectomy (RP) is cancer control. However, the success of RP should also be measured by the most unforgiving long-term morbidity outcomes and by the maintenance of quality-of-life. Incontinence and erectile dysfunction have clearly negative repercussions on a patient's quality-of-life although most men are usually satisfied with treatment and accept these subsequent disorders. Outcomes of continence, erectile function and cancer control after RP are well described in isolation. However, combined oncological and functional results are lacking, especially in laparoscopic procedures. Separate presentation of cancer control and functional results does not provide sufficient patient information, and the report of combined outcomes is a necessary point of discussion between the urologist and his patient. Thus, we reported the combined oncological and functional outcomes 2 years after extraperitoneal laparoscopic radical prostatectomy. OBJECTIVE To determine the proportion of patients who are continent, potent and cancer-free (trifecta rate) 2 years after extraperitoneal laparoscopic radical prostatectomy (ELRP). PATIENTS AND METHODS We included patients who underwent an ELRP at our department and who were followed for at least 2 years. Those who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 911 men were included. All patients prospectively completed objective, self-administered questionnaires before the medical visit, concerning their voiding and sexual disorders, before surgery and 12 and 24 months after ELRP. Biochemical recurrence was defined as any detectable serum PSA (>= 0.2 ng/mL). Potency was defined as the ability to achieve an erection sufficient for penetration with or without the use of phosphodiesterase-5 enzyme inhibitor. Urinary continence was defined as absence, or occasional use, of a pad for anticipated vigorous activity. The primary study endpoint was the trifecta rate (cancer control, continence and potency) at 2 years after the surgery. Factors associated with the trifecta outcome were assessed in univariate analysis. RESULTS Median age and PSA level were 62.2 years and 9.9 ng/mL, respectively. A trifecta outcome was achieved in 29.7 and 54.4% of patients at 12 and 24 months, respectively. The 2-year trifecta rate reached 63.5% in patients undergoing bilateral nerve-sparing surgery and 73.5% in men aged < 60 years. Age < 60 years, PSA level < 10 ng/mL, organ-confined disease and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome. A total of 84.8% of patients were both cancer-free and continent at 24 months, regardless of erectile function. CONCLUSIONS Two years after ELRP, the trifecta outcome is achieved in 54.4% of patients who remained potent and continent. This rate reaches 63.5% in patients undergoing a bilateral nerve-sparing procedure. Combined results of good cancer control and continence recovery are reported in 84.8% of patients, regardless of erectile function.