Hormonal therapy reduces the risk of post-implant urinary retention in symptomatic prostate cancer patients with glands larger than 50 cc

Abstract

Controversy exists regarding the optimal management of men with prostate glands > 50 cc who undergo permanent seed implantation. Previous studies have suggested that pre-treatment with hormonal therapy (HT) may actually increase the risk of urinary retention or urinary symptoms when compared to patients not receiving HT. Unfortunately, no prior studies have analyzed the influence of urinary symptoms prior to the initiation of HT. In this study we compare a cohort of men with prostate glands > 50 cc treated by implant alone to a similar cohort also treated with pre-implant HT in whom the pre-HT data was available for analysis. 404 patients with Gleason score <7, PSA <10, T1c-T2b prostate cancer were treated with implant alone (n = 176) or with 3 months of HT (n = 228) prior to implant. 338 (84%) received I-125 and 66 Pd-103. Prostate volumes (PV) and international prostate symptom scores (IPSS) were determined prior to initiation of HT and just before implantation. IPSS were collected at 3, 6 and every 6 months post implant. Urinary retention (UR) was designated if a patient required reinsertion of a urinary catheter post-implant. PSA failure was determined by ASTRO definition. The effects of hormonal therapy on prostate size, urinary retention and IPSS scores were tested by Chi-Square method. Survival (PSA) was calculated by Kaplan Meier method. Mean follow-up was 36 months (range 1–139). Mean pre-treatment gland size was 74 cc (range 50–151) in the group that received HT and 60.3 cc (range 50–117) in the group that did not (p = 0.037). In the HT group, PV decreased to a mean of 48.6 cc (mean reduction 35%, p < 0.001) prior to implantation. UR occurred in 11.4% in those treated with HT vs. 11.9% without HT (p = 0.84). UR risk did not increase with increasing PV. The mean maximum post implant IPSS score was 16.7 without HT vs. 15.6 with HT (p = 0.261). In patients with initial IPSS > 15, UR occurred in 4/12 (33.3%) of those not receiving HT vs. 0/27 in the HT group (p = 0.002, RR 4.4, 95% CI 2.1–8.1). 24 month mean IPSS remained elevated (10.4 vs. 5.9 pre-implant, p < 0.001) for those without HT, while it returned to baseline in the HT patients (8.2 vs. 9.7, p = 0.06). Urinary QOL also remained elevated in the non HT patients (1.3 vs. 2.3, p < 0.001) compared to the HT group (1.2 vs. 1.7, p = 0.195). 6-year PSA failure free rates were similar for each group (93%). The data from this study confirms the benefit of using pre-implant HT in patients with PV > 50 cc. HT mostly benefits the subgroup of patients who present with symptomatic prostatism and an IPSS > 15. Minor benefit was also noted in 24 month IPSS and QOL scores in the HT group. PSA freedom from failure was no different in the two groups, confirming the lack of benefit for HT in improving disease control in low risk patients