Preoperative Risk Stratification Predicts Likelihood of Concurrent PSA-Free Survival, Continence, and Potency (the Trifecta Analysis) After Radical Retropubic Prostatectomy

Objectives: To assess the likelihood of biochemical disease-free survival, urinary continence, and sexual potency after radical retropubic prostatectomy (RRP) as an aggregate outcome, the "trifecta" analysis. Methods: From the Columbia University Urologic Oncology Database of 2522 patients from 1988 to 2005, 503 had undergone RRP by a single surgeon. Of these, 87 patients were excluded: 31 with inadequate follow-up, 47 who had undergone additional confounding therapy, and 9 with insufficient data for the trifecta analysis. The final sample of 416 patients was stratified according to preoperative prostate-specific antigen level, Gleason sum, and clinical stage. Biochemical disease-free survival, continence, and potency were defined, respectively, as a prostate-specific antigen level of less than 0.2 ng/mL, not requiring daily pads, and having an erection sufficient for intercourse with or without oral pharmacotherapy. Patients achieving all three positive outcomes, the trifecta, were analyzed using analysis of variance. Results: Risk stratification identified 225 low-risk, 144 intermediate-risk and 47 high-risk patients whose biochemical disease-free survival rate was 96.4%, 90.3%, and 78.7% at a median follow-up period of 4.4, 4.8, and 7.1 years, respectively. The corresponding continence rates were 93.8%, 94.4%, and 93.3% and the potency rates were 81.3%, 67.7%, and 69.6% with at least 1 year of follow-up. Of the 314 analyzable patients, 130 (72.6%) of 179 low-risk, 61 (58.1%) of 105 intermediate-risk, and 12 (40.0%) of 30 high-risk patients achieved the trifecta. The trifecta rates were significantly different between the low and intermediate-risk (P = 0.04) and low and high-risk (P = 0.001) groups. Conclusions: Preoperative (RRP) low-risk patients are more likely to remain disease-free, continent, and potent after surgery than are patients of higher risk. Physicians should consider aggregate outcomes when counseling patients regarding the clinical outcomes after RRP.