EAU17: Expert challenges expert

At Thematic Session 2, ‘Expert Challenges Expert,’ specialist surgeons presented opposing surgical treatments, aiming to provide either a critique or an alternative view of a standard procedure; a format which led to an engrossing session covering salvage prostatectomy and the extent of primary lymph node dissection (ePLND).

“We have asked the speakers to present a solid and persuasive case, one that will not only challenge but provoke their opponents to re-think their views. This session will therefore serve as a critique of how we view our own surgical techniques,” said Prof. Bob Djavan (AT) who co-chaired the session with Prof. Gunter Janetschek (AT).

Prof. Axel Heidenreich (DE) argued for open salvage prostatectomy and discussed his surgical techniques as well as pre-surgical preparation, outcomes and complications. He showed videos of the crucial steps necessary to reduce complications since salvage prostatectomy is known to be more technically demanding than primary prostatectomy.

“Radical salvage prostatectomy (RSP) depends on patient selection, and functional outcome depends on the type of radiation therapy and the surgeon’s expertise,” said Heidenreich as he pointed out that particularly with complications, the surgeon’s expertise plays a crucial role.

“In good hands, RSP is the only second-line local therapy with long-term cancer control,” he added.

Prof. Declan Murphy (AU) gave the opposing view and pushed for robotic salvage prostatectomy, saying that “experience is what matters, not the surgical approach.”

“Open salvage radical prostatectomy (RP) is an excellent option if the surgeon is very experienced. But the same applies for robotic salvage prostatectomy,” argued Murphy. He said patient selection is also a key element in his work-up for salvage RP, noting that doctors should look into the life expectancy and fitness of their patient. He also discussed his pre-surgical preparations such as performing PSMA PET/CT scans, an MRI biopsy, and transperineal prostate biopsy.

“In consultations with patients, doctors should give realistic expectations since this influences or is directly related to patient satisfaction,” explained Murphy.

The second and last case was on the extent of primary lymph node dissection, where Dr. Henk Van Der Poel argued for extended lymph node dissection, against the opposing view of Dr. Nicola Fossati (IT).

“Lymph tracer target LND helps identify nodes,” said Van Der Poel, who added that template-guided surgery improves diagnostic accuracy. “The optimal technique has not yet been determined. Lower biochemical recurrence (BCR) is a benefit, but prospective studies are needed.”

Meanwhile, Fossati, argued that despite the advances in imaging approaches, anatomically defined extended PLND “remains the gold standard.”

“Indications for ePLND should be based on models derived from ePLND series since limited PLND equals no PLND,” said Fossati. “Moreover, pre-treatment imaging modalities suffer from limited sensitivity.”