Insights on active surveillance, robotic surgery and radiotherapy for PCa

Updates and insights on advanced prostate cancer (PCa) were provided by uro-oncology experts at the recently 9th EAU Section of Oncological Urology (ESOU) Meeting held in Hamburg, Germany. In his lecture on active surveillance (AS), Axel Heidenreich (DE) said that despite the recommendations of guidelines from many national and international groups, AS for prostate cancer remains underused. He spoke on the challenges and prospects of AS and the reasons why some surgeons have not taken this option in patients with prostate disease.

Saying there are several key considerations that physicians must bear in mind before counseling their patients for AS, Heidenreich underscored the importance of biopsies.

“If we have to think of AS we have to improve our biopsies,” he said stressing that the pitfalls in biopsy techniques should caution urologists from entirely relying on the procedure.

“The challenges are the eligibility among patients, defining the risk progression and the reliability of prostate biopsies,” said Heidenreich in response to questions during the open forum. “Just to rely on PSA kinetics is very difficult to identify risk progression.”

According to Heindenreich, AS is not a treatment of choice but an option. He said doctors must bear in mind that the detection of insignificant PCa is not optimal.

Heidenreich: “We should consider that follow-up examination is not clearly established, that the ideal triggers (or reasons) to treat are not identified (re-biopsy) and finally physicians must consider that the mean follow-up is too short to assess mortality risk.”

Meanwhile, Markus Graefen (DE) provided tips on radical prostatectomy as experienced in a high-volume center, discussing the preservation of continence and sexual function. He noted the importance of properly counseling patients regarding their expectations on potency rates and continence, and pointed out that due to various definitions and understanding of potency, patients are often disappointed on post-surgical results.

In his concluding remarks, Graefen said that improving functional outcome involves individual apical preparation and the high tension and energy-free release of the neurovascular bundles, and that performance feedback is crucial to learning. He also mentioned that in a high-volume centre it is important to implement a meaningful database since it is the backbone for clinical and basic research.

Gunter Janetschek (AT) spoke on minimally invasive procedures as he compared open, laparoscopic and robot-assisted surgeries and their roles in prostate surgery. Regarding robot-assisted laparoscopic radical prostatectomy (RALP), Janetschek said that although it is superior in terms of blood transfusion rate, intra and post-operative complications and length of hospital stay, there is no difference in terms of functional and oncologic outcomes.

“Studies indicate that patients who underwent RALP were more likely to be regretful and dissatisfied possibly because of high expectations of a new procedure,” he said.

Janetschek said there are challenges for surgeons practicing minimally invasive procedures to further work on refining their skills and not overly creating high expectations on patients since robot technology is definitely here to stay.

“Our patients can certainly benefit from laparoscopy, so we have to make sure that they have access to this procedure. Moreover, I expect that the two worlds of standard and robotic-assisted laparoscopy will eventually merge,” he added.

Lecturing on radiotherapy, Thomas Wiegel (DE) asked the provocative question: “What makes radiotherapists so confident to stay in the competition?” He mentioned that in two randomized trials, it was shown that five years after patients had radiotherapy (RT), and for those who took either sildenafil or taldalafil, these patients experienced 50% to 60% improvement in erectile dysfunction. He also gave a brief overview of emerging radiotherapy (RT) techniques such as stereotactic body irradiation, which is comparable with the Cyberknife.

Answering his own rhetorical query on why radiotherapy remains a first choice among patients, Wiegel ended his talk with a tongue-on-cheek jest, saying that urologists and radiotherapists “over time still become friends,” despite the assumption that the latter may eventually outrace the former in terms of delivering effective treatment.