by Steven Joniau, MD, Phd University Hospitals Leuven, Belgium

1. Steven Joniau, MD, PhD
University Hospitals Leuven
Leuven
Belgium
Surgery for localized, locally advanced and
high risk prostate cancer

2.  117,328 patients with prostate cancer
 26,410 low risk (22.5%)
cT1-T2, PSA <10 ng/ml AND Gleason 2-6
 26,611 intermediate risk (22.7%)
cT1-T2 AND PSA 10 - <20 OR Gleason 7
 30,159 high risk (25.7%)
cT3 or PSA 20-50 or Gleason 8-10
 Non-curatively treated
Rider JR et al. Eur Urol 2012
2
Who dies of PCa?
Natural evolution of non-curatively treated PCa

3. 10%
20%
35-40%
Rider JR et al. Eur Urol 2012
All ages <65 years 65-75 years >75 years
Prostate cancer Cardiovascular Other
LowriskMediumriskHighrisk Who dies of PCa?
Natural evolution of non-curatively treated PCa
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4. Complete removal of the prostate, seminal vesicles, and pelvic
lymph nodes (when necessary)
• With minimal perioperative morbidity, no blood transfusions,
and early return to normal activities
• No positive surgical margins
• No long-term loss of continence or potency
Goals of modern radical prostatectomy (RP)
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5. PIVOT Trial
PSA detected
RP vs observation for localised PCa
 RP did not significantly reduce all-cause or PCa-specific mortality as compared
with observation
WiltTJ et al. N Engl J Med 2012;367:203-13
PCa-specific mortality
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6. Low-risk PCa
PCa specific mortality
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Overall mortality
WiltTJ et al. N Engl J Med 2012;367:203-13

7. PCa specific mortality
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Overall mortality
Intermediate risk PCa
WiltTJ et al. N Engl J Med 2012;367:203-13

8. PCa-specific survival
~45%
~17%
P= 0.05
High risk PCa
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WiltTJ et al. N Engl J Med 2012;367:203-13

9. BrigantiA, Spahn M, Joniau S et al. for EMPaCT Eur Urol 2013
Only men ≤ 59 years old had higher risk of PCa-related
death than death-related to other causes
10%
<10%
Prostate cancer Other
MORTALITY RATES FOR SURGICALLY TREATED
HIGH-RISK PCa

10. Cooperberg M, et al.AUA 2015 – Data from CAPSURE
Which treatment for which cancer?
Up untill 2007, Low-risk PCa was too often actively treated,
while high-risk PCa was too often undertreated
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11. Cooperberg M, et al.AUA 2015 – Data from CAPSURE
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After 2007, Low-risk PCa was more often treated with AS/WW,
while high-risk PCa was more often actively treated!!!
Which treatment for which cancer?

12. Cumulative incidence function estimates of cancer
specific and other cause mortality survival curves
(n=34 515), stratified according to treatment type.
Sooriakumaran P et al. BMJ 2014;348:bmj.g1502
M+ or N+ orT4 or
PSA>50
Low Intermediate High
RP
RT
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13. Sooriakumaran P et al. BMJ 2014;348:bmj.g1502
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Cumulative incidence function estimates of cancer
specific and other cause mortality survival curves
(n=34 515), stratified according to treatment type.

14. Cooperberg M, et al.AUA 2015 – Data from CAPSURE
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HIGH-RISK
15-YEARCANCERMORTALITY

15. - Retrospective analysis of data from the Norwegian Prostate Cancer Registry, 2004-2005
- 3486 patients, RP (n = 895), EBRT +/- ADT (n = 1339), or no local treatment (n = 1252)
- Clinical stageT1-T3, PSA ≤100 ng/ml, D’Amico risk group stratification
- Comparison of active local treatment (RP, RAD) versus no active local treatment (NoLocTrt)
PCa mortality
Other cause mortality
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HIGH-RISK

16. Big surgeon, big incision…?

17. • NO difference in positive surgical margins
• NO difference in incontinence
• SMALL difference in erectile dysfunction in favor of RALP

18. The changing role of surgery
• Properly performed, RP is a highly effective treatment
for high-risk prostate cancer in men with a sufficiently
long life expectancy to justify the risks
• Outcomes of RP – cancer control, peri-op complications,
and long-term urinary and sexual function – are directly
related to the skill and experience of the surgeon, but
not to the technology used (open v. robot-assisted)
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