Conseguenze cliniche della sorveglianza attiva Aldo Massimo Bocciardi Urologia, Niguarda Cancer Center, Ospedale Niguarda Ca' Granda, Milano

Criteri di inclusione per la SA EAU Guidelines 2015, www.uroweb.org

Risk classification (700 patients) Personal series, unpublished data

Conseguenze cliniche Conseguenze psicologiche Conseguenze oncologiche Conseguenze funzionali

Conseguenze psicologiche 2.5-year follow-up, QoL remained stable; sexual function scores significantly declined. Illness uncertainty and anxiety increased during time. Interventions to reduce uncertainty and anxiety may enhance QoL for men with prostate cancer on AS. Parker PA et al BJU Int 2015

Conseguenze oncologiche Posto che regga il peso psicologico, si tratta di una scelta sicura?

Conseguenze oncologiche Low risk disease Clinically insignificant disease surgery

«very low risk» = malattia clinicamente insignificante? Mitsuzuka K et al. BJU Int 2013;111:914

La stadiazione clinica è imprecisa! VERY LOW RISK LOW RISK Mitsuzuka K et al. BJU Int 2013;111:914

La stadiazione clinica è imprecisa! Feature Very Low Risk Low Risk p Patients 87 124 pT T2 T3a T3b 89,7% 10,3% 81,5% 16,1% 2,4% 0.08 Gleason Score ≤ 6 7 ≥8 47,1% 46,1% 5,7% 25,8% 63,8% 10,5% 0,01 Mtisuzuka K et al. BJU Int 2013;111:914

Filippou P et al Eur Urol 2015

Filippou P et al Eur Urol 2015

Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. 15 5 10 years 993 men Dead 15% Dead from prostate cancer 1.5% Metastatic disease 2.8% Active treatment 24% 37% 45% Klotz L, J Clin Oncol. 2015

Tools improving selection? Schoot IG et al. Eur Urol 2014

Algoritmo diagnostico Roderick CN et al Eur Urol 2014

Erectile dysfunction (6-86%) Infection (0% - 1,6%) Haematuria (28% - 69%) Erectile dysfunction (6-86%) Infection (0% - 1,6%) Acute Urinary Retention (1-22%) Loeb S et al Eur Urol 2015

Bokhorst LP et al Eur Urol 2015

Conseguenze funzionali Age & comorbidities, TNM Urinary continence Erectile Function Anatomical Damage Age & comorbidities, TNM

Conseguenze funzionali Letteratura?

Retzius-sparing RARP Vescicole seminali

after Active Surveillance Retzius-sparing RARP after Active Surveillance 20 patients Only 33% pT2 and Gleason 3+3!!! Unpublished data, personal series

Retzius-sparing RARP 20 patients Feature General series After AS Continence: Immediate After 1 year 92% 97% 85% Potency Immediate After 1 year 40% 80% - 25%

Conclusions Candidates for Active Surveillance in clinical practice are quite rare The definition of «very low risk» does not assure an insignificant disease. Further instruments should be used to improve the definition of the dieasease (multiparametric MRI) Considering AS from an oncological point of view, we should always remember that: 1. most of the patients will abandon it; 2. the histological results are worse than immediate surgery Functional results of RARP after AS have not been considered in Literature, but it is probable that they will be «disappointing» 23

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