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Ospedale “San Giovanni Bosco” Quale chirurgia? Alessandro Giacobbe Ospedale “San Giovanni Bosco” S.C. Urologia Torino 2 2

Surgical Issues Staging accuracy Surgical Margins PLND Multimodal Approach problematiche

Surgical Issues Staging accuracy Surgical Margins PLND Multimodal Approach problematiche

Staging accuracy Gleason upgrading Extracapsular extension Nodal involvement

Staging accuracy Gleason upgrading Extracapsular extension Nodal involvement

1/3 pts

Staging accuracy Gleason upgrading Extracapsular extension Nodal involvement

Side specific ECE risk PSA 8, cT1c, bGS 7 40%cores 30% Grazie ai nomogrammi è possibile predirre

Staging accuracy Gleason upgrading Extracapsular extension Nodal involvement

LNI risk PSA 7, cT2, bGS 7 40%cores 12% IF EXTENDED PLND!!! Nomogramma memorial e il nomogramma di Briganti sono diversi perché si basano su linfadenectomia limitata ed estesa. Si utilizza ciò che si crede di dover fare

If performed it should be extended PLND! “CLINICAL N STAGING” “The gold standard for N-staging is operative lymphadenectomy, either by open or laparoscopic techniques” PLND limited to the obturator fossa misses about 50% of node metastases If performed it should be extended PLND!

Surgical Issues Staging accuracy Surgical Margins PLND Multimodal Approach

PSM rate >50% In questa casistica monocentrica basata su RRP Open, psm > 50%

SEER DATABASE: 2004-2010 more than 11000 patients SEER, open vs Rarp, in robotica psm è nettamente piu bassa SEER DATABASE: 2004-2010 more than 11000 patients 4400 pts (40%) High Risk PCa (D’Amico)

Surgical Issues Staging accuracy Surgical Margins PLND Multimodal Approach

The indication for RP assumes the absence of clinically detectable nodal involvement. Only limited evidence exists supporting RP of cN+ patients In a recent study, the outcomes of 50 patients with cN+ were compared with those of 252 patients with pN1, but cN0 at preoperative staging: cN+ was not a significant predictor of cancer-specific mortality (CSM) (p = 0.6) Moschini, M., et al. Eur Urol, 2015. 69: 193. Due to the limited evidence, local treatment of cN+ patients, in association with a multimodal approach, should be discussed with patients on an individual basis.

Surgical Issues Staging accuracy Surgical Margins PLND Multimodal Approach

Database nazionale ….registro tumori …livello di evidenza forte

Adjuvant RT or prophylactic whole-pelvis RT ? Gleason score >7 the only predictor of eBCR after RP and aRT in pT3N0 PCa Adjuvant RT or prophylactic whole-pelvis RT ? Should pT3a GS6 R0 with undetectebale Psa receive adj RT? Gs sul margine?