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

2. Criteri di inclusione per la SA
EAU Guidelines 2015,

3. Risk classification (700 patients)
Personal series, unpublished data

4. Conseguenze cliniche
Conseguenze psicologiche
Conseguenze oncologiche
Conseguenze funzionali

5. 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

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

7. Conseguenze oncologiche
Low risk
disease
Clinically insignificant disease
surgery

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

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

10. 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

11. Filippou P et al Eur Urol 2015

12. Filippou P et al Eur Urol 2015

13. 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 %
Active treatment 24% % 45%
Klotz L, J Clin Oncol. 2015

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

15. Algoritmo diagnostico
Roderick CN et al Eur Urol 2014

16. 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

17. Bokhorst LP et al Eur Urol 2015

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

19. Conseguenze funzionali
Letteratura?

20. Retzius-sparing RARP
Vescicole seminali

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Unpublished data, personal series

22. 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%

23. 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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