The paradigm shift in the concept of treatment is unkindly said to occur in medicine when all forms of therapy, except the right one, have been exhaustively used. I believe such a paradigm is currently underway across the face of medical practice and specifically in surgical endeavours, which will probably have a higher impact on the way patients with malignant urologic disease and malignant diseases in other surgical specialities are treated. The paper by Mouraviev et al. [1], in the current issue of European Urology, emphasises how a number of contingent factors can be brought together to create such a paradigm shift. This paper is a comprehensive evaluation of available data published between 1997 and 2006 examining two major ablative techniques—cryoablation and radiofrequency ablation—and their use in minimally invasive treatments for renal cell carcinoma.

The first contingent factor is the development of technology. Over a couple of decades, urologists have been accustomed to using cryoablation, often with unhelpful and occasionally disastrous outcomes. However, the refinement of technology has allowed a more accurate and greater ability to deliver this therapy onto fixed sites while limiting the possibility of damage to adjacent tissues. Similarly, radiofrequency ablation has been used for active therapy of benign prostatic hyperplasia for more than a decade but, again, refinement of its technique has allowed specific targeting of lesions within the kidney.

The second contingent factor has been the increasing diagnosis of smaller lesions, principally due to the greater use of ultrasound over the last 15 yr. This has had two consequences: (1) the unexpected finding, as the lesions got smaller, that many of these were categorised as wholly benign and (2) some series in which lesions are <2cm were treated, with this figure approaching 20% and radical nephrectomy was a wholly disproportionate treatment of that condition.

Further contingent factors are the improvement in imaging techniques and the development of laparoscopic techniques that enabled probes to be placed with accuracy.

The critique of these techniques, both percutaneous true minimally invasive therapy and laparoscopic treatment, is examined in an interesting way in this paper and indeed follows logically from the development of nephron-sparing surgery that has occurred for both open and laparoscopic techniques in the last 6 yr or so. There is always a reluctance to downgrade surgical techniques especially by surgeons because they enjoy doing surgery. This is not out of some simple atavistic feeling but of genuine understanding that surgery continues to deliver the best therapy for cancer and, therefore, there is a decided reluctance to give up a proven and well-tried method. Although many of the headlines are dominated by medical oncologists, it is important to remember that their contribution to the cures of cancer are extremely modest. In the late 1970s, with the advent of cisplatinum and its utility in multiple therapy regimens, they were able to cure testicular cancer, leukaemias, and lymphomas. The unkind would suggest that 30 yr later they have not really added to the tumours that they can cure. In reading the media, one may assume that, based on the additional benefits of chemotherapy, the overall survival of breast cancer is many tens of percent; actually, it is more likely to be a modest 3% or so, whereas the contribution to colorectal cancer is possibly as high as 7%. It emphasises why our medical oncology colleagues thought that the 6% benefit of neoadjuvant chemotherapy for invasive bladder cancer was a major breakthrough, whereas surgeons, who know that they cure at least 50% of patients with invasive bladder cancers, looked on these figures with some degree of scepticism.

Nevertheless, I do feel that the era of genuinely minimally invasive ablative treatments has dawned because many tumours are being found early and are smaller. That laparoscopic surgery will be the exclusive way that these therapies will be delivered, even based on the evidence as reviewed by Mouraviev and colleagues, is probably a hope that will be unfulfilled. The results from Mueller and colleagues from Boston (references 35 and 36 in this review) show quite clearly how long-term data are already being accumulated. The parameters of successful therapy are being laid down and will almost certainly begin to be expanded with adequate and satisfactory results.

We know from the prostate cancer prevention study reported by Ian Thompson, that significant overdiagnosis of prostate cancer is already occurring in the modern era. Minimally invasive therapies as defined by brachytherapy have already overtaken radical surgery as the treatment of choice in the United States and are likely to do the same in Europe in the not too distant future. Even brachytherapy, however, must be perceived as a moderately invasive treatment although based on current results from Hifu, cryoablation remains modest given that the extent of disease being found in prostates is extremely small. Proportionate therapies are more likely to be accepted by patients, especially those with prostate cancer, where active monitoring without any intervention shows an extremely good outcome for a fair number of patients.

If urologic surgeons are reluctant to contemplate giving up doing nephrectomies, even more so, given the amount of energy and time that has been expended in learning first open radical prostatectomy and now laparoscopic radical prostatectomy, will there be a resistance and reluctance of surgeons to give up this therapy? It is precisely these reactionary, if all too understandable responses, that run the risk of allowing other medical disciplines to take over the management of tumours that should be looked after by specialists who understand the anatomy, physiology, and pathology of the urologic organs.

It is no good thinking that we will be spared and left with radical cystectomy. Excellent data from Professor Van der Werf Messing (1970s) showed that seed implantation in bladder tumours achieved good results and it is not at all difficult to see that the combination of cytoreductive chemotherapy and ablative treatment of percutaneously implanted radioactive seeds or other forms of ablative therapy could readily deal with many bladder lesions, while preserving the bladder and reducing the risk of complications associated with radiotherapy.

Unless urologists recognise that a paradigm shift in therapies is underway, train themselves to deliver these new therapies, and more importantly for established specialists, to encourage and train their trainees to deliver these therapies, then much of urologic oncology may well not be performed by urologists in the future.

In theory, urologists should be ideally placed. At present, they can deliver the best therapies with the best outcomes and, as lesions get smaller, because of their expertise and ability to deal with any complications, they should be the primary and, indeed, the only medical practitioners delivering effective treatment to patients with renal, prostate, and ultimately bladder cancers. However, a reluctance to recognise and embrace this development and the continuing adulation of “big operators” will not allow our trainees and younger colleagues to embrace this new technology and keep the management and successful treatment of urologic malignancies safely in the hands where it should be, that is, with urologists. The original Hippocratic specialist was a urologist; over 2000 yr later urologists have shown their ability to adapt to new modes of stone treatment and keep this disease safely in our hands. Urologic oncologists should learn and do the same in their treatment areas.

Reference

UroToday.com Laproscopic and Robotic Section

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