ESOU 2019: Treatment of Gleason 3+4 in a Multidisciplinary Scenario: Surgery

Prague, Czech Republic ( Dr. Henk Van Der Poel was tasked with making the case for surgical treatment of Gleason 3+4 prostate cancer.

Dr. Van Der Poel started by highlighting that in the updated SPCG-4 analysis1, surgery was associated with a 2.9-year net benefit, whereas in PIVOT2 and ProtecT3 there was no overall benefit to surgical treatment. Certainly, any benefit of surgery in intermediate risk disease requires long-term follow-up.

Dr. Van Der Poel subsequently discussed the role of mpMRI in preoperative staging, noting that mpMRI is poor at predicting extracapsular extension, but may affect nerve sparing decisions that hopefully decreases positive surgical margin rates.

Citing literature that is yet to be published in European Urology Focus, a study led by Dr. Van Der Poel prospectively assessed 434 patients at 13 institutions focusing on decision making for localized prostate cancer. Of note, the 12-month decisional regret was less for patients selecting radical prostatectomy than those selecting radiotherapy + hormones. This is important work as 14% of prostate cancer survivors have clinically relevant mental health symptoms, compared to 6% of general population controls (OR 2.45, 95%CI 1.66-3.62) 4. The most important correlates of lower mental health scores in the prostate cancer survivors were being widowed, a lower educational level, lower general health perceptions, more bodily pain, and urinary bother, and less sexual satisfaction. 

Perhaps one way to improve on these mental health concerns is improved counseling of treatment and side-effects thereafter. In study from Dr. Van Der Poel’s group, among 426 patients with newly diagnosed prostate cancer, more than half of the patients did not comprehend that radical prostatectomy patients are at greater risk of urinary incontinence (65%, n = 202) and erectile dysfunction (61%, n = 190), and less at risk of bowel problems (53%, n = 211) compared to radiotherapy patients5.

Several calculators have been reported attempting to predict functional outcomes after surgery, particularly as it relates to earlier continence. Important components in these risk stratification schemes include (i) the degree of fascia sparing, (ii) longer urinary length, and (iii) narrow pelvic exit. Five studies have attempted to improve continence with the posterior reconstruction of the rhabdosphincter, however, none of these have demonstrated an appreciable benefit. Furthermore, fascial preservation scores have been suggested for predicting ED risk following surgery, however, these calculators may not be commonly used. As is importantly summarized by the EAU guidelines, it is crucial to “inform patients that no surgical approach (open, laparoscopic, or robotic radical prostatectomy) has clearly shown superiority in terms of functional or oncological results.”

Dr. Van Der Poel concluded his presentation advocating for surgery in patients with Gleason 3+4 disease with the following take-home messages:

  • Improvements in survival may be obtained only after long follow-up (>15 years)
  • Patients are generally poorly informed
  • Functional outcomes are a driver of treatment regret
  • Personalized prediction tools are available to clinicians and patients to predict continence and erectile function based on surgical findings and patient anatomy

Presented by: Henk G. Van Der Poel, MD, The Netherlands Cancer Institute, Amsterdam, The Netherlands

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

  1. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 2014;370(10):932-942.
  2. Wilt TJ, Jones KM, Barry MJ, et al. Follow-up of prostatectomy versus observation for early prostate cancer. N Engl J Med 2017;377(2):132-142.
  3. Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med 2016;375(15):1415-1424.
  4. Van Stam MA, van der Poel HG, Bosch JLHR, et al. Prevalence and correlates of mental health problems in prostate cancer survivors: A case-control study comparing survivors with general population peers. Urol Oncol 2017 Aug;35(8):531.
  5. Van Stam MA, van der Poel HG, van der Voort van Zyp JRN, et al. The accuracy of patients' perceptions of the risks associated with localised prostate cancer treatments. BJU Int 2018 Mar;121(3):405-414.
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