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Within the last few months of 2013, the Prostatic Urethral Lift procedure, using the UroLift® implant device (NeoTract, Inc., Pleasonton, CA, USA), appeared on the global urology stage. UroLift has the unusual distinction of being both radically new and yet highly studied. The creative crossover study by Cantwell et al. [1] in the present edition of the BJUI adds to the positive evidence for this new treatment option for men with LUTS. Roehrborn et al. [2] have also recently published a high-quality randomized, blinded study. The accumulating published data indicates a new response profile of rapid relief from LUTS and improved urinary flow, while preserving sexual function, including the often overlooked but much valued benefit of preserving ejaculation. In September 2013, Urolift was approved by the US Food and Drug Administration (FDA) [3] and then subsequently by the National Institute for Health and Care Excellence (NICE) in the UK [4]. Gaining regulatory approval at the first attempt is a strikingly unusual achievement but one we can learn from.
The development of this technique began with initial work in 2005 showing that prostatic glandular tissue could be compressed and tethered to the outer prostatic capsule to open up the prostatic urethra [5]. Neotract and its clinical advisors then embarked on years of device development and iteration, culminating in the current version of the UroLift implant device and the currently preferred technique [6]. The rigorous development and clinical testing programme represents a master class in how a new minimally invasive procedure should be developed.
The process illustrates the benefits of cooperation between active clinicians and expert engineers. One particularly important element in this cooperation was the identification of the critical evidence that would be necessary to overcome regulatory hurdles but also to allow clinicians to understand and evaluate this procedure as they adopt it into practice. Neotract’s determination to produce high-quality data first, rather than publicising the method and developing the data to support it later, represents a refreshing change.
So, get a good and novel idea, develop the engineering, do the high-quality studies, et voila – approval! But is it as easy as that? No, the missing element is finance – lots of it. For a company to tread this recommended path, although required by regulators (and indeed by editors), takes a huge amount of money. An FDA pivotal trial of sufficient quality to convince is likely to cost upwards of $20 m. Few start-up companies or indeed established device companies will take that gamble on truly innovative solutions, particularly when economic conditions are tough. NeoTract and its UroLift technology persevered through the economic crash of 2008 and have continued to achieve key clinical milestones against fierce regulatory and financial headwinds. Given these formidable challenges, it is reasonable to wonder how many other developers with novel ideas would be capable of completing the course. Most, unfortunately, would fail.
for detailed instructions and video.
I encourage you to both review the data of Cantwell et al. [1] in this journal and take a look at the Prostatic Urethral Lift technique, as an innovation that is now available for wider adoption (Fig. 1). It does require judgement to select those most likely to benefit and endoscopic skill to achieve the maximum therapeutic benefit, but it appears to be an effective option for men poorly served by drugs, yet wishing to avoid the negative effects of existing surgical options. Additional studies continue to enrol participants, including a European randomized study, but the evidence currently available greatly exceeds that of most newly introduced minimally invasive developments. Why not take the opportunity to assess it yourself?
Tom McNicholas
Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, and University of Hertfordshire, Hatfield, UK
Following the inaugural BJUI Social Media Awards presented at the 2013 AUA Annual Meeting in San Diego, this year’s awards moved across the Atlantic to the EAU Annual Congress in Stockholm. Both of these conferences play host to intense social media activity and it is fitting that the BJUI Social Media Awards gets to acknowledge the Uro-Twitterati on both continents! Individuals and organisations were recognised across 16 categories including the top gong, The BJUI Social Media Award 2014, awarded to an individual or organization who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the all-conquering Urology Match portal which continues to innovate in social and digital media. There had been much anticipation and speculation ahead of time about who would win the top and bottom gongs, and whether or not the King of Twitter, Ben Davies @daviesbj, would be acknowledged
In keeping with the informality of the 2013 BJUI Social Media Awards (held in an Irish Bar in San Diego), this year’s ceremony was held in the Acoustic Bar of the Scandic Grand Central in beautiful Stockholm. Fifty of the World’s leading social media enthusiasts in urology gathered to meet up in person and to see who would be recognised. Yours truly once again played the role of MC wearing my hat of BJUI Social Media Editor, ably assisted by Matt Bultitude, BJUI Website Associate Editor, and Editor-in-Chief Prokar Dasgupta.
The full list of awardees, along with some examples of “best practice” in the urology social media-sphere can be found on this Prezi (https://prezi.com/iukizmhni9_w/bjui-social-media-awards-2014/). The winners are also listed here:
BJUI Editor Prokar Dasgupta presenting awards to Jim Catto, Matt Cooperberg and Stacy Loeb
Many of the Award winners were present to collect their awards themselves, including the omnipresent Stacy Loeb who was awarded our top gong to huge applause.
A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar and Helena Kasprowicz, who manage our social media and website activity and who were present on the night.
For more pictures from the evening, please visit BJUI Associate Editor John Davis’ Flickr https://www.flickr.com/photos/jdhdavis/sets/72157643916525665/ page.
Declan Murphy is Associate Editor for Social Media at BJUI. He is a urologist in Melbourne, Australia
Follow Declan on Twitter @declangmurphy and BJUI @BJUIjournal
This month’s twitter based international urology journal club, found by using #urojc, kicked off with the highly anticipated 20 year follow-up of the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4). This article had twitter buzzing in mid-March when it was published in the New England Journal of Medicine making it an ideal article for April’s journal club. This paper became an instant urology “classic.”
Bill-Axelson et al. published this 18 year follow up of a randomized control trial which separated individuals with early prostate cancer into two groups: watchful waiting or radical prostatectomy. Notable results of the study included a relative risk reduction of 44% from prostate cancer for those who underwent a radical prostatectomy compared to with watchful waiting with the NNT = 8, decreased use of androgen-deprivation therapy in this group, and the benefit of surgery being the most prominent in men <65 years with a 55% decrease in the relative risk of death due to prostate cancer.
Given that these results contradict the well known results of the Prostate Cancer Intervention versus Observation Trial (PIVOT), which started after the advent of PSA screening – the discussion of this article was particularly interesting. They are however, very different studies in terms of era and the populations studied.
During the 48 hour discussion period, key topics discussed were:
As soon as the discussion opened, a question was posed if this was considered a contemporary cohort:
However, this thought was countered by:
The conversation continued to include the importance of time in NNT as pointed out Stacy Loeb. The point was later made, that the NNT might actually be lower with today’s advents of management in high-risk cancer patients.
There was a brief discussion on the statistic that 60% of the participants in the watchful waiting group underwent ADT treatment versus only 40% in the radical prostatectomy group.
Impact of adverse effects was also briefly discussed. The article stated that 84% of prostatectomy patients had ED versus 80% of the patients in WW. However, incontinence was only present in 11% of the watchful waiting group versus 40% of the surgery group. These statistics are interesting to compare, when the third option of radiation therapy is introduced. With RT being a viable alternative today compared to the 1990’s when the initial enrollment for the SPCG-4 study was done, weighing the risk/benefits of treatment becomes much more complicated.
The importance of weighing QOL was not forgotten during this discussion.
Finally, there was some great conversation alluding to the relevance of this study in the future given the new guidelines of the USTPSF which recommend against using PSA to screen for prostate cancer in healthy men of all ages on the account that there is no realized benefit.
Overall the importance of this study can be easily summarized as follows:
We welcomed a new member!
A huge thank you to the American Urological Association who supported the Best Tweet prize of a video box set. The winner is Fardod O’Kelly for the following tweet:
Thank you to everyone who joined the discussion. We look forward to seeing you at the May #urojc!
Meena Davuluri is a 3rd year medical student at Upstate Medical University in Syracuse, NY. She is interested in pursuing a career in Urology. Her interests include cost-effective decision analysis and health policy regarding healthcare delivery models. Follow her on Twitter @MeenaDavuluri.
Ureteric stents are commonly placed after ureteroscopy to protect the ureter and to facilitate subsequent stone fragment passage. They are known to be a cause of significant morbidity as judged by standardised validated questionnaires [1]. Whether placement of a stent is required at all is debatable, with randomised studies suggesting they are unnecessary after routine ureteroscopy [2]. The European Association of Urology (EAU) guidelines recommend stent insertion only ‘in patients who are at increased risk of complications’ and ‘in all doubtful cases to avoid stressful emergency situations’. Despite this, available evidence would suggest that we continue to commonly place stents [3].
If a stent is placed, the principal means of reducing morbidity is by minimising the stent dwell-time. One of the ways of doing this is to leave a stent with extraction strings/tether. This obviates the delay associated with scheduling cystoscopic extraction, the morbidity of cystoscopy and potentially reduces additional hospital visits if the patient is able to remove the stent at home.
Tethered stents are not widely used due to preconceptions about their tolerability, increased risk of complications (e.g. infection, migration) and accidental removal. Perhaps for this reason there have been few studies into the effectiveness of tethered stents in minimising stent-related morbidity to date, with only a handful in the past 30 years that have specifically addressed this issue.
In this issue of BJUI, Barnes et al. [4] report on the results of a prospective randomised trial analysing stented patients with or without the extraction strings attached, for both quality of life and postoperative complications after ureteroscopy for stone disease. This follows on from a retrospective series previously reported by the same group [5]. It is pleasing to see the authors, who originally concluded that randomised trials are needed in this area, actually get on and do the trial!
Two aspects of the trial methodology are worth highlighting: (i) the surgeons were not told that the patient was part of the study until they had made the decision to stent to minimise selection bias; (ii) patients completed the Ureteric Stent Symptom Questionnaire (USSQ) 6 weeks after stent removal as a control for their USSQ scores at postoperative days 1 and 6.
The headline results showed that there was no difference in quality of life and stent-related symptoms between patients with and without the extraction strings. There was also no difference in postoperative complications, emergency room visits or phone calls between the groups. What is surprising is that they found no difference in pain scores between self-removal and cystoscopic removal. This has not been our experience with tethered stents and may be due to the few men in the study. However, stent dwell-time was significantly less for patients with tethers compared with those without (10.6 vs 6.3 days, P < 0.001).
For urologists planning on using this technique it should be noted that the authors removed the original knot and shortened the string considerably to reduce the risk of accidental removal. For this reason the string was not attached to the patient’s skin.
This trial addresses many of the reservations urologists have about the use of tethered stents. Furthermore, reducing accidental removal and encouraging self-removal should be possible with improved patient education and selection. This was addressed by a study in New Zealand [6], which showed the feasibility of self-removal of stents.
The authors also acknowledged weaknesses in their study, which included failure to reach target enrolment, a 68% completion of trial surveys and a larger proportion of women in the study group due to male anxiety about self-removal of stents. In all, 15% of stents were inadvertently removed early and thus this technique should be used with caution in patients where early removal may be detrimental, e.g. in single kidneys. This does of course prompt the question: ‘If you are going to place a stent, how long does the stent need to stay for?’ and hopefully future trials may address this unanswered question.
References
Have You Read This?…A bibliography of cited papers on prostate cancer at the Joint Meeting of The European Section of Oncological Surgery (ESOU) and EORTC—Genito-Urinary Cancer Group.
At the BJUI, as with any journal, the published articles are peer reviewed and editorial board reviewed. The process starts with a triage editor who screens for basic methodology, importance of the topic, and potential for citation factor impact. The top 50% are sent for full peerreview, which includes 3 reviewers (ad hoc or from the board). Full review is organized by an associated editor who assigns (and then begs) the 3 reviewers to complete their task, and then makes a final recommendation to the editor in chief. I could go on about this interesting process, but the point is that a published paper is often really just the opinion of 4-5 experts in the field, including the editor. Once published, however, papers are then kept alive by repeated citation and meeting discussions, or disappear intoPubMed and forgotten. Future papers that cite a previously published paper will help the impact factor of that journal. But what about congress events and their cited works? At the EAU 2014, as with any congress, key opinion leaders are asked to give talks, make arguments, and prove their points. They may do so with personal experiences, videosor modern abstract quotes, but often they cite recent peer review publications. At the joint session meeting of the ESOU and EORTC-GUCG, I noted the following cited publications from the prostate cancer talks. How many have you read so far?
On the topic of circulating tumor cells (CTCs) in prostate cancer, Professor S. Osanto of Leiden (NL) cited (partial citations):
From these papers, the conclusions were many and included: 1) CTS can detect early relapse, genomic signatures, target identification, and treatment decisions, 2) surrogate marker for response, and 3) emergence of resistance.
Next, the focus shifted to the popular technical points and outcomes of open versus minimally invasive radical prostatectomy. Bernardo Rocco (IT) cited the following papers in support of robot-assisted radical prostatectomy for high risk PCa
From these citations, the conclusions were that: 1) RP is an adequate treatment for high risk prostate cancer, 2) robotic approach is not inferior to open as far as oncological outcome, 3) lymph node template and yield are adequate in experienced hands in RARP setting, 4) functional outcome after RARP in high risk is preserved, nerve sparing is feasible in selected patients, and 5) Costs of RARP are related to surgical volume and experience. So there you see a typical meeting presentation—13 papers in 15 minutes plus additional commentary and abstract data.
Next, Prof. Declan Murphy presented the Australian experience with robot-assisted RP for cT3a prostate cancer. With overlapping topics, it was no surprised some papers were recited from above including #9, #12,He cited:
From these citations, Prof. Murphy concluded that: 1) radical prostatectomy has minimal benefit for low risk men, especially older, 2) The biggest benefit is in high risk disease, 3) active surveillance is being embraced in Australia, 4) RARP is safe and effective with similar outcomes to ORP, 5) RARP has less positive margins and less additional therapy compared to ORP 6) extended PLND not limited by robotic approach.
Prof. Axel Heidenreich then took the opposite point of view in support of open radical prostatectomy. Despite the references above, he pointed out that there is still no long-term data for robotic prostatectomy, although not proving that with pathologic staging we would expect anything different. Cost of course can be quite better for open. He also cited for papers showing positive margins of < 12% in pT3 disease, compared to many other open and minimally invasive series where it is usually 25% and higher. Repeat citations: #9. He also cited:
From these citations, he concluded that 1) open radical prostatectomy is still viable, 2) not needed for low risk, 3) lack of long-term data for RARP, 4) no inferiority in terms of functional and oncological outcome, or quality of life, 5) better cost effectiveness, especially with median case load of < 300 RP’s per year.
I hope you find this reading list useful. Could you transfer such a bibliography to an effective review article? Probably not, and we can ask associate editor Quoc Trinh to comment or write a separate blog on the emerging field of systematic reviews, such as the multiple cited reference 9 by Yuh et al. A systematic review needs to conform to standards such as the PRISMA guidelines—see www.prisma-statement.org –which is “an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. Therefore we have an interesting difference in standards between a meeting presentation and a formal peer-reviewed systematic review—the former can hand-pick articles to make a point, while the latter must be thorough, transparent, and reproducible.
John W. Davis, MD FACS
Houston, Texas (USA)
Associate Editor, BJUI
A famous version of a saying attributed to Benjamin Franklin states “…but in this world nothing can be said to be certain, except death and taxes.” As a urologic oncologist, I cannot help with the taxes, but strive to delay the latter when threatened by urologic cancers. Our colleagues in andrology, however, are charged with the task of being sure the life lived is of high quality, and I am impressed at the large number of problems they face including infertility, erectile dysfunction, andhypogonadism. The latter problem is quite comprehensive when you consider the associated risks of cardiovascular disease, type 2 diabetes, sexual dysfunction, reduced energy, reduced muscle mass, weight gain, and many more. With this challenge, the first plenary session at the 2014 EAU gave an update on andrology with significant cross-over appeal to the uro-oncologist.
Prof W.H-G. Weidner started the session with an overview of male factor infertility, which comprises 50% of the contribution to childless couples. The causes can be idiopathic but then include primary testicular failure,varicocele, genetic disorder, obstruction, male accessory gland infection, hypogonadism, germ cell malignancy, and ejaculatory dysfunction. The diagnosis requires a comprehensive andrological exam if two separate semenalyses are abnormal.
Figure 1 Prof. W.H-G. Weidner from Giessen (DE) gave the first plenary presentation at the 2014 EAU, Stockholm, Sweden
Varicocele repair is known to improve ejaculate quality, however the effect on pregnancy rates does not always follow—counseling for the couple is also effective. The other major surgical intervention involves various techniques of microscopic sperm retrieval with essentially 100% retrieval rates. All factors considered, this leads to an approximate 20% “baby take-home” rate when used with ICSI. An interesting new trend is pediatric oncologist requesting sperm retrieval and cryopreservation for pre-pubertal patients who need chemotherapy.
Prof. S. Arver from Stockholm (SE) then reviewed the topic of testosterone supplementation in the ageing male. As a uro-oncologst in the 4th largest city in the USA, this is an every day topic. On the way to work I heard radio advertisements for local “Low-T Centers” that aim to attract potential patients who may be tired, or having problems with their sex life. Once I get to work, I see the new patients with an elevated PSA discovered as a downstream event once they’ve started testosterone replacement and had subsequent screenings. What do we know about the diagnosis of testosterone insufficiency and risks/benefits of replacements?
First, the diagnosis of testosterone (T) insufficiency is a combination of symptoms and laboratory assessment. Total serum T should be measured as a morning sample between 7-10am and fasting. If an afternoon measurement is low, it should be repeated in the proper circumstance. If the level is > 12 nmol/L it is likely normal, while 8-12nmol/L is a “grey zone” and < 8 nmol/L is probably associated with symptoms that would respond to therapy. The grey zone implies that some men can be symptomatic in the lower end of a normal range. In addition, a serum LH > 9 supports deficiency as the internal thermostat is trying to compensate, whereas LH 2-9 is uncompensated and may be a transient state.
The symptoms of low T are quite a list and organized under the categories is Physical/metabolic (decreased bone mineral density, muscle strength, etc.), sexual symptoms (libido, ED), and psychological (energy, fatigue, mood, etc.). To make matters worse, hypogonadism has a high prevalence with chronic renal failure, rheumatic disease, HIV, COPD, cancer therapy, opioid use, steroids, and male infertility. Of course, the most significant long-term concerns would be cardiovascular risk and type II diabetes. You can infact try using SARMs rather than steroids which is lot more better than steroids as per research studies. You can visit ceasar-boston.org to know more about SARMs.
T replacement is associated with significant responses in properly diagnosed patients, but dosing may be different—older patients may not clear it as fast and need dose titrations.
Prof. G.R. Dohle, Rotterdam (NL) continued the presentation with an emphasis on guidelines. Overall, the incidence of hypogonadism is 6% of middle age men and increasing in older men. Testosterone replacement may help with symptoms, increase weight reduction, and improve diabetes and bone mineralization. The side effects to note include increasing hematocrit, fluid retention, BPH, prostate cancer, gynacomastia, and recently sleep apnea, Arizona sleep apnea care offers treatment for this last one.
Is TRT a “fuel” for prostate cancer? Based on level 2 evidence, TRT should not be used for locally advanced or metastatic PCa. For PCa risk itself, there is a lack of evidence of association. For patients with localized disease treated with radical prostatectomy, there are only observational studies, but no risk of tumor recurrence with limited follow-up. A saturation model has demonstrated that the androgen receptor is saturated just over the castration level and therefore additional T should not increase further growth. The guidelines recommend careful monitoring with hematology levels, cardiovascular assessment, and PSA monitoring (for age > 40). Specifically, hematocrit and hemoglobin and PSA should be checked at 3, 6, and 12 months and then annually. They recommend at least 1 year of biochemical NED follow-up.
Figure 2 Prof. G.R. Dohle from Rotterdam (NL) presents he EAU guidelines on testosterone replacement andprostate cancer. #EAU2014.
The session then switched into another gear with the presentation by Prof John P. Mulhall from New York (USA) with the focused question as to whether or not TRT causes an increased risk of cardiovascular events. This topic has been covered by the New York Times and the Wall Street Journal based upon a hand full of studies concluding that the risk exists. These reports, of course, have led to many patients wanting to stop therapy, and the U.S. legal system creating a new industry of tort claims. This was a “getting into the weeds” talk by an expert with impressively high words per minute speaking pace. The theme was all about methodology, and I could never re-create the whole talk in summary. The bottom line was that 3 high profile papers including Basaria et al NEJM 2010,Finkle WD PLOS ONE 2014, and Vigen R JAMA 2013 all had significant limitations in the methods, which ProfMulhall concluded led to erroneous conclusions. To quote: “Bad science can hurt people,” and “ The good thing about good science is that it is true whether or not you believe it (reference Neil deGrasse Tyson).”
Professor A.L. Burnett from Baltimore (USA) delivered the AUA lecture on sexual function after urologic surgery. This was more of a review talk and a very complete one given the short time. Of course I am biased in his favor as he highlighted one of my publications on sural nerve grafting (Davis et al Eur Urol 2009) which effectively diminished the previous trend in this procedure with the randomized cohorts showing no difference from unilateral nerve sparing alone. There are certainly numerous teachings and publications on nerve sparing surgery technique, but even high volume surgeons have demonstrated and published that technique alone does not seem to eliminate the risk of post-operative erectile dysfunction. Therefore much focus has shifted to post-operative management and novel techniques.
In the post-operative management area, the commonly used term is “penile rehabilitation.” The concept is straightforward: to stimulate blood, maintain tissue oxygenation, protect endothelial function, and reduce tissue damage/atrophy. While the data certainly suggests that PDE5 inhibitors, vacuum erection devices, and injections can improve erections after surgery, the data are still not conclusive that a scheduled, rehabilitation is superior to on demand use. There are papers suggesting a benefit, but reasonable to conclude that this is not “holy grail” in solving the problem. He then outlined the various other research and alternative pathways under evaluation from neurotropic factors, androgen replacement in select patients, treatment of ejaculatory dysfunction, and counseling—the latter of which seems to augment the standard treatments).
Figure 3: Professor A.L. Burnett, Baltimore (USA) at #EAU2014
Prof. M. Albersen of Leuven (BE) continued this theme with a review of bench research in erectile dysfunction and the progress of stem cell research. Early work shows potential benefits at the smooth muscle, fibrosis, and innervation endpoints. At least 6 trials are now registered at clinicaltrials.gov in this area, but many are still looking at the safety aspects first. Prof M.J.H. Van Griethuysen ofRotterdam (NL) concluded the session with a review of future research funding.
Congratulations to the organizers and speakers for a strong start to #EAU2014. Where you in the audience? What were your take home messages?
John W. Davis, MD, FACS
Houston, Texas
Associate Editor, Urologic Ongology, BJU International
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The full technique and results in 200 patients are reported in Dutton et al. BJU Int 2014; 113: 246–253. doi: 10.1111/bju.12316
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Surgical management of prostate cancer is one of the most frequently performed urological procedures [1]. Available data suggests that surgeons’ experience is correlated with both oncological and functional outcome [2]. These initial observations stress the importance of concentration of prostatectomy in high-volume institutes. This centralisation could improve documentation and monitoring of outcome. The data presented by Røder et al. [1] from Denmark show a rapid increase in registered prostatectomy procedures in recent years in six institutes. It remains to be studied whether this is caused by centralisation and better registration or the results of an increased overtreatment. For that, data on the incidence of low-risk disease over time in their series needs analysis.
At least one-third of the population was treated since 2008. The relatively short follow-up and associated few events, and high number of low-risk patients (47% had biopsy Gleason ≤6) make outcome analysis of less value. It is therefore not surprising that in their analysis low- and intermediate-risk tumors had similar outcome. On the other hand, despite prostatectomy, one-third of deaths during follow-up were prostate cancer related in their population. Consistent with reported data at 15 years after prostatectomy more patients died from prostate cancer than from other causes [3]. But still a considerable number of men died from prostate cancer. This also seems the case in the group of men often soothed for having indolent, low-risk disease. At 15 years Røder et al., reported 8.9% of these men with low-risk disease still dying from prostate cancer in Denmark, despite prostatectomy. And although this percentage was lower than that of the prostatectomy group in the Scandinavian Prostate Cancer Group Study Number 4 (SCPG-4) study (14.6%) [4], most men will still find it disturbingly high and it is three-times higher than the 3% life-time risk of dying from prostate cancer for all men. In other words, it may be perceived that prostatectomy does only partly reverse the risk of dying from prostate cancer, even in men with low-risk disease.
The data from Røder et al. [1] can, with longer follow-up, set the standard for oncological outcome on a national level. Of interest is the observation that, although not significant in the multivariate analysis, variation among institutes for outcome seems to exist but not clearly dependent on institutes volume. Variations of case-mix and patient selection could be topics of further study. With the short follow-up available we are also looking forward to data on functional outcome and perioperative complications that may be more mature. Comparison with now also available registries in Belgium and the Netherlands would be of interest.
It always strikes me that prostate cancer seems to be a systemic disease from the start even in assumed ‘low-risk’ disease, yet surgical management is only focused at loco-regional control. Perhaps the mortality improvement shown in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial by prostatectomy is merely caused by disease delay provided by local control even in the presence of systemic disease. Initial encouraging data from an ongoing study evaluating the role of radiotherapy to the prostate in the presence of bone metastases seem supportive of this notion. Is prostatectomy a debulking management of a systemic disease at most, and an unneeded cure for many, or is there this sub-sub group of men that is eventually fully benefiting from the intervention reversing not only death but also the debilitating effects of androgen ablation.
References
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Image from Wah et al. BJU Int 2014; 113: 416–428. doi: 10.1111/bju.12349
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