“New surgery is conservative, in 40% of cases the organ is saved”

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Save and preserve: it is the new ‘must’ of urological surgery in oncology, bringing excellent results from the point of view of efficacy and safety. In fact, conservative surgery is on the rise, that set of treatments – mainly managed with robots – that aim to save the organ or gland affected by the neoplasm, instead of removing it. Every year in Italy about 40% of patients with urological oncological pathology, who until a few years ago had to undergo interventions that involved the removal of an organ (prostate, kidney or bladder) today can benefit from approaches whose objective main is to better contrast the disease, while safeguarding those physiological functions that most strongly involve the patient’s quality of life: from continence to the ability to erect and ejaculate. It was discussed at the 93rd National Congress of the Siu, the Italian Society of Urology, in Rome.





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Today, cancers of the prostate, kidneys and bladder provide valid alternatives to radical surgery. From focal ultrasound therapy for the prostate, to ‘trimodal’ therapy (chemotherapy, radiotherapy and endoscopic resection) dedicated to the bladder, we then move on to the great role of robotics and its rapid development over the last 10 years. In the case of prostate cancer, a targeted treatment that does not involve its removal, in fact, is focal therapy with the use of high-intensity ultrasound: “It seems to have satisfactory oncological results, without leading to functional impairment – notes Francesco Porpiglia, Professor of Urology at the University of Turin and Head of the Scientific Office of the Siu – It is carried out using a dedicated transrectal ultrasound probe, capable of emitting special ultrasounds that cause the death of cancer cells. The postoperative hospital stay is 24-48 hours and the side effects in terms of irritative or obstructive symptoms (weak jet or urge urination) are minimal. No problems are found on erection and ejaculation. Cancer specific survival can reach 99% at 5 years of follow-up”.

Conservative surgery is also increasingly being considered for kidney cancer: “Today 70% of patients with tumor confined to the kidney can benefit from this type of surgery – adds Walter Artibani, secretary general of Siu – In particular, thanks to robotics, the direct approach to safeguarding the organ can also be proposed in case of complex tumor masses to be removed. This is because maintaining valid renal function (in terms of creatinine) is also essential to increase the overall survival of the population. The balance between oncological safety and functional advantage is currently at the center of a wide debate especially among experienced surgeons: despite being technically able to remove the bulky tumor or very difficult to eliminate, they are faced with the doubt whether to preserve the organ. is a fairer solution than a more radical intervention”.

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Analogous discourse for the treatment of muscle invasive bladder cancer: “”Beside the solution that today constitutes the first choice, that is the removal of the bladder with urinary derivation, today a new multidisciplinary approach is gaining ground between urologist, radiologist and oncologist who, for selected patients (for example with comorbidities that do not radical surgery is possible and all patients strongly motivated to preserve the bladder), certainly constitutes a promising alternative – observes Porpiglia – It is the so-called ‘trimodal’ therapy, which combining the advantages of chemotherapy, radiotherapy and endoscopic resection of the bladder tumor , allows to control the tumor without the need to remove the organ with obvious benefits for the patient’s quality of life. With this type of approach, the 5-year cancer specific survival is 65%. The key element for the good efficacy of the treatment – he adds – is the radical nature of the endoscopic resection of the tumor alone (without removal of the bladder), which varies the complete response rate from 57% to 79%. The advantages? It allows to obtain good oncological results, preserves physiological urination and ensures a good quality of life for the patient because it maintains erections, ejaculations and fertility”.

At the heart of this new conservative surgery is the great technological evolution that took place with the advent of robotic surgery (which offers the surgeon the possibility of ‘seeing in 3D’, guaranteeing ever finer and more precise movements) and the introduction of new platforms for minimally invasive treatments. This together with the increasing request from patients to be able to preserve their physiological functions in terms of urination and sexual capacity; have strongly pushed third millennium surgery in this direction.

In the field of prostate cancer, thanks to ‘precision surgery’, which aims to preserve continence and postoperative power as much as possible, robotics makes it possible to guarantee a postoperative continence rate already in the immediate vicinity of over 70 %, and 95% at three months; while about 60% of patients can benefit from a preservation of the nerves responsible for erection “with a resumption of erectile function at 3 months of more than 60%, which goes up to almost 90% one year after surgery in young patients – concludes Porpiglia – In addition, the introduction of new ways of viewing the tumor, such as ” use of 3D images and augmented reality, allow to maximize oncological results even in the case of locally advanced disease”.

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