The Thematic Session “Controversies on EAU Guidelines: Prostate, bladder cancer and men’s health” took place on day three of EAU23 and was chaired by Prof. Nicolas Mottet (FR), Prof. Andrea Salonia (IT) and Prof. Alfred Witjes (NL). Three lively debates allowed for experts to share their research and experience, scrutinise various guidelines for pelvic lymph node dissection and PET PSMA in radical prostatectomy procedures, as well as dive into the best peri-operative treatment for muscle-invasive bladder cancer (MIBC).
Prof. Mottet introduced the topic debate “Lymph node dissection remains valuable at radical prostatectomy despite prostate-specific membrane antigen (PSMA) imaging”, with a graphic of the current EAU Guidelines which show that extended pelvic lymph node dissection (ePLND) has a strong recommendation, but what about the other options?
In her presentation “Based on nomogram”, Prof. Derya Tilki (DE) cited several studies to defend her case that ePLND is the most reliable staging procedure. “The low sensitivity of PSMA imaging in detecting smaller nodules metastases will hinder its use as a substitute to ePLND, and the information obtained from nodal staging by ePLND can help in guiding further therapy. Results from randomised trials comparing LND vs no LND have to be awaited to answer the questions about its therapeutic value”. She concluded with details on a current prospective randomised trial that is evaluating the prognostic role of LND in men with prostate cancer treated with radical prostatectomy (Predict study: NCT04269512)
Prof. Johan Stranne (SE) opened his rebuttal by addressing three important questions. Firstly, does ePLND improve oncological outcome? He shared results from three studies (Lestingi et al Eur Urol 2021 and Touijer et al Eur Urol Onc 2021) that showed no difference in BCR (biochemical recurrence), and a direct therapeutic effect is still not evident from the current literature.
Secondly, does ePLND cause harm? “The majority of studies showed that ePLND is associated with worse intraoperative and perioperative outcomes”. Prof. Stranne’s last question was what are the alternatives? “PSMA-PET can be used preoperatively on those with preoperative high-risk of N+/M+ on nomogram and then treat according to stage, and postoperatively on those with preoperative lower risk of N+/M= on nomogram, but a postoperative PSA ≠ 0.”
The panel deliberated on the Guidelines perspective, with Prof. Philip Cornford (GB) sharing his conclusions, “In high-risk disease, PSMA PET still struggles to identify small volume metastatic lymph node deposits, thus PSMA-PET will not replace ePLND because it doesn’t tell you the truth, only some of the truth. The question remains how much do you want to know and what does it matter how many lymph nodes are involved?”
A second insightful debate followed on the topic of “Best peri-operative treatment in MIBC” with presentations from Prof. Witjes (NL), Dr. Richard Cathomas (CH) and Prof. Anja Lorch (CH), and the last debate in the sessions included rebuttals from Mrs. Paraskevi-Sofia Kirana (GR) and Dr. David Ralph (GB) on “Does penile size matter?” To (re)watch the full presentations, please go to EAU On Demand on the Virtual Platform.