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cancer-sparing techniques at the time) and when we
started working on robotic prostatectomy. We personally
did not find any patient who met the Villers’ criteria for
partial prostatectomy when we modeled the operation in
thousands of whole-mount sections from our robotic
prostatectomy tissue bank (Idea, Development, Exploration,
Assessment, Long-term Follow-up
[14_TD$DIFF]
[IDEAL] Stage 0 study).
However, many large specimen banks exist that will allow
independent preclinical simulation of those who may be an
appropriate candidate for a partial prostatectomy. Such
attempts should entail a detailed, retrospective, whole-
mount analysis of the radical prostatectomy samples from
patients who were initially diagnosed to have focal disease
on their biopsy. The final pathology correlation would then
provide an estimate on what proportion of such patients
had truly focal disease versus those that harbored signifi-
cant disease elsewhere in the prostate gland. In our
[15_TD$DIFF]
IDEAL
Stage 0 series (unpublished data), only patients with a
prostate-specific antigen
<
6 ng/dl and who had less than
three foci of cancer in the prostatic base could have been
candidates for partial prostatectomy, as only 6% of such
patients had apical cancer, and none of those apical cancers
were clinically significant.
These preclinical simulation studies may also allow for
the development of stricter inclusion criterias and/or
development of predictive instruments to identify the ideal
candidates for the partial prostatectomy.
For the moment, Villers and colleagues
[1]should be
congratulated on a fresh, bold way of thinking about
prostate cancer. For the future, we are left wondering, is
partial prostatectomy ready for primetime? Are the
recurrence rates following focal therapy high because
prostate cancer is essentially a multi-focal disease
[[16_TD$DIFF]
13]or
is it because current diagnostic methods are not sophisti-
cated enough to detect the index lesion
[[17_TD$DIFF]
14,15]? Is adding a
few years of potency worth risking cancer control—what
does a patient want? Or are surgeons the ones being
unsophisticated in their approach to treating many prostate
cancers early?
With continual improvements in nuanced approaches to
prostate cancer, perhaps we will soon say, ‘‘Je le pansai, et il
guerit.’’
Conflicts of interest:
The authors have nothing to disclose.
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