A trend to minimize the radicality of surgery

Abstract

Various kinds of malignancies have become the leading cause of death in Taiwan.1 Therefore, efforts have been made to minimize cancer-related morbidity and mortality.2 Similar to all other chronic or acute illnesses, many strategies, such as risk identification in the general population,3 healthy life style, and behavior,4,5 a cost-effective screening method,6 and an early detection7,8 for the slowing down development and/or reducing disease-related mobility and mortality have been approved effectively, although many struggles still impede to reach the satisfactory results. All need further continuous development of advanced technology and more effective therapeutic strategies to provide a better chance to prolong the life span of diseased people and minimize therapy-related adverse events (AEs).9,10 It is always stated in the dilemma between saving lives and losing valuable organs and/or destruction or impairment of normal function, presenting a heavy burden to patients themselves, their families, and society, and also forming the biggest challenge for both physicians and patients. However, more and more patients have re-considered their needs when they faced the diseases. Their wish is not only to focus on curing diseases uneventfully but also attempting to preserve the organ or at least maintain the function of a targeted or damaged organ eventually. Regenerative medicine, organ transplantation, three-dimensional printing of custom-made prosthetic reconstructions, etc. have been reported to effectively assist in maintaining the basic or alternative function of damaged organs and/or tissue.11 However, if an accurate and precise evaluation and the following appropriate therapeutic plan can be guided before the initiation of treatment, particularly for those who are candidates suitable for surgical intervention, a minimally traumatic and/or sparing organ strategy as well as an establishment of the physiological and morphological function of damaged tissues and/or organs should be conducted to minimize the risk of overtreatment-related subsequent AEs and severe sequelae.11 Sometimes, no need for extra cost from new technology can be achieved,11 contributing to the refreshing or reminding of our thoughts while we do more but may lose more.”12 The recent publication in the current issue of the Journal of the Chinese Medical Association entitled “Effects of nerve-sparing procedures on surgical margins after robot-assisted radical prostatectomy” attempted to discuss the highly debated issue,13 since these cancer patients not only wish to be managed successfully (cure) to save their lives but also look eagerly forward to having preservation of function of the targeted organs and/or surrounding organs after cancer treatment.11 The authors retrospectively enrolled 417 prostate cancer (PC) patients undergoing robot-assisted radical prostatectomy (RARP) either with nerve sparing (NS) or without techniques to investigate their association with the presence of positive surgical margins (PSMs).13 The authors found that PSM rates were not statistically significantly different among unilateral, bilateral, and non-NS procedures, regardless of which pathological tumor size (pathological stage, pT) was classified, but in terms of specific site evaluation, such as posterolateral PSM rates, the authors found that the partial NS RARP had a statistically significantly higher risk of an increased PSM rate compared to those in either complete NS RARP (odd ratio [OR] 2.187) or non-NS RARP (OR 2.237).13 Therefore, the authors concluded that partial NS RARP had a potential risk of increasing the PSM rate than complete and non-NS RARP did.13 The current article is very interesting and worthy of further discussion. It is well known that complete tumor resection is the most critical and independent prognostic factor involving both progression-free survival and overall survival in patients undergoing surgical treatment for their malignant diseases,9 contrib