Laniado rise of the machine 16 nov 17_queries 2
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Transcript of Laniado rise of the machine 16 nov 17_queries 2
Rise of the machine: Robotic prostate surgery as part of the treatment paradigm
Marc Laniado MD FEBU FRCS(Urol)
UKGDV04170006ah;Nov2017
Disclosures
• No paid consultancy
• No industry grants
• Conflicts of interest:
§ Share ownership in Nuada Medical - a company that provides MRI-targeted transperineal prostate biopsies equipment
Prostate cancer: a big problem
Black: 1 in 4 diagnosed, 1 in 12 die
Asian: 1 in 20 diagnosed, 1 in 44 die
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White: 1 in 8 diagnosed; 1 in 24 die
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PCa should respond to early treatment if cancer spreads sequentially
Localised Prostate Secondary spread to boneLymph nodes involved
If so, screening should reduce numbers with metastases
Localised Prostate Secondary spread to boneLymph nodes involved
↓ Metastatic prostate cancer after PSA testing late 1980s, unlike breast
cancer
Welch 2015 NEJM
Screening using PSA & transrectal ultrasound prostate biopsies led to 21% less deaths
Organised PSA screening compared to NONE ⬇ 21% chance of dying, 50% fewer mets at presentation
ScreenedUncreened
Schroder 2012 NEJM
After diagnosis, disease-risk, life expectancy & patient preferences
determine management
Life expectancy determines need for curative treatment:< 10 y: conservative/palliative treatment> 10 y: curative treatment
Age and life expectancy
Higher disease stage requires treatment, even in older men with short life expectancy
Localised Locally advanced
Images from Prostate Cancer UK
Advanced
Patient preferences & trade-offs important in deciding treatment
Avoid dying Hoping for long life May need to accept these
Treatment for clinically localised cancer dependent on disease risk & tumour location
Radical prostatectomy
Active surveillance
Low Risk PCa
favourable, Intermediate-Risk PCa
High Risk PCa
Radical RadiotherapyBrachytherapy Focal
Therapy
unfavourable, Intermediate-Risk PCaD
isea
se R
isk
Trea
tmen
t
Adapted from NCCN/AUA/ASTRO 2017
Androgen deprivation therapy, chemotherapy & radiotherapy for advanced prostate cancer
Androgen deprivation therapy androgen antagonists Chemotherapy
Multiple treatments may be needed over time
mpMRI gives anatomical location of cancer & widens treatment options
Cancer
Targeted biopsy:Gleason score 4 + 3 = 7Maximum cancer core length8 mm
Classified as“unfavourable, intermediate risk prostate cancer”
Age 71 yearsNo comorbidityPSA 8 mcg/L
For unilateral, intermediate-risk PCa, focal therapy treats cancer, keeps erections & continence
Prostate cancer on one side only
Half the prostate treated ∴ fewer side-effects
CAVEAT: Focal therapy regarded as ‘experimental’ & not ‘standard of care’ or ‘usual care’ because no long-term comparative data with existing treatments
HIFU treatment animation
Valerio 2014 Eur UrolFeijoo 2016 Eur Urol
mpMRI essential post-focal therapy to identify treatment success/failure
UnaffectedNeurovascular
bundleAblated cancer
Nerve bundle
Follow up with MRI over time Dickinson 2017 Urol Oncol
MRI identifies men for nerve-sparing surgery but more accurate by intraoperative check of prostate margin - NeuroSAFE technique
NERVE BUNDLE
• Cancer close to nerve bundle
• Nerve bundle preservation:- Benefit: better erections & continence
- Risk: leaving cancer at surgical margin & cancer recurrence
• NeuroSAFE: intentional nerve spare, prostate sent for frozen section, if tumour at margins —> secondary removal of nerve bundle
mpMRI: tumour contact length identifies wider margin needed & predicts PSA rise after surgery
Long tumour contact length indicates surgical technique modification: more tissue to be removed Kongnyuy 2016 Urol Onc
mpMRI can identify SV invasion
Surgical technique needs to be modified to preserve tissue around seminal vesiclesBrachytherapy unsuitable
Radiotherapy needs to include the SVUnsuitable for low-dose rate brachytherapy
mpMRI improves surgical selection: avoid men with short sphincter, ⬆ incontinence
Mungovan 2016
Short membranous urethral length (MUL) associated with incontinence – need 13 mm
Matsushita 2015
Robotic prostatectomy traditionally releases bladder from abdominal wall
Weakens continence support
Hernias more common
Easy to remove fat from front of prostate
New ‘Retzius-sparing’ approach to prostatectomy gives fastest continence recovery
Posterior approach preserves bladder & urethral attachments important for continence
Fewer hernias compared withanterior approach
Impossible by open surgery
Demonstrated at RCTDalela 2017 Eur Urol
Anterior tumours indicate either traditional anterior approach or modification of Retzius-sparing
technique
Tumour
Traditionally, fat not removedPotentially ⇧ positive margins
Adapted approach: Incision includes going far anterior to take fat
Controversy over benefit of robotic vs open prostatectomy
But all studies analysed were BEFORE Retzius-sparing V anterior approach RCT
Summary mpMRI & robotic prostatectomy
• Selection of men more suitable for active surveillance
• Selection of men for focal therapy
• Avoidance of men with short sphincters & risk for incontinence
• Plan extent of “radical” and/or nerve sparing surgery
• Modification or adaption of surgical approach to robotic prostatectomy