Role of surgery. Theo M. de Reijke MD PhD FEBU Department of Urology Academic Medical Center Amsterdam

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1 Role of surgery Theo M. de Reijke MD PhD FEBU Department of Urology Academic Medical Center Amsterdam

2 Surgery and alternative treatments Radical prostatectomy Open Laparoscopic Robot-assisted Temperature based treatments Focal treatment

3 Surgical treatment of localized prostate cancer Pre-operative staging Approaches Extent of surgery

4 Surgical treatment of localized prostate cancer Pre-operative imaging Approaches Extent of surgery

5 Surgical treatment of localized prostate cancer Optimal cancer control Minimal morbidity Best functional results

6 Selection of treatment

7 Approaches Open Perineal (Young 1905) Retropubic (Millin 1945, Walsh 1983) Laparoscopic (Robotic) (Raboy 1997, Schuessler 1997) Transperitoneal Extraperitoneal

8 Robotics in Laparoscopy Surgeons Console Immersive 3D Display Close Up of surgical field No goggles / headset

9 Robotics in Laparoscopy Finger Ring Attachments Allow Endoscopic surgery to be performed using same skills as Open Surgery

10 Robotics in Laparoscopy EndoWrist Instruments Allow complex manipulative surgery

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12 Radical prostatectomy - Complications Complications more frequent than generally reported N= RRP (n=93.986) RPP (n=7.718) 28.8% 25% Lu-Yao et al Urology 54: , 1999

13 Laparoscopic prostatectomy Advantage patient recovery better anastomosis/continence?? Disadvantage only in experienced hands, learning curve time consuming no tactile information on specimen similar cancer control?? Beware of patient selection

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15 Continence at 1 year

16 Potency rate at 1 year (bilateral NS)

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19 Ficarra et al Eur Urol 55: , 2009

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21 Open: Lap: 57,303 RALP: Tewari et al Eur Urol 62:1-15, 2012

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23 Conclusions surgery In experienced hands all treatment options comparable Long term follow up seems to result in same oncological results

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25 Rationale for focal treatment for prostate cancer Proven concept in other tumours (Breast, Renal, Testis, Bladder etc.) Could possibly reduce morbidity Could improve Quality of Life Reduce costs?? Same efficacy compared with traditional treatment??

26 Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser

27 Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser

28 Principles of Cryobiology 1. Intracellular ice formation membrane damage 2. Cell dehydration 3. Ischaemia 4. Immunology

29 Focal cryotherapy

30 Whole gland treatment vs focal therapy COLD registry

31 Results focal cryotherapy Technique N-pts FUP (mean) bdfs no. (%) Bx proven recurrence Potent Continence target ys 52 (95) ASTRO 4 (7%) outfield 44 (85%) 54 (95%) unilateral mos 26/28 (93) ASTRO 1/25(45) outfield 13/27 (48%) 11/27 (40%) with Tx 31 (100%) unilateral mos 21 (88) 50 PSA nadir 2 (8%) outfleld 1 (4%) infield 17 (71%) 25 (100%) unilateral mos 42 (80%) ASTRO 14 (23%) total 24/34 (71%) 53/55 (96%) Unilateral mos (mean) 72.7% Phoenix unilateral yrs 70% PSA reduction 3/10 infield 7/10 outfield 12 outfield 1 infield 86% 100% Onik et al Urology 70(suppl):16-21, 2007 Ellis et al Urology 70(suppl):9-15, 2007 Bahn et al J Endourol 20: , 2006 Truesdale et al Cancer J 16: , 2010 Lambert et al Urology 69: , 2007 Bahn et al Eur Urol 2012 Epub ahead of publication

32 N=1160/5853 (19.8%) Biochemical recurrence-free rate 75.7% Incontinence: 1.6% ED: 41.9% Urinary retention: 1.1% Fistula: 0.1% Ward & Jones BJUint 2011

33 Ward & Jones BJUint 2011

34 Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser

35 High Intensity Focused Ultrasound

36 HIFU - Physical Principle Each shot consists of a burst of ultrasound waves with a duration of 5 seconds The focal volume is very small: mm in length by 1.7 mm in diameter

37 Adjuvant treatment-free survival brfs

38 HIFU in localized prostate cancer: conclusions The place of HIFU has still to be defined It should be considered experimental and should be performed in strictly controlled trials Role as salvage therapy??

39 Ahmed et al Lancet Oncol 2012

40 N= years Low to high risk (PSA 15, GS 4+3, ct2) HIFU to all lesions Ahmed et al Lancet Oncol 2012

41 Median IIEF-15 similar at baseline and 12 months Median EPIC score similar at baseline and 12 months IPSS no difference between baseline and 12 months Positive Bx in 9/39 men at 6 months Ahmed et al Lancet Oncol 2012

42 Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser

43 RFA PDT Electroporation Onik et al Techn Cancer Res Treatm 6: , 2007 Lepor Rev Urol 10: , 2008

44 Focal therapy MR-temperature map Killing zone c. J. Feller, Palm Springs USA

45 Lindner et al J Urol 182: , 2009

46 Challenges FUP of focal treatment Prostate in situ Untreated side PSA kinetics? ASTRO/Phoenix? Imaging

47 Ongoing trials on focal therapy Different selection criteria!!!

48 Definitions need to be uniform Focal Targeted Conformal Zonal Hemi-treatment Lumpectomy

49 Focal therapy Does an index tumour exist and if yes, can we identify it?

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51 Future? VEGF-R2 peptides CEUS Fixed bubble imaging