State-of-the-art: vision on the future. Urology

Transcription

1 State-of-the-art: vision on the future Urology Francesco Montorsi MD FRCS Professor and Chairman Department of Urology San Raffaele Hospital Vita-Salute San Raffaele University Milan, Italy

2 Disclosures I make my living on prostate surgery!

3 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

4 Pca detection High-grade detection Take home message for everyday clinical practice: 1. PSA alone is no longer enough 2. Use of novel serum biomarkers is expected by patients and is recommended The 4K panel and PHI similarly improved discrimination when predicting PCa and high-grade Pca Both are simple blood tests that can reduce the number of unnecessary biopsies compared with screening with total PSA, representing important new options to reduce harm Nordstrom et al. Eur Urol 2015; in press

5 Are there new markers? MRI-GUIDED PROSTATE BIOPSY Siddiqui et al. JAMA Jan 27;313(4):390-7.

6 Are there new markers? MRI-GUIDED PROSTATE BIOPSY Take home message for everyday clinical practice: 1. Multiparametric MRI is here to stay and will significantly increase its role in PCa detection 2. Excellent technology is needed! 3. Partnership with experienced radiologists is needed! Targeted MR/ultrasound fusion biopsy, compared with standard extendedsextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of lowrisk prostate cancer Schoots et al. Eur Urol 2015, in press Siddiqui et al. JAMA Jan 27;313(4):390-7

7 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

8 For patients with adverse pathology after RP, outcomes vary greatly Decision curve analysis Patients with GC (Decipher) > 0.6 had a significantly increased risk of CSM Future studies will be required to determine whether the use of genomic and clinical risk prediction models actually improves patient cancerspecific and quality-of-life outcomes Cooperberg et al. Eur Urol 2014, in press

9 Biochemical recurrence The hazard ratio for BCR per 1-unit increase in the CCP score was 1.63 Take home message for everyday clinical practice: 1. Genomic tools are here to stay and will be significantly implemented in PCa management This is important to avoid longterm complications due to radical intervention and the deterioration of quality of life that follows Cancer-Specific Mortality Sommariva et al. Eur Urol 2015, in press

10 MRI is positive in roughly two-thirds of men suitable for active surveillance MRI can be used to detect clinically significant prostate cancer in men on active surveillance Future studies are needed to support the use of MRI in place of repeat standard biopsy to detect progression over time Van der Bergh et al. Eur Urol 2014;65(6): Schoots et al. Eur Urol 2015, in press

11 Use of MRI to Determine Preservation of the Neurovascular Bundles at RARP Take home message for everyday clinical practice: MRI will progressively acquire importance for: 1.Non-invasive monitoring of active surveillance patients 2.Non-invasive planning of curative-intent treatments (surgery and radiotherapy) MR imaging information influenced the extent of surgery (nerve-sparing vs non nerve-sparing technique) in 30% of the patients without affecting the risk of positive margins Thompson et al. BJU Int 2015, in press McClure et al. Radiology 2012;262

12 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

13 Manny et al. Eur Urol 2014;

14 Intraoperative injection of indocyanine green positively identified the prostate with uniform fluorescence relative to the obturator nerve, seminal vesicles, vas deferens, and neurovascular pedicles at a mean time of 10 min postinjection Take home message for everyday clinical practice: 1. Percutaneous robot-guided injection of indocyanine green might significantly facilitate the expansion of this technique (technically easier and less morbid that endorectal injection) 2. Real clinical advantages still to be proven Sentinel nodes were identified in 76% of patients at a mean time of 30 min postinjection Manny et al. Eur Urol 2014;

15 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

16 Positive surgical margins Thompson et al. Eur Urol 2014;65:

17 Sexual function recovery Take home message for everyday clinical practice: 1. An experienced open surgeon needs at least 100 robotic procedures to achieve comparable results 2. Results with robot-assisted surgery continue to improve up to 700 cases Thompson et al. Eur Urol 2014;65:

18 Volpe et al. Eur Urol 2015, in press

19 This study establishes the effectiveness of the first structured training curriculum for robot-assisted surgery Take home message for everyday clinical practice: 1. Modular training programs are badly needed to improve the quality of robotic surgical care The study shows that the 12-wk curriculum is valid, feasible, and acceptable The training curriculum allowed participants to improve their robotic skills and their ability to perform the surgical steps of RARP Volpe et al. Eur Urol 2015, in press

20 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

21 LOGISTIC REGRESSION COMPARING PSM RARP leads to a significant reduction of PSM across all risk-groups patients However, the benefit of RARP in achieving negative surgical margins reaches its highest in patients with high-risk disease This multinational, multi-institutional study of 22,393 men after open RP, laparoscopic RP, and robotic RP suggests that PSM rates might be lower after minimally invasive techniques compared with the open approach Caseload volume might be an important determinant of PSM outcome for both laparoscopic RP and robotic RP Sooriakumaran P et al. Eur Urol 2014;66:450-6

22 RARP vs. ORP in High-risk PCa: The San Raffaele Experience RARP is associated with acceptable continence RARP and potency outcomes in high-risk patients Neurovascular bundle preservation is feasibleorp in selected cases and may improve functional outcomes P<0.001 Take home message for everyday clinical practice: RARP ORP 1. It is likely that RARP 3-year will EF recovery replace rates (%) robot-assisted radical prostatectomy even in patients with high-risk PCa!! EF recovery was defined as an IIEF- EF >21 N=1975 patients with intermediate- and high-risk PCa Briganti et al. EAU 2015

23 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa

24 IS THERE A ROLE FOR SURGERY IN THE MANAGEMENT OF METASTATIC PCA? CYTOREDUCTIVE RADICAL PROSTATECTOMY? MAYBE IN SELECTED PATIENTS Group 1: 23 pts with M1 prostate cancer ( 3 hot spots on bone scan, absence of visceral disease, and PSA 1.0 ng/ml after neoadjuvant ADT) Group 2: a control group, which consisted of 38 pts treated with ADT without local therapy Median time to castration resistant prostate cancer was 40 months (range 9 to 65) and 29 months (range 16 to 59) in groups 1 and 2, respectively (p=0.04) TIME TO CASTRATION RESISTANCE Take home message for everyday clinical practice: 1. In the next future curative-intent treatments might play an important role in the management of selected patients Group 1 with metastatic PCa at diagnosis Group 2 Heidenreich et al. J Urol. 2014, in press

25 Vision on the future: Urology Novel biomarkers in Pca diagnosis Improvement in stratification of PCa patients: molecular markers and multiparametric MRI Intraoperative fluorescence imaging Improving surgical quality Will robot-assisted radical prostatectomy completely replace the open approach even in high-risk patients? Radical prostatectomy in patients with metastatic PCa