Brachytherapy for Bladder carcinoma

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1 Brachytherapy for Bladder carcinoma Geert Smits MD PhD FEBU Onco-urology, Robotsurgery 010

2 Intuitive: International proctor Electa: Scientific collaboration Stichting vrienden Rijnstate Intellectual property NO patents NO shares

3 Robot Assisted Laparoscopy and Brachytherapy for Bladder carcinoma Geert Smits MD PhD FEBU Onco-urology, Robotsurgery 010

4 020

5 Elzbieta vd Steen-Banasik Geert Smits

6 Muscle Invasive Bladder Cancer Cystectomy Lnn dissection Part.cystectomy Chemotherapy Neo / Adjuvant Brachytherapy EBRT Multimodality- treatments

7 Bladder preserving brachytherapy muscle invasive bladder cancer 1/ External Beam RT 2/ Surgery ± lnn dissection / ± tumorexcision (partial cystectomy) placement of brachytherapy catheters/source carier tubes Open surgery laproscopy robot assisted laparoscopy 3/ Interstitial RT = Brachytherapy

8 Bladder preserving brachytherapy muscle invasive bladder cancer Open surgery

9

10

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12 Bladder preserving brachytherapy muscle invasive bladder cancer What do we know? UCC is radiosensitive!! Can be curative in well defined cases Survival: comparable with cystectomy data Considerable toxicity Extensive and intensive collaboration Only few centres perform this technique N>1000 patients worldwide

13 Bladder preserving brachytherapy muscle invasive bladder cancer Literature: Ann Oncol, nov 2012 Int J Radiat Oncol Biol Phys, march 2014

14 Bladder preserving brachytherapy muscle invasive bladder cancer Literature: J of contemp brachytherapy, juni 2014 Radiother Oncol, nov 2009

15 Cystectomy vs Brachytherapy Overall survival Brachytherapy Cystectomy Disease specific survival Brachytherapy Cystectomy At risk: Time [y] At risk: Time [y] Radiotherapy & Oncology: 93 (2009)

16 Bladder preserving brachytherapy muscle invasive bladder cancer Conclusions literature: Multimodality bladder-sparing regimen using IRT offers excellent long-term oncological outcome in selected patients with MIBC Still considerable toxicity

17 OUR GOAL Organ preservation Improve toxicity Enhance effectivity ROBOT-assisted laparoscopy 3D monitors real-time virtual&augmented reality

18 RIJNSTATE

19 Surgery OPEN LAPAROSCOPIC Patiënt: Lithotomy & Trendelenburg position Simultaneous Laparoscopy and Cystoscopy Exposure and defining the target-volume Placing the canulas with the Arnhem-needle davinci robot platform N=57

20 Arnhem-needle

21 Arnhem-needle Luneray

22

23 Brachytherapy-bladdercarcinoma TUR-Bladder tumor, radical Solitary, rec. T1 or T2-3 tumor, no CIS 2-4 weeks post TUR-B: MRI and Cystoscopy it3a in0. 5 cm Not in the trigone or bladderneck Sufficient bladderfunction Informed consent 20 x 2Gy Implantation canulas +/- partial cystectomy +/- lymphenodedissection Afterloading: HDR (few cases PDR)

24

25

26 ing Position

27 ing Dock

28 Docking

29 Assistent

30 Simultaneous cystoscopy

31 Simultaneous laparoscopic and cystoscopic view

32 2D vs 3D vision

33

34 View in console

35 Needle handling

36 Positioning clips

37 Robot assisted partial cystectomy

38

39

40 Postop Hospital stay: 4-6 days afterloading Bloodloss: nihil (90%) max 200ml

41 Follow-up 1 year: 3m cystoscopy and cytology 2 year: 4m 3 year: 5m 4 year: 6m PET-CT or MRI when indicated (6/58)

42 na 3 mnd na 7 mnd

43 na 3 mnd na 7 mnd

44 na 5 mnd na 3 mnd na 7 mnd

45 na 5 mnd na 3 mnd na 7 mnd

46 Bladder preserving brachytherapy muscle invasive bladder cancer ct2-3a, cn0, solitary tumor, no CIS Should be mentioned in EAU guidelines Should be discussed in MDT Increasing awareness for bladder preservation Increasing number of patients can benefit Standardisation of treatment protocols Studies: sentinal node, HDR, comb. chemo, imaging

47 In the long history of human kind (and animal kind too), those who learned to collaborate and improvise most effectively have prevailed Ch. Darwin 2013 MVVDSTEEN

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