Prostate Cancer and BPH Management Revolutionised Marc Laniado MD FEBU FRCS(Urol)! Consultant Urologist
Prostate cancer is common and causes death worldwide Prostate Cancer BPH incidence by Age 2
Conventional diagnosis is haphazard & treatments have side-effects 3
Adopt innovations in imaging & treatment technology Multparametric MRI to show cancer Focal Treatment to treat target + margin Urolift treat BPH retain quality of life 4
The OLD PATHWAY to get tissue 5
Transrectal prostate biopsies to sample prostate Prostate Rectum Ultrasound Probe significant infection in 1 to 4% of men 6
Transrectal biopsies miss cancer at the front of the prostate 1 Underdiagnosis CANCER Front PROSTATE Back Transrectal biopsy needles passing from rectum into prostate 7
On unguided biopsies, a direct hit of a small cancer may be over-interpreted 1 Underdiagnosis! 2 Overdiagnosis Front CANCER Back Transrectal biopsy needles passing from rectum into prostate 8
Traditional diagnostic pathway has multiple problems Overemphasis men with inflammation or big prostates Misses men with cancer in small prostates Prostate examination is unreliable Transfaecal" biopsy Unguided & misses abnormalities May have found an insignificant cancer False negative May save lives but could overtreat Still has cancer! 9
Active surveillance fails in1/3 men because high-risk disease not recognised at diagnosis on TRUS biopsy 64% at 10 years no treatment Klotz 2015 JCO 10
The cool new pathway 11
Multiparametric MRI shows the location of prostate cancer 12
Enhanced mpmri can see prostate cancer that cannot be felt The same part of the prostate examined by MRI in different ways ( multiparametric MRI ) exposes cancer 13
Having identified potential cancer on MRI, target the biopsy to it Transperineal biopsies can reach the front of the prostate 14
Transperineal biopsies reach front & back of prostate 15
By fusing the USS and MRI images, the biopsy needle is guided into exactly the correct place 16
mpmri-targeted prostate biopsies: 30% high grade & 20% low grade Biopsy naive and previous negative biopsies MRTB v 12-core biopsies 33% v 24% high grade cancer 30% more high risk, 17% fewer low risk If add 12 core systematic biopsies 200 standard 12-core biopsies to detect one extra significant cancer 17 low risk cancers detected for each high grade Panebianco 2014 Urol Oncol Siddiqui 2015 JAMA Valerio 2015 Eur Urol 17
mpmri, targeted & mapping biopsies identify men likely to fail AS when selected bytrus bx 18
Treatment Options are Broad & Unclear? 19
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Brachytherapy - radioactive seeds 21
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There is a prboblem 23
Do all cancers need the same treatment? 24
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When confident cancer confined to one, treating that part may be enough - i.e. focal treatment Prostate cancer on right side Half the prostate scheduled for treatment fewer side-effects 27
3D Models of the Prostate show location of cancer & treatment effect 28
Treatment Effect of HIFU Cancer shown Cancer + MARGIN treated 29
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Current treatments for BPH improve LUTS but cause sexual dysfunction Drugs: α blocker Surgery: HOLEP 31
Most men want urinary symptom relief & normal sexual function 32
UroLift relieves symptoms AND preserves sexual function 33
Normal ejaculation requires an intact bladder neck 34
Bladder neck dysfunction gives retrograde ejaculation 35
UroLifts implant designed to compress prostate lobes Implant Delivery device 36
UroLift retract prostate lobes without affecting bladder neck 37
UroLifts relieve urinary symptoms (IPSS) for at least 3 years with no attrition IPSS Questionnaire Points Storage symptoms Voiding symptoms 1 year 2 years 3 years Roehrborn 2015 Can J Urol 38
Faster quality of life recovery after UroLift compared to TURP UroLift TURP Sonksen 2015 Eur Urol 39
Faster urinary flow rates after TURP than UroLift 40
Residual Urine decreased less after UroLift compared tp HoLEP UroLift 10 ml TURP 200 ml HoLEP 230 ml 41
Antegrade wet ejaculation & better sex after UroLift compared to TURP Ejaculatory & Sexual Function UroLift TURP Sonksen 2015 Eur Urol 42
Incontinence less after UroLift UroLift 5% TURP 11% HoLEP 14% 43
Side effects are transient & well tolerated 44
Day case UroLift saves money HOLEP 2,355 UroLift 2,405 Bipolar TURP 2,562 Monopolar TURP 2,691 45
NICE 2015: UroLift recommended 46
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UroLift fits well into the existing pathway UroLift HoLEP 48