Role of surgery Theo M. de Reijke MD PhD FEBU Department of Urology Academic Medical Center Amsterdam
Surgery and alternative treatments Radical prostatectomy Open Laparoscopic Robot-assisted Temperature based treatments Focal treatment
Surgical treatment of localized prostate cancer Pre-operative staging Approaches Extent of surgery
Surgical treatment of localized prostate cancer Pre-operative imaging Approaches Extent of surgery
Surgical treatment of localized prostate cancer Optimal cancer control Minimal morbidity Best functional results
Selection of treatment
Approaches Open Perineal (Young 1905) Retropubic (Millin 1945, Walsh 1983) Laparoscopic (Robotic) (Raboy 1997, Schuessler 1997) Transperitoneal Extraperitoneal
Robotics in Laparoscopy Surgeons Console Immersive 3D Display Close Up of surgical field No goggles / headset
Robotics in Laparoscopy Finger Ring Attachments Allow Endoscopic surgery to be performed using same skills as Open Surgery
Robotics in Laparoscopy EndoWrist Instruments Allow complex manipulative surgery
Radical prostatectomy - Complications Complications more frequent than generally reported N=101.606 RRP (n=93.986) RPP (n=7.718) 28.8% 25% Lu-Yao et al Urology 54:301-307, 1999
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
Continence at 1 year
Potency rate at 1 year (bilateral NS)
Ficarra et al Eur Urol 55:1037-1063, 2009
Open: 167.184 Lap: 57,303 RALP: 62.389 Tewari et al Eur Urol 62:1-15, 2012
Conclusions surgery In experienced hands all treatment options comparable Long term follow up seems to result in same oncological results
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??
Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser
Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser
Principles of Cryobiology 1. Intracellular ice formation membrane damage 2. Cell dehydration 3. Ischaemia 4. Immunology
Focal cryotherapy
Whole gland treatment vs focal therapy COLD registry
Results focal cryotherapy Technique N-pts FUP (mean) bdfs no. (%) Bx proven recurrence Potent Continence target 55 3.6 ys 52 (95) ASTRO 4 (7%) outfield 44 (85%) 54 (95%) unilateral 31 70 mos 26/28 (93) ASTRO 1/25(45) outfield 13/27 (48%) 11/27 (40%) with Tx 31 (100%) unilateral 25 28 mos 21 (88) 50 PSA nadir 2 (8%) outfleld 1 (4%) infield 17 (71%) 25 (100%) unilateral 60 16.7 mos 42 (80%) ASTRO 14 (23%) total 24/34 (71%) 53/55 (96%) Unilateral 77 24 mos (mean) 72.7% Phoenix unilateral 73 3.7 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 20:688-692, 2006 Truesdale et al Cancer J 16:544-549, 2010 Lambert et al Urology 69:1117-1120, 2007 Bahn et al Eur Urol 2012 Epub ahead of publication
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
Ward & Jones BJUint 2011
Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser
High Intensity Focused Ultrasound
HIFU - Physical Principle Each shot consists of a burst of ultrasound waves with a duration of 5 seconds The focal volume is very small: 19-24 mm in length by 1.7 mm in diameter
Adjuvant treatment-free survival brfs
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??
Ahmed et al Lancet Oncol 2012
N=42 45-80 years Low to high risk (PSA 15, GS 4+3, ct2) HIFU to all lesions Ahmed et al Lancet Oncol 2012
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
Techniques for non-radiation focal therapy are available Cryotherapy High Intensity Focused Ultrasound Radio Frequency Ablation Photodynamic therapy Electroporation Indigo laser
RFA PDT Electroporation Onik et al Techn Cancer Res Treatm 6:295-300, 2007 Lepor Rev Urol 10:254-261, 2008
Focal therapy MR-temperature map Killing zone c. J. Feller, Palm Springs USA
Lindner et al J Urol 182:1371-1377, 2009
Challenges FUP of focal treatment Prostate in situ Untreated side PSA kinetics? ASTRO/Phoenix? Imaging
Ongoing trials on focal therapy Different selection criteria!!!
Definitions need to be uniform Focal Targeted Conformal Zonal Hemi-treatment Lumpectomy
Focal therapy Does an index tumour exist and if yes, can we identify it?
Future? VEGF-R2 peptides CEUS Fixed bubble imaging