theo m. de reijke md phd febu department of urology ... · prostate delineation few soft tissue...

D e p a r t m e n t o f U r o l o g y, A c a d e m i c M e d i c a l C e n t e r A m s t e r d a m

Role of surgery

Theo M. de Reijke MD PhD FEBU

Department of Urology

Academic Medical Center

Amsterdam


TRUSgrayscale ultrasounds

Ultrasound imaging

Cancer ? Cancer F. Debruyne


TRUS: Pulse inversion

• Compared to Power Doppler


Future?

CEUS Fixed bubble imaging

VEGF-R2 peptides


Prostate DelineationProstate Delineation

Few soft tissue contrast at midprostate and apex

No tumor definition

Computed TomographyProstate

F:%5CBureaublad%5CAnatomie%5CMan%20CT%20Abdomen.avi

F:%5CBureaublad%5CAnatomie%5CMan%20CT%20Abdomen.avi


Prostate Cancer StagingMRI

Capsular penetration = irregular capsular bulge

OR infiltration of periprostatic fat OR

neurovascular bundle asymmetry

T


Prostate Cancer StagingBone Scintigraphy

High sensitivity for osteoblastic mets

Excellent high risk screening modality

Whole body scan +/- SPECT


Prostate Cancer StagingMRI

Plain Film MRI


Prostate Cancer - PET

• Prostate Cancer has low

metabolism so FDG-PET is not

very sensitive

• Primary activity obscured by

bladder

• Cannot distinguish BPH from

cancer in central gland

• May have some small role in

evaluation of metastatic disease

• Other isotopes under

investigation – 11C acetate

- 11C choline

Oyama et al J Nucl Med 43:181, 2002

Schmid et al Radiology 235:623, 2005


PET scan

• Low sensitivity in PC

– Glucose utilization is not enhanced

enough

• Interpretation is difficult

– Renal clearance: hampers interpretation of

loco-regional involvement

• Conclusion: limited role in staging


Lymph Node staging

• Contemporary incidence of LN+:

25% 1-2%

• imaging studies are unreliable

– low resolution

– observer dependent

– false (+): x based on size (>1 cm)

– false (-): microcopic LN involvement


Non-invasive lymph node staging

Harisinghani et al N Engl J Med 348:2491-2499, 2003


• Radical prostatectomy

– Open

– Laparoscopic

– Robot-assisted

• Temperature based treatments

• Focal treatment

Surgery and alternative treatments


Surgical treatment of localized

prostate cancer

• Pre-operative staging

• Approaches

• Extent of surgery



prostate cancer

• Pre-operative imaging

• Approaches




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



Finger Ring Attachments

Allow Endoscopic surgery

to be performed using

same skills as Open

Surgery



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


Lap vs open

Open

(219)

Lap early

(219)

Lap late

(219)

OR time 196 288 218

Blood loss 1,550 1,100 800

Compl rate 19,2% 13,7% 6,4%

Analgesia 50.8 mg 33.8 mg 30.1 mg

TUC time 12 7 7

Rassweiler et al J Urol 169:1689, 2003


Oncological results


Romero-Otero et el Urol Oncol 25:499-504, 2007


Conclusions surgery

• In experienced hands all treatment

options comparable

• Long term follow up seems to result in

same oncological results


Ficarra et al Eur Urol 55:1037-1063, 2009


Tewari et al Eur Urol 62:1-15, 2012

Open: 167.184

Lap: 57,303

RALP: 62.389


Radical prostatectomy

• Numbers are important

In men undergoing radical prostatectomy

the rates of postoperative and late urinary

complaints are significantly reduced if the

procedure is performed in a high volume

hospital and by a surgeon who performs a high

number of these procedures…

Begg et al N Engl J Med 346:1138-1144, 2002


Ann Int Med 148:435-448



prostate cancer

• Pre-operative staging

• Approaches



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


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 cryotherapyTechnique 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

3/10 infield

7/10 outfield

unilateral 73 3.7 yrs 70% PSA

reduction

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


Ward & Jones BJUint 2011

N=1160/5853 (19.8%)

Biochemical recurrence-free rate 75.7%

Incontinence: 1.6%

ED: 41.9%

Urinary retention: 1.1%

Fistula: 0.1%




• Cryotherapy




• 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


bRFS

Adjuvant treatment-free survival


“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??

HIFU in localized prostate cancer:

conclusions


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



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




• Cryotherapy




• Electroporation

• Indigo laser


Onik et al Techn Cancer Res Treatm 6:295-300, 2007

Lepor Rev Urol 10:254-261, 2008

RFA

PDTElectroporation

MR-temperature map Killing zone

c. J. Feller, Palm Springs USA

Focal therapy


Lindner et al J Urol 182:1371-1377, 2009


Challenges – FUP of focal treatment

• Prostate in situ

• Untreated side

• PSA kinetics? ASTRO/Phoenix?

• Imaging


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?

theo m. de reijke md phd febu department of urology ... · prostate delineation few soft tissue...

Documents