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

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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

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Page 1: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Page 2: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

TRUSgrayscale ultrasounds

Page 3: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

Ultrasound imaging

Cancer ? Cancer F. Debruyne

Page 4: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

TRUS: Pulse inversion

• Compared to Power Doppler

Page 5: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Future?

CEUS Fixed bubble imaging

VEGF-R2 peptides

Page 6: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Prostate DelineationProstate Delineation

Few soft tissue contrast at midprostate and apex

No tumor definition

Computed TomographyProstate

Page 7: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Prostate Cancer StagingMRI

Capsular penetration = irregular capsular bulge

OR infiltration of periprostatic fat OR

neurovascular bundle asymmetry

T

Page 8: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Prostate Cancer StagingBone Scintigraphy

High sensitivity for osteoblastic mets

Excellent high risk screening modality

Whole body scan +/- SPECT

Page 9: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Prostate Cancer StagingMRI

Plain Film MRI

Page 10: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 11: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 12: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 13: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Non-invasive lymph node staging

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

Page 14: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

• Radical prostatectomy

– Open

– Laparoscopic

– Robot-assisted

• Temperature based treatments

• Focal treatment

Surgery and alternative treatments

Page 15: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Surgical treatment of localized

prostate cancer

• Pre-operative staging

• Approaches

• Extent of surgery

Page 16: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Surgical treatment of localized

prostate cancer

• Pre-operative imaging

• Approaches

• Extent of surgery

Page 17: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Surgical treatment of localized

prostate cancer

• Optimal cancer control

• Minimal morbidity

• Best functional results

Page 18: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Selection of treatment

Page 19: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Approaches

• Open• Perineal (Young 1905)

• Retropubic (Millin 1945, Walsh 1983)

• Laparoscopic (Robotic) (Raboy 1997, Schuessler 1997)

• Transperitoneal

• Extraperitoneal

Page 20: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Robotics in Laparoscopy

Surgeons Console

Immersive 3D Display

Close Up of surgical

field

No goggles / headset

Page 21: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Robotics in Laparoscopy

Finger Ring Attachments

Allow Endoscopic surgery

to be performed using

same skills as Open

Surgery

Page 22: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Robotics in Laparoscopy

EndoWrist Instruments

Allow complex

manipulative surgery

Page 23: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 24: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 25: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 26: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Oncological results

Page 27: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 28: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Conclusions surgery

• In experienced hands all treatment

options comparable

• Long term follow up seems to result in

same oncological results

Page 29: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 30: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Page 31: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Open: 167.184

Lap: 57,303

RALP: 62.389

Page 32: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 33: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Ann Int Med 148:435-448

Page 34: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Surgical treatment of localized

prostate cancer

• Pre-operative staging

• Approaches

• Extent of surgery

Page 35: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Page 36: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Page 37: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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??

Page 38: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Techniques for non-radiation focal

therapy are available

• Cryotherapy

• High Intensity Focused Ultrasound

• Radio Frequency Ablation

• Photodynamic therapy

• Electroporation

• Indigo laser

Page 39: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Techniques for non-radiation focal

therapy are available

• Cryotherapy

• High Intensity Focused Ultrasound

• Radio Frequency Ablation

• Photodynamic therapy

• Electroporation

• Indigo laser

Page 40: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Principles of Cryobiology

1. Intracellular ice

formation membrane

damage

2. Cell dehydration

3. Ischaemia

4. Immunology

Page 41: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Focal cryotherapy

Page 42: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Whole gland treatment vs focal therapy

COLD registry

Page 43: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 44: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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%

Page 45: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Techniques for non-radiation focal

therapy are available

• Cryotherapy

• High Intensity Focused Ultrasound

• Radio Frequency Ablation

• Photodynamic therapy

• Electroporation

• Indigo laser

Page 46: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

High Intensity Focused Ultrasound

Page 47: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 48: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

bRFS

Adjuvant treatment-free survival

Page 49: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

“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

Page 50: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Ahmed et al Lancet Oncol 2012

Page 51: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 52: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 53: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Techniques for non-radiation focal

therapy are available

• Cryotherapy

• High Intensity Focused Ultrasound

• Radio Frequency Ablation

• Photodynamic therapy

• Electroporation

• Indigo laser

Page 54: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Lepor Rev Urol 10:254-261, 2008

RFA

PDTElectroporation

Page 55: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

MR-temperature map Killing zone

c. J. Feller, Palm Springs USA

Focal therapy

Page 56: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

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

Page 57: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Challenges – FUP of focal treatment

• Prostate in situ

• Untreated side

• PSA kinetics? ASTRO/Phoenix?

• Imaging

Page 58: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Definitions need to be uniform

• Focal

• Targeted

• Conformal

• Zonal

• Hemi-treatment

• Lumpectomy

Page 59: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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

Focal therapy

Does an index tumour exist

and if yes,

can we identify it?

Page 60: Theo M. de Reijke MD PhD FEBU Department of Urology ... · Prostate Delineation Few soft tissue contrast at midprostate and apex No tumor definition ... learning curve ... Lap vs

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