Rise of the machine: Robotic prostate surgery as part of the treatment paradigm

Marc Laniado MD FEBU FRCS(Urol)

UKGDV04170006ah;Nov2017

Disclosures

• No paid consultancy

• No industry grants

• Conflicts of interest:

§ Share ownership in Nuada Medical - a company that provides MRI-targeted transperineal prostate biopsies equipment

Prostate cancer: a big problem

Black: 1 in 4 diagnosed, 1 in 12 die

Asian: 1 in 20 diagnosed, 1 in 44 die

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White: 1 in 8 diagnosed; 1 in 24 die

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PCa should respond to early treatment if cancer spreads sequentially

Localised Prostate Secondary spread to boneLymph nodes involved

If so, screening should reduce numbers with metastases

Localised Prostate Secondary spread to boneLymph nodes involved

↓ Metastatic prostate cancer after PSA testing late 1980s, unlike breast

cancer

Welch 2015 NEJM

Screening using PSA & transrectal ultrasound prostate biopsies led to 21% less deaths

Organised PSA screening compared to NONE ⬇ 21% chance of dying, 50% fewer mets at presentation

ScreenedUncreened

Schroder 2012 NEJM

After diagnosis, disease-risk, life expectancy & patient preferences

determine management

Life expectancy determines need for curative treatment:< 10 y: conservative/palliative treatment> 10 y: curative treatment

Age and life expectancy

Higher disease stage requires treatment, even in older men with short life expectancy

Localised Locally advanced

Images from Prostate Cancer UK

Advanced

Patient preferences & trade-offs important in deciding treatment

Avoid dying Hoping for long life May need to accept these

Treatment for clinically localised cancer dependent on disease risk & tumour location

Radical prostatectomy

Active surveillance

Low Risk PCa

favourable, Intermediate-Risk PCa

High Risk PCa

Radical RadiotherapyBrachytherapy Focal

Therapy

unfavourable, Intermediate-Risk PCaD

isea

se R

isk

Trea

tmen

t

Adapted from NCCN/AUA/ASTRO 2017

Androgen deprivation therapy, chemotherapy & radiotherapy for advanced prostate cancer

Androgen deprivation therapy androgen antagonists Chemotherapy

Multiple treatments may be needed over time

mpMRI gives anatomical location of cancer & widens treatment options

Cancer

Targeted biopsy:Gleason score 4 + 3 = 7Maximum cancer core length8 mm

Classified as“unfavourable, intermediate risk prostate cancer”

Age 71 yearsNo comorbidityPSA 8 mcg/L

For unilateral, intermediate-risk PCa, focal therapy treats cancer, keeps erections & continence

Prostate cancer on one side only

Half the prostate treated ∴ fewer side-effects

CAVEAT: Focal therapy regarded as ‘experimental’ & not ‘standard of care’ or ‘usual care’ because no long-term comparative data with existing treatments

HIFU treatment animation

Valerio 2014 Eur UrolFeijoo 2016 Eur Urol

mpMRI essential post-focal therapy to identify treatment success/failure

UnaffectedNeurovascular

bundleAblated cancer

Nerve bundle

Follow up with MRI over time Dickinson 2017 Urol Oncol

MRI identifies men for nerve-sparing surgery but more accurate by intraoperative check of prostate margin - NeuroSAFE technique

NERVE BUNDLE

• Cancer close to nerve bundle

• Nerve bundle preservation:- Benefit: better erections & continence

- Risk: leaving cancer at surgical margin & cancer recurrence

• NeuroSAFE: intentional nerve spare, prostate sent for frozen section, if tumour at margins —> secondary removal of nerve bundle

mpMRI: tumour contact length identifies wider margin needed & predicts PSA rise after surgery

Long tumour contact length indicates surgical technique modification: more tissue to be removed Kongnyuy 2016 Urol Onc

mpMRI can identify SV invasion

Surgical technique needs to be modified to preserve tissue around seminal vesiclesBrachytherapy unsuitable

Radiotherapy needs to include the SVUnsuitable for low-dose rate brachytherapy

mpMRI improves surgical selection: avoid men with short sphincter, ⬆ incontinence

Mungovan 2016

Short membranous urethral length (MUL) associated with incontinence – need 13 mm

Matsushita 2015

Robotic prostatectomy traditionally releases bladder from abdominal wall

Weakens continence support

Hernias more common

Easy to remove fat from front of prostate

New ‘Retzius-sparing’ approach to prostatectomy gives fastest continence recovery

Posterior approach preserves bladder & urethral attachments important for continence

Fewer hernias compared withanterior approach

Impossible by open surgery

Demonstrated at RCTDalela 2017 Eur Urol

Anterior tumours indicate either traditional anterior approach or modification of Retzius-sparing

technique

Tumour

Traditionally, fat not removedPotentially ⇧ positive margins

Adapted approach: Incision includes going far anterior to take fat

Controversy over benefit of robotic vs open prostatectomy

But all studies analysed were BEFORE Retzius-sparing V anterior approach RCT

Summary mpMRI & robotic prostatectomy

• Selection of men more suitable for active surveillance

• Selection of men for focal therapy

• Avoidance of men with short sphincters & risk for incontinence

• Plan extent of “radical” and/or nerve sparing surgery

• Modification or adaption of surgical approach to robotic prostatectomy