precise, minimally invasive prostate cancer removal

David Lieber MD

Springfield Clinic Urology

Precise, Minimally Invasive Prostate Cancer Removal

What is the Prostate?

• Male sexual gland

• Adds nutrients and fluids for sperm

• This fluid is added to sperm during ejaculation

• Urethra (urine channel) runs through the middle of the prostate

Testes

Prostate

Seminal Vesicles

Rectum

Bladder

Urethra

Photo sourced from: www.daVinciprostatectomy.com

http://www.davinciprostatectomy.com/

What is Prostate Cancer

• Abnormal cells growing out of control

• Spreads and invades local tissues

• Prostate Cancer…

– Begins with a small tumor in

the gland

– First spreads to the local

lymph nodes

– Then spreads to the bony skeleton and other areas of the body



Prostate Cancer: Highly Prevalent

• Prostate cancer is the most common non-skin cancer in America, affecting 1 in 6 men1

• Prostate cancer is the second most frequently diagnosed cancer in men, and the sixth leading cause of cancer death in men 2



Early Detection & Aggressive Treatment = Highly Survivable

• 91% of prostate cancer diagnosed in the US is clinically localized3

• US 5-year survival rate is 99% vs. <80% for many other developed nations4

Staging of Prostate Cancer

• Prostate Specific-Antigen (PSA)• Digital Rectal Exam• Trans Rectal Ultrasound• Gleason Score• Bone Scan• +/- CT scan or MRI• Biopsy and TNM staging system

– Tumor, Nodes, Metastases



http://images.google.com/imgres?imgurl=http://www.aacc.org/publications/cln/2009/June/PublishingImages/June09-CoverImage.jpg&imgrefurl=http://www.aacc.org/publications/cln/2009/June/Pages/CovStory1June09.aspx&usg=__bAxhZKNhdLsfkv1IKGMy4WXG0jo=&h=224&w=300&sz=10&hl=en&start=12&um=1&tbnid=-Ojy0JCL1xJMoM:&tbnh=87&tbnw=116&prev=/images%3Fq%3DPSA%2Btesting%26ndsp%3D18%26hl%3Den%26sa%3DN%26um%3D1

• Tumor cannot be felt• T1a – cancer found in

≤ 5% TURP specimen• T1b - cancer found in

≥ 5% TURP specimen• T1c – cancer found as

a result of PSA elevation only

Prostate Cancer – T1 Disease


• Tumor can be felt during DRE (digital rectal exam)

• T2a – felt on ≤ one half of one side of prostate

• T2b – felt on ≥ one half of both sides of prostate

• T2c – felt on both sides of prostate



• Cancer has spread beyond the prostate

• T3a – extra capsular extension

• T3b – tumor invades seminal vesicle(s)



• Cancer has invaded local organs/tissues

– Bladder muscle

– Pelvic side wall

• May cause pain in joints and back



What do my biopsy results mean?

• Prostate cancer graded on appearance of cancer cells

• Gleason grading system– Gleason grade ranges

from 1 (least aggressive) to 5 (most aggressive)

• Gleason score (2-10)– Most common cell grade

(first) added to second most common cell grade, e.g., Gleason 7 (3+4)

Gleason Grading

Least aggressive

Most aggressive

1

2

3

4

5


Prostate Cancer Treatment Options

• When prostate cancer is believed to be localized, there are five common treatment options available to a patient:

– Surgery to remove the cancerous prostate (radical prostatectomy)

– Radiation of the cancerous prostate, through either external radiation or radioactive seed implants (radiation therapy or brachytherapy, respectively)

– Freezing of the cancerous prostate (cryotherapy)

– Hormonal therapy, which is non-curative and often done in conjunction with radiation therapy or cryotherapy

– Observation (watchful waiting)

Effective cancer removal

Quicker recovery and return to normal urinary function

Better chance of preserving delicate nerve structures that responsible for sexual function

Prostate posterior

Neurovascular bundle and nerve branches

da Vinci® Advantage for Prostatectomy

Why da Vinci® for Prostatectomy?Precise, Minimally Invasive Cancer Removal

Enables Meticulous DissectionEndowrist instruments for precise dissection

Provides Superior Visualization3D High Definition View

Allows Precise SuturingIntuitive motion with tremor filtration & motion scaling

Photos sourced from: www.daVinciprostatectomy.com

da Vinci Surgery is minimally invasive

Instruments of the da Vinci Surgical System are small and fit through tiny incisions

Photos sourced from: www.daVinciprostatectomy.com

Surgery: Gold Standard Treatment for Localized Prostate Cancer

“Because the entire prostate gland is removed with radical prostatectomy, the major potential benefit of this procedure is a cancer cure in patients in whom the prostate cancer is truly localized."

--(2007 AUA clinical guidelines3)

Surgery: Confidence to Know Status

• Up to 35% of tumors can actually be more aggressive than the pre-surgery assessment and biopsy results indicated5

• Choosing surgery can: – Enable easier detection of cancer

recurrence through PSA monitoring after a radical prostatectomy than after radiation therapy6

– Preserve your treatment options if there is a recurrence7

Long-Term Survival and Localized Prostate Cancer

A study of 3,159 patients found that 15 years after treatment, those who had undergone radical prostatectomy had a 40% lower risk of death from prostate cancer than radiation patients.8


Surgery: Longer Survival vs. Any Other Treatment

9) Merglen A, et al. Short- and long-term mortality with localized prostate cancer. Arch Intern Med 2007; 167:1944-1950.Photo sourced from: www.daVinciprostatectomy.com

Long-Term Survivability Matters

• Why should we be focused on just 10-year survival for older patients?

• Average 65 year old can expect to live for 18.4 years (CDC 2007 estimates)

Clinical Concerns for Prostatectomy

1.Cancer Control – Margins

2.Urinary Control – Continence

3.Sexual Function – Potency

“The Big 3”

Precision Matters: Cancer Control

10

11

12

13

Effective Cancer Control Shown with da Vinci Surgery (T2 positive margins)


Precision Matters: Urinary Control

1414

15

15

16

16

Faster Return to Continence with da Vinci

Precision Matters: Urinary Symptoms

17

17

17

17

Increased Pain with Radiation


Precision Matters: Cancer Control

Several studies have shown that patients potent prior to surgery have experienced a high level of recovery of sexual function (defined as an erection sufficient for intercourse) within a year following da Vinci Surgery.

1819

2021

High Level of Sexual Function at 1 Year with da Vinci


da Vinci: Get Back to Your Life

• As a minimally invasive treatment, da Vinci Surgery for prostate cancer offers numerous potential benefits compared to traditional open surgery.

• Potential benefits include:– Shorter hospital stay22

– Significantly less pain23

– Less blood loss and fewer transfusions24

– Less scarring– Faster return to normal activities25

Growth of robotic-assisted prostatectomy

da Vinci® Prostatectomy is the Number #1 treatment for Prostate Cancer in the

U.S.


Appendix

Surgery vs. Surgery

Outcome da Vinci Surgery Open Surgery Laparoscopic Surgery

Cancer control

T2 margin status 2.51 5.92 7.73

Complications

Length of hospital stay 1.2 days4 3 days5 2.5 days13

Major 1.7%4 6.7%5 3.7%6

Minor 3.7%4 12.6%5 14.6%6

Urinary function

3 month 92.9%7 54%8 62%9

6 month 94.9%7 80%8 77%9

12 month 97.4%7 93%8 83%9

Sexual Function

12 month 86%10 71%11 76%12

da Vinci Surgery vs. Traditional Surgical Approaches to Prostate Cancer

da Vinci Surgery is the #1 Treatment Choice for Prostate Cancer.

More men in the United States choose da Vinci Surgery than any other treatment option.14

28)

References: Surgery vs. Surgery

1) Patel VR, Thaly R, Shah K.Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109-12

2) Scardino PT. Open Radical Retropubic Prostatectomy. Presented at the American Urological Association’s Carcinoma of the Prostate Course, San Francisco, California, Sept. 30 – Oct. 1 2005

3) Touijer K, Kuroiwa K, Saranchuk JW, Hassen WA, Trabulsi EJ, Reuter VE, Guillonneau B. Quality improvement in laparoscopic radical prostatectomy for pT2 prostate cancer: impact of video documentation review on positive surgicalmargin. J Urol. 2005 Mar;173(3):765-8. p. 766 (Results)

4) Bhandari, A., McIntire, L., Kaul, S.A., Hemal, A.K., Peabody, J.O., and Menon, M. (2005). Perioperative complications of robotic radical prostatectomy after the learning curve. J Urol 174, 915-918.

5) Brown, J.A., Garlitz, C., Gomella, L.G., McGinnis, D.E., Diamond, S.M., and Strup, S.E. (2004). Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy. Urologic oncology 22,102-106.

6) Guillonneau, B., Rozet, F., Cathelineau, X., Lay, F., Barret, E., Doublet, J.D., Baumert, H., and Vallancien, G. (2002). Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. The Journal ofurology 167, 51-56.

7) Locke, DR, Klimberg IW and Sessions RP. Robotic Radical Prostatectomy With Continence And Potency Sparing Technique: An Analysis Of The First 250 Cases. Submitted To Journal Of Urology, Publication Date TBD. p. 5 table 4.

8) Walsh PC. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. J Urol. 2000 Jul;164(1):242. p. 59 table 1.

9) Goeman, L., Salomon, L., La De Taille, A., Vordos, D., Hoznek, A., Yiou, R., and Abbou, C.C. (2006). Long-term functional and oncological results after retroperitoneal laparoscopic prostatectomy according to a prospective evaluation of 550 patients. World J Urol 24, 281-288.

10)Kaul, S., Bhandari, A., Hemal, A., Savera, A., Shrivastava, A., and Menon, M. (2005). Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study. Urology 66, 1261-1265.

11)Parsons JK, Marschke P, Maples P, Walsh PC. Effect of methylprednisolone on return of sexual function after nerve-sparing radical retropubic prostatectomy. Urology. 2004 Nov;64(5):987-90.

12)Su, L.M., Link, R.E., Bhayani, S.B., Sullivan, W., and Pavlovich, C.P. (2004). Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique. Urology 64, 123.

13)Dahl DM, L’esperance JO, Trainer AF, Jiang Z, Gallagher K, Litwin DE, Blute RD Jr. “Laparoscopic radical prostatectomy: initial 70 cases at a U.S. university medical center.” Urology. 2002 Nov;60(5):859-63.

14)Claim based upon U.S. data on file.

precise, minimally invasive prostate cancer removal

Health & Medicine

prevalent prostate cancer

diagnosed cancer

local tissues prostate

prostate cancer abnormal

common nonskin cancer

leading cause of cancer

control spreads

men2 photo