WCE 2017: Prostate Cancer

Vancouver, Canada (UroToday.com) Dr. Chaussy, from University of Munich and University of Regensburg began the session on prostate cancer, focusing on focal therapies. The ultimate aim of focal therapy is precise targeting of a small tumor with minimally invasive ablation while preserving the rest of the organ. For this to be successful, it is necessary for cancer biology to be favorable, patient selection has to be meticulous, and the technical intervention has to be trustworthy.

In the past we did not know the effectivity of focal therapy. However, now we have a better definition of cancer, better diagnostic ability, and localization. A few long term publications with HIFU that looked at 500 – 1000 patients with a follow up of 14 – 17 year follow up has shown a high survival rate for low grade cancer, and even comparable outcomes to prostatectomy for patients with high grade cancer.  Studies have also shown a high survival rate, high sexual function and continence rates, and low complication rates. 

Dr. Chaussy concluded by stating that focal therapy of the prostate is safe, has a low impact on Quality of Life, and the short-term outcomes are promising, however, more long term follow up is needed, there is difficulty with multifocal disease, and finally there is a lack of a standardized definition for the eligibility criteria.

Dr. Kural began his part on how to improve continence after robotic-assisted radical prostatectomy by stating there are multiple surgical techniques that could be done. Of all those that are considered, he stated that carefully dissecting and limiting energy near the apex at the dorsal venous complex (DVC) and leaving the urethra as long as safely possible are the most important. Dr. Kural showed a video of his technique where he uses extreme care near the DVC and uses the bulldog clamps on the DVC and then exposing the urethra. 

Dr. Porter from the Swedish Medical Center in Seattle spoke about the new techniques in the management of prostate cancer. When biochemical recurrence occurs after curative surgery, he suggested using Ga-PSMA ligand instead of F-Choline for imaging. He stated that the robotic salvage lymphadenectomy is feasible, that it helps facilitate the dissection, but vascular and lymphatic complications needs to be considered. 

Dr. Kaouk from the Cleveland Clinic stated that the highly popularized robotic surgery has helped reduce complications of prostatectomy, and reduced the learning curve. He proposes using a single port, and believes revisiting the perineal approach will be beneficial and is worth considering. 

Dr Tewari from the Icahn School of Medicine at Mount Sinai presented on the art of nerve-sparing during a robotic prostatectomy. He indicated that there are 3 components that are crucial for optimal nerve sparing, understanding the anatomy, knowing the technique, and tailoring the surgery to each case.

Dr. Tewari explains that the network of nerves is like a hammock. During the dissection, particular attention is needed to be given when approaching the prostatic fascia as nerves tend to hide and it is really important to appreciate the planes here. He recommends using the most delicate instrument, the sharp monopolar scissors, and to not use any cautery. The apex is the critical pathway, he explains one needs to understand the nerves traveling there and be very careful as many of these nerves are related to sexual function and some can be found on the anterior side. It is also crucial to tailor the operation to the cancer being treated by getting all of the appropriate imaging. Finally, after the anastamosis has been completed Dr. Tewari is a proponent of using the fat around the area and put it around the DVC to help with the healing process.

Dr. Davis from Anderson Cancer Center reflects on their experience of 10,000 RALP and finds it interesting that their positive margin rates go up and down throughout the years. Interestingly, the literature states that to get below a 10% positive margin, one needs to do roughly 1600 cases. Dr. Davis goes on further about lymph node dissection. They found that their ability to detect positive nodes has increased ever since they began doing deep lymph node collection, but they do caution that the therapeutic value of taking out the nodes has not been established yet.

Presented by: Christian Chaussy, MD, FRCShon,  Ali Kural, MD,  James Porter, MD, Jihad Kaouk, MD, Ashutosh Tewari, MD, John Davis, MD, 

Plenary Chairs: Raju Thomas, MD, FACS, MHA,  Jean Joseph, MD, MBA, FACS,  James Porter, MD
Session Chair: James Porter, MD

Affiliations: Department of Urology, Tulane University School of Medicine, University of Rochester Medical Center, Swedish Urology Group, Seattle, Washington, University of Munich, University of Regensburg, Acibadem University, Cleveland Clinic,  Icahn School of Medicine at Mount Sinai, Anderson Cancer Center

Written by: Egor Parkhomenko, Department of Urology, University of California-Irvine at 35th World Congress of Endourology– September 12-16, 2017, Vancouver, Canada.