Prostate Cancer and BPH Management...

Marc Laniado MD FEBU FRCS(Urol)!Consultant Urologist

Prostate Cancer and BPHManagement Revolutionised

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Prostate cancer is common and causes death worldwide

BPH incidence by AgeProstate Cancer

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Conventional diagnosis is haphazard& treatments have side-effects

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Adopt innovations in imaging& treatment technology

Multparametric MRIto show cancer

Focal Treatment totreat target + margin

Urolift treat BPHretain quality of life

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The OLD PATHWAY to get tissue

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Transrectal prostate biopsies to sample prostate

ProstateRectum Ultrasound

Probe

significant infection in 1 to 4% of men

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Transrectal biopsies miss cancerat the front of the prostate

CANCER

PROSTATE

Front

Back

1 Underdiagnosis

Transrectal biopsy needles passing from rectum into prostate

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On unguided biopsies, a direct hit of asmall cancer may be over-interpreted

CANCER

Front

Back

1 Underdiagnosis!

Transrectal biopsy needles passing from rectum into prostate

2 Overdiagnosis

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Traditional diagnostic pathway hasmultiple problems

Overemphasis men withinflammation or big prostates

Misses men with cancer insmall prostates

Prostate examination is unreliable

“Transfaecal" biopsy Unguided & misses abnormalities

May have found aninsignificant cancer

May save lives butcould overtreat

‘False negative’

Still has cancer!

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Active surveillance fails in1/3 men because high-riskdisease not recognised at diagnosis on TRUS biopsy

64% at 10 years no treatment

Klotz  2015  JCO

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The cool new pathway…

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Multiparametric MRI showsthe location of prostate cancer

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Enhanced mpMRIcan “see”prostate cancerthat cannot be felt

The same part of the prostate examined by MRI in differentways (“multiparametric MRI”) exposes cancer

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Having identified potential canceron MRI, target the biopsy to it

Transperineal biopsies can reach the front of the prostate

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Transperineal biopsies reachfront & back of prostate

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By fusing the USS and MRI images, the biopsyneedle is guided into exactly the correct place

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mpMRI-targeted prostate biopsies:↑30% high grade & ↓20% low grade

•  Biopsy naive and previous negative biopsies•  MRTB v 12-core biopsies•  33% v 24% high grade cancer•  30% more high risk,•  17% fewer low risk•  If add 12 core systematic biopsies•  200 standard 12-core biopsies to detect one extra

significant cancer•  17 low risk cancers detected for each high grade

Panebianco 2014 Urol OncolSiddiqui 2015 JAMAValerio 2015 Eur Urol

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mpMRI, targeted & mapping biopsies identifymen likely to fail AS when selected byTRUS bx

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Treatment Options are Broad & Unclear

?

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Brachytherapy - radioactive seeds

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There is a prboblem…

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Do all cancers need the same treatment?

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When confident cancer confined to one, treatingthat part may be enough - i.e. focal treatment

Prostate cancer on right side

Half the prostatescheduled for treatment∴ fewer side-effects

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3D Models of the Prostate showlocation of cancer & treatment effect

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Treatment Effect of HIFU

Cancer shown Cancer + MARGIN treated

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Current treatments for BPH improveLUTS but cause sexual dysfunction

Surgery:HOLEP

Drugs:𝝰 blocker

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Most men want urinary symptom relief& normal sexual function

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UroLift relieves symptomsAND

preserves sexual function

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Normal ejaculation requiresan intact bladder neck

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Bladder neck dysfunctiongives retrograde ejaculation

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UroLifts implant designed tocompress prostate lobes

Implant

Delivery device

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UroLift retract prostate lobeswithout affecting bladder neck

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UroLifts relieve urinary symptoms (IPSS)for at least 3 years with no attrition

IPSS

Que

stio

nnai

re P

oint

s

1 year 2 years 3 years

Storagesymptoms

Voiding symptoms

Roehrborn 2015 Can J Urol

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Faster quality of life recoveryafter UroLift compared to TURP

Sonksen 2015 Eur Urol

UroLiftTURP

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Faster urinary flow ratesafter TURP than UroLift

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Residual Urine decreased lessafter UroLift compared tp HoLEP

• UroLift 10 ml•  TURP 200 ml• HoLEP 230 ml

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Antegrade wet ejaculation & bettersex after UroLift compared to TURP

Sonksen 2015 Eur Urol

UroLiftTURP

Ejac

ulat

ory

& Se

xual

Fun

ctio

n

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Incontinence less after UroLift

•  UroLift 5%•  TURP 11%•  HoLEP 14%

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Side effects are transient & well tolerated

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Day case UroLift saves money

HOLEP £2,355

UroLift £2,405

Bipolar TURP £2,562

Monopolar TURP £2,691

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NICE 2015: UroLift recommended

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UroLift fits well into the existing pathway

UroLift

HoLEP