Marc Laniado MD FEBU FRCS(Urol) Consultant Urologist Prostate Cancer and BPH Management Revolutionised
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