How we advise patients on the optimal treatment for their early Prostate Cancer

1. How we advise patients on the optimal treatment for their early Prostate Cancer Richard K. Babayan, MD Boston Medical Center - B.U.S.M Anthony Zietman, MDMassachusetts General Hospital

2. Localized Prostate Cancer Organ confined - Stages T1 and T2 Most commonly discovered due to ? PSA Stage T1c - nl DRE, ? PSA Stage T2 - palpable nodule

3. Localized Prostate Cancer If PSA < 10 and gleason score < 7 cancer is likely confined to prostate Risk of extra-capsular disease increases with PSA > 10 or gleason 8, 9 or 10

4. Curative Treatments - Localized P Ca Surgery Open radical prostatectomy -retropubic/perineal Laparoscopic radical prostatectomy Robot assisted lap radical prostatectomy ? Cryoablation of prostate Radiation Therapy XRT - external beam radiation Brachytherapy - radioactive seed implantation

5. Surgery - Advantages Tissue for pathologic analysis Confirms whether tumor is organ-confined Allows lymph node sampling for staging Nerve sparing for preservation of erections PSA will drop to 0 within 30 days Allows for post-op radiation if needed

6. RRP: The Surgical Approach

7. Emerging Therapy: Laparoscopic Radical Prostatectomy Eliminates the need for a large incision by using a telescopic instruments called a laparoscopes. Small camera attached to the laparoscope allows the surgeon to view inside the abdomen.

8. The Robotic Prostatectomy

9. Surgery - Disadvantages Operative Morbidity Anesthetic risk Potential blood loss -20-25% transfusion with open RP, < 2 % with lap or robotic Incontinence - 5-30% Impotence - 50% preservation with nerve-sparing

10. Radiation- Advantages No anesthesia - except for brachytherapy Outpatient treatment Same 10 year survival as Surgery Can be given to patients with co-morbidities May be combined with hormone therapy

11. External Beam Radiation

13. Radiation- Disadvantages No tissue to confirm effectiveness PSA will decrease but never go to 0 Radiation morbidity Radiation cystitis / hematuria Radition enteritis Erectile dysfunction in > 50% - ? with time

14. Treatment Decisions - multiple factors Age Stage and gleason score Family history / Race Life Expectancy Past & present medical history Quality of Life Patient preference

15. Patient Scenario - # 1 48 year old with family history of p ca PSA 3.7 / DRE - nl Prostate size - 30 cc by u/s Path - gleason 3+3 in 20% of 2 cores No prior surgery, no systemic illnesses

16. Patient Scenario - # 1- Options Open RP Lap RP Robot assisted lap RP Brachytherapy XRT

17. Surgical Options Open Radical Retropubic traditional approach large incision nerve-sparing & PLND blood loss ? length of stay longer recovery Laparoscopic/Robotic RP minimally invasive straw-holes vs incision nerve-sparing & PLND blood loss length of stay recovery time

18. Surgical Options Robot assisted RP 3-D camera straw-holes nerve-sparing & PLND articulating instruments comfortable position technical ease - rapid learning curve Laparoscopic RP 2-D camera straw-holes nerve-sparing & PLND straight instruments tiring position difficult & lengthy, acquired technical skill

19. Superior 3-D image Stereoscopic design with two 3-chip cameras Better resolution than standard laparoscopy tower   One significant deterrent to growing an endoscopic procedural base is the lack of 3 dimensional orientation, which skews the surgeons’ depth perception. This can greatly increase the time it takes to complete the case and can also compromise the quality of the operation. The Intuitive In-Site? Vision System is the only system that restores 3D vision to the operating surgeon without the added necessity of goggles or other peripheral attachments. This is achieved by utilizing two optical channels which remain isolated from one another through the entire optical chain, beginning at the scope, where (2) 5mm optical channels reside in one 12mm cannula. The image transmits through the channels to (2) 3-chip cameras, (2) light guide cables, (2) light sources, (2) camera control units, (2) synthesizers and, finally, (2) CRT monitors that reside under the hood of the surgeon’s console. Mirrors envelop the monitors to fuse the image to create a true 3-D image. The benefit to the surgeon is restored depth perception and improved visual acuity, allowing for greater precision and economy of movement.   One significant deterrent to growing an endoscopic procedural base is the lack of 3 dimensional orientation, which skews the surgeons’ depth perception. This can greatly increase the time it takes to complete the case and can also compromise the quality of the operation. The Intuitive In-Site? Vision System is the only system that restores 3D vision to the operating surgeon without the added necessity of goggles or other peripheral attachments. This is achieved by utilizing two optical channels which remain isolated from one another through the entire optical chain, beginning at the scope, where (2) 5mm optical channels reside in one 12mm cannula. The image transmits through the channels to (2) 3-chip cameras, (2) light guide cables, (2) light sources, (2) camera control units, (2) synthesizers and, finally, (2) CRT monitors that reside under the hood of the surgeon’s console. Mirrors envelop the monitors to fuse the image to create a true 3-D image. The benefit to the surgeon is restored depth perception and improved visual acuity, allowing for greater precision and economy of movement.

21. Patient Scenario - # 2 58 year old with gleason 4+3 PSA 5.7 / DRE - nl Prostate size - 30 cc by u/s History of inflammatory bowel disease and multiple prior abdominal operations

22. Patient Scenario - # 2- Options Open RP ? Lap RP ? Robot assisted lap RP ? Brachytherapy ? XRT

23. Patient Scenario - # 3 62 year old with gleason 4+3 PSA 4.7 / DRE - nl Prostate size - 120 cc by u/s History of hypertension & prostate ca Obesity - 5’5” tall - 290 lbs

24. Patient Scenario - # 3- Options Open RP -retropubic / perineal ? Lap RP ? Robot assisted lap RP XRT

25. Radical Perineal Prostatectomy

26. Patient Scenario - # 4 72 year old with gleason 3+2 PSA 5.8 / DRE - nl Prostate size - 60 cc by u/s History of Diabetes, coronary artery disease, COPD and hypertension

27. Patient Scenario - # 4- Options Observation + serial PSA XRT ? Open RP ? Brachytherapy ? Hormone therapy

28. Localized P Ca - Conclusions No single ideal treatment There are pros and cons to all treatments Must individualize treatment to patient Patients should be encouraged to seek out all options and make the best decision for their lifestyle and long-range concerns