surgery as primary treatment in prostate cancer Donata Villari Sod Urologia II Azienda Ospedaliera Universitaria Careggi Firenze
Prostatectomia radicale (PR) Terapia "gold standard del tumore prostatico localizzato mediante rimozione in blocco di prostata e vescicole seminali Life expectancy >10 anni Età 75 anni (?) Stadio ct1b-t2, T2 N0, M0 T3a, GS>8, PSA<20ng/mL Prostatectomia retropubica open Prostatectomia videolaparoscopica Prostatectomia robotica
Stadiazione clinica accurata - il paziente ideale Età e performance status Familiarità ER PSA alla diagnosi Gleason score bioptico, numero e sede dei frustoli positivi T clinico IIEF-5
Fig. 4 Number of men aged 70 years and 80 years in more developed countries. Men over the age of 70 years are the fasted growing segment of the population. Data from 2010 to 2050 are projections <ce:cross-ref refid="bib8"> [8]</ce:cross-ref>. Jean-Pierre Droz, Lodovico Balducci, Michel Bolla, Mark Emberton, John M. Fitzpatrick, Steven Joniau, Michae... Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults Critical Reviews in Oncology/Hematology, Volume 73, Issue 1, 2010, 68-91
Fig. 6 Life expectancy in senior adults: a large variability reflecting health status variability. For a given age, a proportion of men in the top 25th percentile have a good health status and may have a longer life expectancy than men who are 5, 10 or eve... Jean-Pierre Droz, Lodovico Balducci, Michel Bolla, Mark Emberton, John M. Fitzpatrick, Steven Joniau, Michae... Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults Critical Reviews in Oncology/Hematology, Volume 73, Issue 1, 2010, 68-91
Fig. 7 General scheme for the treatment decision-making in senior adults with prostate cancer. Jean-Pierre Droz, Lodovico Balducci, Michel Bolla, Mark Emberton, John M. Fitzpatrick, Steven Joniau, Michae... Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults Critical Reviews in Oncology/Hematology, Volume 73, Issue 1, 2010, 68-91
Fig. 7 General scheme for the treatment decision-making in senior adults with prostate cancer. Jean-Pierre Droz, Lodovico Balducci, Michel Bolla, Mark Emberton, John M. Fitzpatrick, Steven Joniau, Michae... Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults Critical Reviews in Oncology/Hematology, Volume 73, Issue 1, 2010, 68-91
2014
Low risk < 25% PSA failure ng/ml T2a and Gleason 6 and PSA < 10 Intermediate risk 25-50% PSA failure T2b or Gleason 7 or PSA 10-20 ng/ml High risk > 50 % PSA failure T2c or Gleason 8-10 or PSA> 20 ng/ml
Contemporary Trends in Low Risk Prostate Cancer: Risk Assessment and Treatment J Urol. 2007 Matthew R. Cooperberg,* Jeannette M. Broering,* Philip W. Kantoff and Peter R. Carroll, 7 Biochemical survival among radical prostatectomy patients with low risk prostate cancer. Kaplan Meiercurvesfor biochemical recurrence free survivalamongamong patients with low risk prostate cancer undergoing radical prostatectomy, stratified by Cancer of the Prostate Risk Assessment (CAPRA) score.
L importanza delle categorie di rischio J Clin Oncol 2011 Click to edit the outline text format Second Outline Level Third Outline Level Fourth Outline Level Fifth Outline Level
La stadiazione clinica VOLUME GLEASON + PSA = STADIO PRESUNTO Partin AW Combination of Prostate-specific antigen,clinical stage, and Gleason score to predict pathological stage of localized prostate cancer :a multiisituzional update JAMA 1997
VOLUME DELLA NEOPLASIA
PENETRAZIONE CAPSULARE T2 (intra) T3(extra) T3(extra) T2 (intra)
Very promising technique Useful in selected cases. Could suggest to perform first or repeated biopsy
2014
Fascio vasculo-nervoso T1 T2
Achieving the balance between preserving the neurovascular bundles and eliminating the entire tumour continues to be a difficult task. The more the crucial structures are spared, the higher the chance that parts of the tumour will be left behind.
Trifecta outcomes in radical prostatectomy series according to the literature
Quality of life Fig. 1 Patient flow chart. CaPSURE = Cancer of the Prostate Strategic Urologic Research Endeavor; QoL = quality of life. Sanoj Punnen, Janet E. Cowan, June M. Chan, Peter R. Carroll, Matthew R. Cooperberg Long-term Health-related Quality of Life After Primary Treatment for Localized Prostate Cancer: Results from the CaPSURE Registry European Urology, 2014 Median follow up:74 mo (50 102)
Adjusted mean summary scores for the Medical Outcomes Studies 36-item Short Form (a) physical function and (b) mental health, and for the University of California, Los Angeles, Prostate Cancer Index (c) sexual function, (d) sexual bother, (e) urinary function, (f) urinary bother, (g) bowel function, and (h) bowel bother are displayed over time by primary treatment type among 3294 men in the study cohort. BT =brachytherapy; EBRT =external beam radiotherapy; NSRP = nervesparing radicalprostatectomy;nonnsrp=non t t N NSRP nerve sparing radical prostatectomy PADT = primary androgen deprivation therapy; PRE = before treatment; WW/AS = watchful waiting/active surveillance. Sanoj Punnen, Janet E. Cowan, June M. Chan, Peter R. Carroll, Matthew R. Cooperberg Eur Urol 2014 Long-term Health-related Quality of Life After Primary Treatment for Localized Prostate Cancer: Results from the CaPSURE Registry
Mean health-related quality of life summary scores at baseline for 3294 men in the study cohort by primary treatment modality BT = brachytherapy; EBRT = external beam radiotherapy; NSRP = nerve-sparing e radical prostatectomy; PADT = primary androgen deprivation therapy WW/AS = watchful waiting/active surveillance Health NSRP Non NSRP NSRP BT EBRT PADT WW/AS domain SF 36 Physical 93 (14) 88 (19) 82 (22) 78 (23) 74 (24) 71 (29) function Mental health UCLA PCI Sexual function 79 (16) 78 (16) 79 (15) 81 (15) 80 (16) 77 (19) 65 (26) 54 (28) 43 (30) 35 (28) 32 (26) 32 (28) Sexual bother 71 (34) 61 (37) 54 (39) 53 (40) 55 (41) 44 (41) Urinary 93 (12) 93 (13) 92 (13) 91 (14) 90 (16) 87 (22) function Urinary bother 89 (19) 85 (24) 83 (24) 81 (27) 79 (28) 77 (33) Bowel 90 (12) 88 (14) 88 (14) 87 (13) 84 (17) 86 (17) function Bowel 93 (16) 90 (20) 88 (21) 86 (23) 83 (25) 87 (22) bother Data are shown as mean (standard deviation).
2014
CHIRURGIA ROBOT-ASSISTED IN ITALIA L Italia è il secondo paese in Europa e il quarto nel mondo per numero di robot «Da Vinci» attualmente in uso: 1.U.S.A. (2000) 2.Giappone (138) 3.Francia (69) 4.Italia (64) Oltre 9000 procedure robotiche eseguite in Italia nel 2013
POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA. 1361 procedure a Settembre2014 Dept. Of Urology, AOUC Careggi, Florence 12 10 8 6 4 2 0
POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Stratificazione per tipo di intervento Dept. Of Urology, AOUC Careggi, Florence 0 2 4 6 8 10 12
POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Vantaggi dell impiego del sistema robotico monodisciplinare in struttura con alto volume operatorio Rapida acquisizione di casistica adeguata Riduzionedella della curva diapprendimento Formazione rapida di una equipe Miglioramento outcomes oncologici e funzionali e riduzione dei costi
POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA RAPN Open VS. Simple Laparoscopic VS. Robot assisted procedures Dept. Of Urology, AOUC Careggi, Florence 140 120 100 80 60 40 20 0 107 138 118 49 43 47 39 45 35 32 35 15 20 9 0 0 0 0 2009 2010 2011 2012 2013 Jan Sept 2014 Open VLP Robot
Dati intraoperatori Clinica Urologica, AOUC Careggi Procedure Radical (non NS) (5,6%) NS Monolateral (18.3%) NS Bilateral (76.3%) Linfoadenectomy (8,9%) Operative time (min) mean (range) 208 (70 540) Consolle time (min) mean (range) 178 (40 510) Estimated Blood Loss (cc) mean (range) 240 (50 800)
Dati peri e postoperatori Clinica i Urologica, AOUC Careggi Open (1) Robot (2) P Catheter removal (day) 14 (10 21) 7 (6 12) 0.003 Drainage removal (day) 52 5.2 (3 34) 34) 3 (2 14) 005 0.05 Length of hospitalization (days) 6.5 (4 36) 4 (2 16) 0.04 Positive surgical Open (1) Robot (2) P margins Overall 9.5% 16.1% <0.0001 Apex Lateral Posterior pt2a b pt2c pt3a pt3b 4% 3.3% 2.1% 0 5.9% 11.2% 23.4% 5.1% 6.4% 4.6% 2.1% 13.2% 34.6% 35.7%
* Ratio drainage creatinine/serum creatinine 2 Complicanze Clinica i Urologica, AOUC Careggi Perioperative complications P OPEN (1) ROBOT (2) (INTRA + POST) Conversion to open 0 Bleeding requiring transfusion 3,4% 0,8% 0.08 Bleeding requiring reintervention 0,6% 0 Infections 5,2% 4,0% 0.55 Drain leakage for urine fistula * 4,6% 2,7% Reintervention for urine fistula 0 0 Drain leakage for lymphorrea 7,6% Not applicable Thrombosis/Embolisms 2,1% 1,3% 0,74 Bowel lesions (suture) 1,2% 0,4% 0.65 Overall surgical complications 24% 9,1% 0,0001 Clavien grade 3 4 surgical complications 4,9% 0,4% 0,0007 Cardiac/respiratory 3,4% 3,5% 0,89
Continenza Clinica i Urologica, AOUC Careggi URINARY CONTINENCE Open (1) Robot (2) P (zero pad) 1 month 46.8% 64.4 % 0.0046 3 month 79.5 % 82.7 % 0.0650 6 month 87.2 % 88.0 % 0.6117 12 month 92.3 % 94.1 % 0.559
Potenza Clinica i Urologica, AOUC Careggi NS Bilateral 6 months potency rate: Open (1) RALP (2) P 38.3% 77.7% 74.3% 79.5% 0.24 NS Monolateral 29% 17.3% 6 months potency rate: 43.0% 62.5% 0.032 Non NS 32.7% 8.4% 6 months potency rate:
UTILIZZO DEL SISTEMA ROBOTICO «MONODISCIPLINARE» ANOMALIA??