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Donata Villari Sod Urologia II Azienda Ospedaliera Universitaria Careggi Firenze surgery as primary treatment in prostate cancer Slide 2 10 anni Et 75 anni (?) Stadio cT1b-T2, N0, M0 T3a, GS>8, PSA Prostatectomia radicale (PR) Terapia "gold standard del tumore prostatico localizzato mediante rimozione in blocco di prostata e vescicole seminali Life expectancy >10 anni Et 75 anni (?) Stadio cT1b-T2, N0, M0 T3a, GS>8, PSA Slide 3 Stadiazione clinica accurata - il paziente ideale Et e performance status Familiarit ER PSA alla diagnosi Gleason score bioptico, numero e sede dei frustoli positivi T clinico IIEF-5 Slide 4 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 [8]. 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 Slide 5 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 Slide 6 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 Slide 7 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 Slide 8 Slide 9 2014 Slide 10 Slide 11 Low risk < 25% PSA failure T2a and Gleason 6 and PSA < 10 ng/ml 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 Slide 12 Biochemical survival among radical prostatectomy patients with low-risk prostate cancer. Kaplan-Meier curves for biochemical recurrence-free survival among patients with low-risk prostate cancer undergoing radical prostatectomy, stratified by Cancer of the Prostate Risk Assessment (CAPRA) score. Contemporary Trends in Low Risk Prostate Cancer: Risk Assessment and Treatment J J Urol. 2007 Matthew R. Cooperberg,* Jeannette M. Broering,* Philip W. Kantoff and Peter R. Carroll, 7 Slide 13 Click to edit the outline text format Second Outline Level Third Outline Level Fourth Outline Level Fifth Outline Level Sixth Outline Level Seventh Outline Level Eighth Outline Level Ninth Outline LevelClick to edit Master text styles Second level Third level Fourth level Fifth level J Clin Oncol 2011 Limportanza delle categorie di rischio Slide 14 GLEASON + PSA = STADIO PRESUNTO VOLUME 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 La stadiazione clinica Slide 15 Slide 16 VOLUME DELLA NEOPLASIA Slide 17 T2 (intra) T3(extra) PENETRAZIONE CAPSULARE Slide 18 Very promising technique Useful in selected cases. Could suggest to perform first or repeated biopsy Slide 19 Slide 20 2014 Slide 21 Fascio vasculo-nervoso T1 T2 Slide 22 Slide 23 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. Slide 24 Trifecta outcomes in radical prostatectomy series according to the literature Slide 25 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) Quality of life Slide 26 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 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 = nerve- sparing radicalprostatectomy;NonNSRP=non nerve sparing radical prostatectomy PADT = primary androgen deprivation therapy; PRE = before treatment; WW/AS = watchful waiting/active surveillance. Slide 27 Health domain NSRPNon-NSRPBTEBRTPADTWW/AS SF-36 Physical function 93 (14)88 (19)82 (22)78 (23)74 (24)71 (29) Mental health 79 (16)78 (16)79 (15)81 (15)80 (16)77 (19) UCLA PCI Sexual function 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 function 93 (12)93 (13)92 (13)91 (14)90 (16)87 (22) Urinary bother 89 (19)85 (24)83 (24)81 (27)79 (28)77 (33) Bowel function 90 (12)88 (14) 87 (13)84 (17)86 (17) Bowel bother 93 (16)90 (20)88 (21)86 (23)83 (25)87 (22) 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 radical prostatectomy; PADT = primary androgen deprivation therapy WW/AS = watchful waiting/active surveillance Data are shown as mean (standard deviation ). Slide 28 Slide 29 Slide 30 Slide 31 Slide 32 Slide 33 2014 Slide 34 Slide 35 CHIRURGIA ROBOT-ASSISTED IN ITALIA LItalia 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 Slide 36 . 1361 procedure a Settembre2014 Dept. Of Urology, AOUC Careggi, Florence POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Slide 37 Stratificazione per tipo di intervento POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Dept. Of Urology, AOUC Careggi, Florence Slide 38 POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Vantaggi dellimpiego del sistema robotico monodisciplinare in struttura con alto volume operatorio Rapida acquisizione di casistica adeguata Riduzione della curva di apprendimento Formazione rapida di una equipe Miglioramento outcomes oncologici e funzionali e riduzione dei costi Slide 39 RAPN POLO DI CHIRURGIA ROBOTICA DELLA REGIONE TOSCANA Dept. Of Urology, AOUC Careggi, Florence Open VS. Simple Laparoscopic VS. Robot-assisted procedures Slide 40 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 intraoperatori Clinica Urologica, AOUC Careggi Slide 41 Positive surgical margins Open (1)Robot (2)P Overall9.5%16.1%