1) mpMRI and robotic prostatectomy can improve treatment selection and outcomes for prostate cancer patients. mpMRI helps identify patients suitable for active surveillance or focal therapy instead of radical treatments. 2) mpMRI also identifies patients at risk for incontinence after surgery and helps surgical planning for nerve-sparing or modified procedures. 3) New robotic techniques like Retzius-sparing prostatectomy provide faster recovery of continence compared to traditional open or robotic approaches. mpMRI helps determine if modifications of this technique are needed for individual tumor locations.

1. Rise of the machine: Robotic prostate
surgery as part of the treatment paradigm
Marc Laniado MD FEBU FRCS(Urol)
UKGDV04170006ah; Nov 2017

2. Disclosures
• No paid consultancy
• No industry grants
• Conflicts of interest:
§ Share ownership in Nuada Medical - a company that provides MRI-targeted
transperineal prostate biopsies equipment

3. Prostate cancer: a big problem
Black: 1 in 4 diagnosed, 1 in 12 die
Asian: 1 in 20 diagnosed, 1 in 44 die
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
White: 1 in 8 diagnosed; 1 in 24 die
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`

4. PCa should respond to early treatment
if cancer spreads sequentially
Localised Prostate Secondary spread to boneLymph nodes involved

5. If so, screening should reduce numbers with
metastases
Localised Prostate Secondary spread to boneLymph nodes involved

6. ↓ Metastatic prostate cancer after
PSA testing late 1980s, unlike breast
cancer
Welch 2015 NEJM

7. Screening using PSA & transrectal ultrasound
prostate biopsies led to 21% less deaths
Organised PSA screening compared to NONE
➡ 21% chance of dying, 50% fewer mets at presentation
Screened
Uncreened
Schroder 2012 NEJM

8. After diagnosis, disease-risk,
life expectancy & patient preferences
determine management

9. Life expectancy determines need for curative treatment:
< 10 y: conservative/palliative treatment
> 10 y: curative treatment
Age and life expectancy

10. Higher disease stage requires treatment, even in
older men with short life expectancy
Localised Locally advanced
Images from Prostate Cancer UK
Advanced

11. Patient preferences & trade-offs
important in deciding treatment
Avoid dying Hoping for long life May need to accept these

12. Treatment for clinically localised cancer
dependent on disease risk & tumour location
Radical
prostatectomy
Active
surveillance
Low Risk
PCa
favourable, Intermediate-Risk PCa
High Risk PCa
Radical
Radiotherapy
Brachytherapy
Focal
Therapy
unfavourable, Intermediate-Risk
PCa
DiseaseRiskTreatment
Adapted from NCCN/AUA/ASTRO 2017

13. Androgen deprivation therapy, chemotherapy
& radiotherapy for advanced prostate cancer
Androgen deprivation therapy
androgen antagonists
Chemotherapy

14. Multiple treatments may be needed over time

15. mpMRI gives anatomical location of
cancer & widens treatment options
Cancer
Targeted biopsy:
Gleason score 4 + 3 = 7
Maximum cancer core length
8 mm
Classified as
“unfavourable, intermediate risk
prostate cancer”
Age 71 years
No comorbidity
PSA 8 mcg/L

16. For unilateral, intermediate-risk PCa, focal therapy
treats cancer, keeps erections & continence
Prostate cancer
on one side only
Half the prostate treated
∴ fewer side-effects
CAVEAT: Focal therapy regarded as ‘experimental’ & not ‘standard of care’ or
‘usual care’ because no long-term comparative data with existing treatments
HIFU treatment animation
Valerio 2014 Eur Urol
Feijoo 2016 Eur Urol

17. mpMRI essential post-focal therapy to
identify treatment success/failure
Unaffected
Neurovascular
bundle
Ablated
cancer
Nerve bundle
Follow up with MRI over time Dickinson 2017 Urol Oncol

18. MRI identifies men for nerve-sparing surgery but more accurate by
intraoperative check of prostate margin - NeuroSAFE technique
NERVE BUNDLE
• Cancer close to nerve bundle
• Nerve bundle preservation:
- Benefit: better erections &
continence
- Risk: leaving cancer at surgical
margin & cancer recurrence
• NeuroSAFE: intentional nerve spare,
prostate sent for frozen section,
if tumour at margins —> secondary
removal of nerve bundle

19. mpMRI: tumour contact length identifies wider
margin needed & predicts PSA rise after surgery
Long tumour contact length indicates surgical
technique modification: more tissue to be removed Kongnyuy 2016 Urol Onc

20. mpMRI can identify SV invasion
Surgical technique needs to be modified to preserve tissue around seminal vesicles
Brachytherapy unsuitable
Radiotherapy needs to include the SV
Unsuitable for low-dose rate brachytherapy

21. mpMRI improves surgical selection:
avoid men with short sphincter, ⬆ incontinence
Mungovan 2016
Short membranous urethral length (MUL) associated with incontinence – need 13 mm
Matsushita 2015

22. Robotic prostatectomy traditionally
releases bladder from abdominal
wall
Weakens continence support
Hernias more common
Easy to remove fat from front of
prostate

23. New ‘Retzius-sparing’ approach to prostatectomy
gives fastest continence recovery
Posterior approach preserves
bladder & urethral attachments
important for continence
Fewer hernias compared with
anterior approach
Impossible by open surgery
Demonstrated at RCT
Dalela 2017 Eur Urol

24. Anterior tumours indicate either traditional anterior
approach or modification of Retzius-sparing
technique
Tumour
Traditionally, fat not removed
Potentially ⇧ positive margins
Adapted approach:
Incision includes going
far anterior to take fat

25. Controversy over benefit of robotic vs open
prostatectomy
But all studies analysed were
BEFORE Retzius-sparing
V anterior approach RCT

26. Summary mpMRI & robotic prostatectomy
• Selection of men more suitable for active surveillance
• Selection of men for focal therapy
• Avoidance of men with short sphincters & risk for incontinence
• Plan extent of “radical” and/or nerve sparing surgery
• Modification or adaption of surgical approach to robotic
prostatectomy