Prostate Cancer David C. Wei, MD FACS Urology Consultant, Inc. Clinical Assistant Professor of Surgery, University of Hawaii MD Anderson Cancer Center Network

Prostate and Prostatic Specific Antigen (PSA)

Prostate Function Production of ejaculatory fluid Production of anti-infective agents And Cause problem for men Benign prostate hyperplasia (BPH) Prostate cancer

Prostate Cancer Detection Screening for prostate cancer through Digital rectal exam (DRE) Prostate Specific Antigen (PSA) test Diagnosis of prostate cancer through Transrectal ultrasound-guided prostate biopsy (TRUS-Bx).

Prostate Cancer Incidence 2001 2016

Prostate Cancer Death 2001 2016

Trend of Prostate Cancer Incidence

Trend of Prostate Cancer Death

Prostate Cancer

Prostate Cancer Prostate cancer death is reduced by 40% in 40 years Likely due to early detection through annual screening with DRE and PSA blood test Better treatment technique Robotically-assisted laparoscopic prostatectomy Intensity Modulated radiation treatment New medical treatment methods such as Provenge, Xtandi, Zytiga

Controversies of PSA Screening No need of prostate cancer detection and treatment because: Majority of prostate cancer is slow growing and people live with it – But are you in the majority? PSA blood test result cause anxiety – persistent high PSA level and negative prostate biopsy Prostate biopsy causes pain and severe infection

Controversies of PSA Screening A large number of prostate cancer patient needs to be diagnosed and treated to save one patient from dying from prostate cancer Too much harm to too many people Not Economical Medicare is contemplating of penalizing physicians for ordering PSA blood test

Prostate cancer screening – D Grade

Without PSA Screening We will be back to Pre-PSA era: Solution Patient will be diagnosed with prostate cancer at late stage Increased number of patient dying from supposedly treatable prostate cancer if diagnosed early. Solution Prostate biopsy only after a series of PSA blood test that shows a consistent rising trend of the PSA level

Minimally Invasive Surgery (MIS) LAPAROSCOPIC surgery Inflate the peritoneal cavity with CO2 to create a space between intestines and abdominal wall and then insert small camera inside to visualize the diseased organ and insert small surgical instrument to remove or repair diseased organ. Advantages Small incisions, better cosmesis, less pain, shorter stay in hospital, faster recovery. Disadvantages Steep learning curve.

Improved MIS –Robotic Surgery da Vinci Surgical System A derivative of laparoscopic surgery. However, instead of rigid, less maneuverable instruments, Endowrists type of surgical instruments were used. Now, surgery can be performed as if your pair of hands are inside patient’s abdomen. Advantages Everything a surgeon wishes for in surgery. Disadvantages Cost.

Genesis Late 1980’s – US Army contracted SRI International to develop a system that would perform battle field surgery remotely. 1995 – Intuitive Surgical was founded to explore the commercial application of remote surgery. 1999 – da Vinci Surgical System was launched. 2000 – First robotic system to be cleared by FDA for laparoscopic surgery.

Da Vinci Surgical System S and Si

Da Vinci Surgical System Xi

da Vinci Surgical System Set Up

Surgeon Console Using the da Vinci Surgical System, the surgeon operates while seated comfortably at a console viewing a 3-D image of the surgical field.

Surgeon Console The surgeon's fingers grasp the master controls below the display, with hands and wrists naturally positioned relative to his or her eyes. The system seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of surgical instruments inside the patient.

Patient-side Cart Provides either three or four robotic arms—two or three instrument arms and one endoscope arm—that execute the surgeon's commands. The laparoscopic arms pivot at the 1-2 cm operating ports, eliminating the use of the patient's body wall for leverage and minimizing tissue damage.

EndoWrist Instruments The instruments are designed with seven degrees of motion that mimic the dexterity of the human hand and wrist.

EndoWrist Instruments Each instrument has a specific surgical mission such as clamping, suturing and tissue manipulation.

Vision System The Vision System, with high-resolution 3-D endoscope and image processing equipment, provides the true-to-life 3-D images of the operative field.

FDA approved procedures since 2000 Urology Removal of cancerous prostate (Radical prostatectomy) Repair Renal pelvis (Pyeloplasty) Removal of cancerous bladder (Cystectomy) Removal of kidney (Nephrectomy) Reconnect ureter to bladder (Ureteral reimplantation) Gynecology Removal of uterus (Hysterectomy) Removal of fibroid in uterus (Myomectomy) Repair of uterine prolpase (Sacrocolpopexy)

FDA approved procedures since 2000 General Surgery Removal of Gallbladder (Cholecystectomy) Repair of stomach reflux (Nissen fundoplication) Weight reduction surgery (Gastric bypass) Harvest kidney for transplant (Donor nephrectomy) Removal of adrenal gland (Adrenalectomy) Removal of spleen (Splenectomy) Partial removal of intestine (Bowel resection)

FDA approved procedures since 2000 Cardiothoraic surgery Internal mammary artery mobilization and cardiac tissue ablation Mitral valve repair, endoscopic atrial septal defect closure Mammary to left anterior descending coronary artery anastomosis for cardiac revascularization with adjunctive mediastinotomy

Popularity Over 1000 da Vinci Surgical Systems have been installed worldwide. 5 years ago, less than 5% of prostate cancer surgeries were done by robotic-assisted laparoscopic prostatectomy (RLP). More than 70% of all prostate cancer surgery were done via RLP in the US. In Hawaii, greater than 95%.

Why is robotic surgery popular? Reduced trauma to the body Size of incision: One long incision vs. several small “keyholes”. Tissue manipulation – Minimal injury to tissues with small, manipulative surgical instrument vs. hand and finger dissection. Less risk of infection Smaller incision and therefore less exposure of wound to outside.

Benefits Reduced blood loss and need for transfusions Less post-operative pain and discomfort Shorter hospital stay Faster recovery and return to normal daily activities Less scarring and improved cosmesis

At the beginning, only OPEN surgery To remove or repair diseased organ via an OPEN incision. Advantages Direct inspection of the diseased organ with hands and eyes. Better control of bleeding. Shorter surgical time in the hands of experienced surgeon. Standard for trauma surgery, transplant surgery, vascular surgery, etc. Disadvantages More blood loss for certain procedures. Big incision. Postoperative pain.

Prostate

Open Surgical Incision Laparoscopic Surgical Incision The differences between Robotic-Assisted Surgery and the traditional open procedure are the way we access the prostate and other anatomy. In the open procedure on the left, we had to make a long incision down the center of the abdomen. In the Robotic-Assisted Procedure on the right, we make several small “key hole” incisions. These access points allow us to insert a high-powered 3-dimensional camera as well as robotic instruments into the abdomen. We can now see, under high-magnification, the prostate and surrounding anatomy. We can then perform a precise & delicate operation with the robotic instruments. Open Surgical Incision Laparoscopic Surgical Incision

Example of open surgery – Open prostatectomy

Laparoscopic Prostate Dissection

RLP – DVC Dissection and Stapling

RLP – Bladder Neck Dissection

RLP – NVB Sparing

RLP – Urethra Divison

RLP – Anastomsis

RLP – Anastomosis - Si

Robotic-Assisted Procedure Compare the Benefits Open Procedure Long Incisions Hospital Stay of 3.5 days Blood Loss 900ml Catheter removal 14 to 21 days Robotic-Assisted Procedure 5 or 6 small keyhole incisions Hospital stay of 1.2 days Blood Loss 153 ml Catheter 5 to 7 days