1. Prostate Cancer Treatment: What’s Best For You?
Clark Atlanta University Center for Cancer Research and Therapeutic Development Prostate Cancer Symposium July 17th, 2010
Prostate Cancer Treatment: What’s Best For You?
Rajesh G. Laungani, MD
Director, Robotic Urology
Chairman, Prostate Cancer Center
Saint Joseph’s Hospital, Atlanta

2. 2008 Estimated US Cancer Cases*
Men 745,180
Women 692,000
Prostate 25%
Lung and bronchus 15%
Colon and rectum 10%
Urinary bladder 7%
Melanoma of skin 5%
Non-Hodgkin 5%
lymphoma
Kidney 4%
Leukemia 3%
Oral Cavity 3%
Pancreas 3%
26% Breast
14% Lung and bronchus
10% Colon and rectum
6% Uterine corpus
4% Non-Hodgkin lymphoma
4% Melanoma of skin
4% Thyroid
3% Ovary
3% Kidney
3% Leukemia
Now we will turn our attention to the number of new cancers anticipated in the US this year. It is estimated that 1.37 million new cases of cancer will be diagnosed in Cancers of the prostate and breast will be the most frequently diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers both in men and in women.
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2008.
JEMAL ET AL. CA CANCER J CLIN 2008 2

3. 2008 Estimated US Cancer Deaths*
Men 294,120
Women 271,530
26% Lung and bronchus
15% Breast
9% Colon and rectum
6% Ovary
6% Pancreas
3% Leukemia
3% Non-Hodgkin lymphoma
3% Uterine corpus
2% Liver & IBD
2% Brain/ONS
Lung and bronchus 31%
Prostate 10%
Colon & rectum 8%
Pancreas 6%
Leukemia 4%
Esophagus 4%
Liver and intrahepatic 4% bile duct (IBD)
Non-Hodgkin %
Lymphoma
Urinary bladder 3%
Kidney 3%
Lung cancer is the most common fatal cancer in men (31%), followed by prostate cancer (10%), and colon & rectum cancer (10%). In women, lung (27%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.
ONS=Other nervous system.
Source: American Cancer Society, 2005.
JEMAL ET AL. CA CANCER J CLIN 2008. 3

4. Approach To Treatment of Prostate Cancer:
A Multidisciplinary & Individualized Approach
External Beam Radiation
Open Surgery
Good morning
Our study is directed towards finding accurate predictions of treatment related outcomes in patients with prostate cancer.
Watchful Waiting
Brachytherapy
Robotic Surgery 4

5. Treatment Options for Prostate Cancer
Active Surveillance
Radiation Therapy
External Beam
Brachytherapy aka “seeds”
HDR Therapy
Proton Therapy
Hormonal Therapy
Chemotherapy
Surgery
Robotics
Laparoscopic
Traditional Open
Retropubic
Perineal
Cryosurgery
HIFU

6. “One Size Does NOT Fit All”
Age
Gleason Grade
Stage
Co-Morbidities
Individual Characteristics

7. What does a positive biopsy mean?
Gleason Grade
Gleason Gleason 10
LOW GRADE
HIGH GRADE

8. Staging Clinical: Pathological: DRE CT Scan Bone Scan MRI Margins
Lymph nodes
Extracapsular Extension
Seminal Vesical Invasion

9. STAGE
SUB-STAGE
DEFINITION T1
Clinically unapparent tumor, not detected by DRE nor visible by imaging
T1a
Incidental histologic finding; <5% of tissue resected during TURP
T1b
Incidental histologic finding; >5% of tissue resected during TURP
T1c
Tumor identified by needle biopsy due to elevated PSA T2
Confined within the prostate (detectable by DRE, not visible on TRUS)
T2a
Tumor involves half of the lobe or less
T2b
Tumor involves more than one half of one lobe but not both lobes
T2c
Tumor involves both lobes T3
Tumor extends through the prostate capsule but has not spread to other organs
T3a
Unilateral extracapsular extension
T3b
Bilateral extracapsular extension
T3c
Tumor invades seminal vesicle(s) T4
Tumor is fixed or invades adjacent structures other than seminal vesicles
T4a
Tumor invades bladder neck and/or external sphincter and/or rectum
T4b
Tumor invades levator muscles and/or is fixed to pelvic wall
Node (N)
Regional lymph nodes N0
No lymph nodes metastasis N1
Metastasis in single lymph node <2 cm in greatest dimension N2
Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm N3
Metastasis in lymph node >5 cm in greatest dimension
Metastasis
Systemic spread M0
No distant metastasis
M1a
Non-regional lymph node metastasis
M1b
Bone metastasis      a) Axial skeleton only      b) Extending to peripheral skeleton also
M1c
Metastasis at other sites

10. Robotic Surgery Decreased Pain Shorter Hospital Stay
Decreased Blood Loss
Quicker Recovery
Improved Quality of Life after Surgery

11. Current Trends
36%
63%

12. Robotic Prostatectomy

13. Do Advanced Tools result in Better Outcomes ?

14. Vision and Control

17. How do attributes of robotic surgical systems translate into outcomes?
Operative parameters
Oncologic parameters
Quality of life parameters
Potency & continence

18. Urinary Continence Joseph et al. 2006 N=325 Mean age: 60
Method of Assessment: Questionairre
Definition used: No pad
Time of assessment: 6 mos
Continence Rate: 96%
Joseph et al. J Urol 2006

19. Bilateral Nerve Preservation Technique “The Veil of Aphrodite”
Menon et al.
N=250
Mean age: 59.9
Method of Assessment: Questionairre
Definition used: Intercourse
Time of Assessment: 6 mos
Potency Rate: 64%
Menon et al. Urol Clin of Amer 2004

20. Oncologic Efficacy Badani et al. N=2766 Gleason 7 or >: 64%
Median follow up: 22 mos
PSA recurrence rate: 7.3%
5 year biochemical free survival: 84%
Badani et al. Cancer 2007

21. Robotics vs. Open vs. Laparoscopic
RRP
daVP
LRP
Parameter
164
140
248
Op time (min)
900
<100
380
Blood Loss(ml)
12% 8%
24%
Positive Margins
15% 5%
10%
Complications 15
5-7 8
Catheter(d)
3.5
1.2
1.3
Hospitalization

22. How do I choose the best surgeon?

23. What questions should I ask?
Training?
Fellowship?
Experience?
How many cases have you done?
Reputation?
Having a robot and knowing how to do robotic surgery are very different things?

24. Steady and Experienced
Behind the Wheel

26. Thank You