1 00:00:00,450 --> 00:00:09,990 I think it's just sort of. 2 00:00:09,990 --> 00:00:26,670 This money saga is about salvage options for people who had already definitive therapy for prostate cancer, as shown in here. 3 00:00:26,670 --> 00:00:40,040 There has been increasing use of a prostatectomy radiotherapy a for a locally advanced and very high risk of prostate cancer worldwide. 4 00:00:40,040 --> 00:00:47,630 Well, because of that, there are certainly is a increasing needs for a therapy. 5 00:00:47,630 --> 00:00:55,070 But when we apply or indicate salvage therapy, we've got to think a lot of things. 6 00:00:55,070 --> 00:01:04,280 But at least in theory, it says it has a well, it has to deal with the recurrent tumour. 7 00:01:04,280 --> 00:01:12,530 Expectant management option won't be enough. Well, castration. 8 00:01:12,530 --> 00:01:17,210 So expect the management may not apply, certainly to recurrent diseases. 9 00:01:17,210 --> 00:01:24,430 So basically, we should deal with high risk patients high-risk diseases. 10 00:01:24,430 --> 00:01:29,080 But in world literature, salvage therapy options, 11 00:01:29,080 --> 00:01:37,780 this is from a paper urologic oncology and only a two to three percent of patients who present with recurrence after radiotherapy, 12 00:01:37,780 --> 00:01:43,210 for example, receive local salvage therapy. 13 00:01:43,210 --> 00:01:54,390 And ninety seven to 80 percent managed, usually managed with observation or a politician with 80. 14 00:01:54,390 --> 00:02:05,100 Well, forty nine percent of observation and 36 percent with ADT and only one point five percent with definitive therapy, 15 00:02:05,100 --> 00:02:17,130 including brachytherapy, talvez brachytherapy and prostatectomy. So now I would like to introduce some complicated surgeries after a prostatectomy. 16 00:02:17,130 --> 00:02:23,640 Well, before I start, I would like to know how many of you know, urologist. 17 00:02:23,640 --> 00:02:28,380 Yes. OK, well, thank you very much for being here. 18 00:02:28,380 --> 00:02:43,890 I like it. Well, you know, since they all had a recurrence after a prostatectomy, they are a high risk again, biologically, as I said. 19 00:02:43,890 --> 00:02:49,620 But at the same time, technically really demanding a biologically and technically. 20 00:02:49,620 --> 00:02:59,440 So that's an high risk. Well, first of all, I would like to mention about I talk about a prostatectomy. 21 00:02:59,440 --> 00:03:05,470 You know, oh, well, sort of an interesting situation. 22 00:03:05,470 --> 00:03:10,400 Prostatectomy. After prostatectomy. 23 00:03:10,400 --> 00:03:22,560 So that's what I'm going to show. Well, here comes a gentleman fifty six year old, very, very young and diagnosed in Country X, 24 00:03:22,560 --> 00:03:30,210 I don't mean England diagnosed in Country X initial PSA 13 and Gleason score six. 25 00:03:30,210 --> 00:03:37,740 Only what one out of six calls a positive accuracy, meaning early stage prostate cancer. 26 00:03:37,740 --> 00:03:48,330 He underwent laparoscopic prostatectomy in that country and but because of a rising PSA after surgery, 27 00:03:48,330 --> 00:03:55,260 he visited me two years later and PSA at that time was one point five percent. 28 00:03:55,260 --> 00:03:59,950 But incontinent and multi parametric MRI. 29 00:03:59,950 --> 00:04:09,390 That's a standard test for prostate cancer shows like this thing? 30 00:04:09,390 --> 00:04:23,430 Something in their dorm, the bladder and, well, similar vessels like structures still remains and a side view of the prostate. 31 00:04:23,430 --> 00:04:28,470 I mean, pelvis shows prostate and seminal vessels. 32 00:04:28,470 --> 00:04:40,950 This is bizarre. And we took a biopsy from that part, and it turns out to be a Gleason score seven five out of 18 quite as positive. 33 00:04:40,950 --> 00:04:47,510 And the prostate volume was very small. Six point zero. 34 00:04:47,510 --> 00:04:56,960 Well, he ASPCA went up further and actually, I contacted the doctor in charge in that country and well, 35 00:04:56,960 --> 00:05:02,030 I asked him to send me another pathological information. 36 00:05:02,030 --> 00:05:12,800 And well, interestingly, that documents chose a perfect PETA Non Gleason score, six and margin negativity, et cetera, et cetera. 37 00:05:12,800 --> 00:05:20,750 So I was just wondering why and well, because of his age, we had a long, long, 38 00:05:20,750 --> 00:05:29,180 long discussion with him and he opted for went for prostatectomy as selfish. 39 00:05:29,180 --> 00:05:42,800 Again, his PSA looked like this. Well, I hear you say some videos during his surgery laparoscopic again. 40 00:05:42,800 --> 00:05:57,010 And we also have a robot. We had a discussion about it yesterday, but we have Robert and we it's up to the preference of surgeon I prefer to do. 41 00:05:57,010 --> 00:06:02,800 A laparoscopic most of the times and but in a posterior approach. 42 00:06:02,800 --> 00:06:06,760 Well, this is to identify it correctly, identify seven of vesicles. 43 00:06:06,760 --> 00:06:13,750 I usually use anterior approach, but in his case, I opted for the posterior approach. 44 00:06:13,750 --> 00:06:26,570 But during that surgery, I didn't notice any any adhesion at all. 45 00:06:26,570 --> 00:06:33,060 Well, probably I can use this mouse. 46 00:06:33,060 --> 00:06:40,610 But how can I proceed? 47 00:06:40,610 --> 00:06:47,270 Well, this video clip is a bit redundant, so I'd like to. 48 00:06:47,270 --> 00:06:57,990 Oh, here. Most. If. 49 00:06:57,990 --> 00:07:10,020 Well, if I can have a technical assistance. Yes, move faster. 50 00:07:10,020 --> 00:07:26,390 Not enough to do that, anybody else? Makes sense because they know that. 51 00:07:26,390 --> 00:07:51,970 So. Well, I was actually in my mouth. 52 00:07:51,970 --> 00:07:57,190 You just won't see this. You can't miss a mouth that if is your present, you can't. 53 00:07:57,190 --> 00:08:08,400 You can't. Yeah. And how? It is here that it hasn't. 54 00:08:08,400 --> 00:08:12,810 Oh, yes. OK, OK. 55 00:08:12,810 --> 00:08:22,120 All right, well, thank you very much. Well, anyway, you know, all. 56 00:08:22,120 --> 00:08:41,570 No. Well, after a transacting the bladder neck and then. 57 00:08:41,570 --> 00:08:55,310 Yes, it's a mess in here. I think that's a peripheral zone, remaining peripheral zone. 58 00:08:55,310 --> 00:09:01,460 I'll try to find a correct plane in between the bladder wall and the Paracha ozone. 59 00:09:01,460 --> 00:09:11,950 And here we have a. I mean, obviously again. 60 00:09:11,950 --> 00:09:17,530 And back to the V.A. board, other than again. 61 00:09:17,530 --> 00:09:28,720 And then. We change to find the plane again. 62 00:09:28,720 --> 00:09:38,740 Well, the difficulty of the surgery. The surgery is sort of a surgery is a we cannot rely on the landmark and anatomical landmark, 63 00:09:38,740 --> 00:09:45,950 but we can manage to find the correct plane in between the bladder wall and the peripheral zone. 64 00:09:45,950 --> 00:10:05,600 Here you see a whole peripheral zone. Then we could dissect and find a seminal vesicle. 65 00:10:05,600 --> 00:10:15,640 There you go. Well, the risks of the procedure is, say, an eventful or. 66 00:10:15,640 --> 00:10:22,210 Yes, except the part of the Apex Apex was very adhesive. 67 00:10:22,210 --> 00:10:29,530 Certainly, they did something there. It's no. 68 00:10:29,530 --> 00:10:42,650 I hear. Oh. 69 00:10:42,650 --> 00:10:50,600 Doesn't work very well. Sorry for that. I'm not used. 70 00:10:50,600 --> 00:11:00,380 Well, what I would like to show here is a removal of the prostate and recovery, but four days later, 71 00:11:00,380 --> 00:11:05,840 unfortunately, he developed an erectile perforation and leading to peritonitis. 72 00:11:05,840 --> 00:11:14,210 And because of the ischaemia caused by dissection, well, perforated the rectum. 73 00:11:14,210 --> 00:11:21,680 I think, well, probably you are you aware of A. Part of the withdrawal, a stamp is gone. 74 00:11:21,680 --> 00:11:32,530 That's why he has a. Incontinence, but in a first interview, we could save him and well, 75 00:11:32,530 --> 00:11:44,050 the lesson I got we had at that time was I wish I should offer him to having a colostomy in an advance. 76 00:11:44,050 --> 00:11:54,500 But well, my point here is this sort of a surgery is technically at least technically feasible. 77 00:11:54,500 --> 00:12:04,280 This is a quite unusual case, I daresay. Well, the second case I'd like to show here is another a complicated surgery after prostatectomy, 78 00:12:04,280 --> 00:12:12,440 and sometimes we encounter the advanced bladder tumour. 79 00:12:12,440 --> 00:12:27,090 A couple of years later, after a prostatectomy, and in this situation, we indicated that it's an other topic bladder construction. 80 00:12:27,090 --> 00:12:33,770 Sixty seven years old, and he is very motivated to have isotopic letter. 81 00:12:33,770 --> 00:12:37,940 And before such surgery, he was totally continent. 82 00:12:37,940 --> 00:12:50,270 And before proceeding, we contacted Dr. Wells to at the time, and his recommendation at the time was if the patient is totally continent, go for it. 83 00:12:50,270 --> 00:12:57,050 And if his not just to forget about it and their there is recommended. 84 00:12:57,050 --> 00:13:01,820 Since he, the patient himself had a total continent. 85 00:13:01,820 --> 00:13:09,900 So it continues and we proceed at. 86 00:13:09,900 --> 00:13:22,330 For a steward of. The surgery itself is totally uneventful and well, 87 00:13:22,330 --> 00:13:34,060 she had previously 80 years ago laparoscopic prostatectomy, but we didn't encounter any adhesions at all. 88 00:13:34,060 --> 00:13:46,240 You'll see a rectal wall very easily dissected. 89 00:13:46,240 --> 00:13:57,970 Well, this is down there, not really as much. But of course, I don't doubt the. 90 00:13:57,970 --> 00:14:07,510 As you see here, there's no scar formation told the ABC, it looks like this and very. 91 00:14:07,510 --> 00:14:17,000 Well, if probably you cannot imagine he had there was this. 92 00:14:17,000 --> 00:14:42,520 Violated are being violated with this place. 93 00:14:42,520 --> 00:14:49,900 Well, I'd like to take any questions during procedure and during the videos, if you like. 94 00:14:49,900 --> 00:14:58,310 And in the well, in the well, technically we. 95 00:14:58,310 --> 00:15:10,310 When we dissect the apex, we what do we call lateral approach procedure is conducted. 96 00:15:10,310 --> 00:15:21,530 This is a we insert the camera from the port down below that are right down below pelvis. 97 00:15:21,530 --> 00:15:29,750 So this way we can have a. a very clear view of the side of the urethra like this. 98 00:15:29,750 --> 00:15:39,200 And this enables us to preserve the lengths of the Earth as long as possible. 99 00:15:39,200 --> 00:15:47,270 Anyway, the surgery went at an eventful, and he didn't the other with a rectal injury at all. 100 00:15:47,270 --> 00:15:59,870 So this could be done. Well, about an hour after the surgery, he had an estimated more structure, 101 00:15:59,870 --> 00:16:06,140 but after incision, he's just fine and totally continent and no recurrence since then. 102 00:16:06,140 --> 00:16:12,670 Already a couple of years, a three years and maybe. Just fine. 103 00:16:12,670 --> 00:16:23,230 Well, our next case, I would like to show here is a constructive letter and two more. 104 00:16:23,230 --> 00:16:29,170 Sixty nine years old, initial years, sixty point two, Gleason score pretty high, 10. 105 00:16:29,170 --> 00:16:33,400 Five out of eight cause positive clinical eighty three. 106 00:16:33,400 --> 00:16:43,990 He had open prostatectomy and extended lymph node dissection over 10 years ago and because of his pathology, 107 00:16:43,990 --> 00:16:50,300 and he underwent adjuvant radiotherapy, a sixty seven degree as grace. 108 00:16:50,300 --> 00:16:55,520 Well, he had multiple complications later on. 109 00:16:55,520 --> 00:17:05,390 And the structure and the structure and the radiation cystitis necessitating multiple sessions of hyperbaric 110 00:17:05,390 --> 00:17:15,200 therapy and also a contracted bladder capacity less than 100 and also repeated pubic osteomyelitis. 111 00:17:15,200 --> 00:17:22,670 And because of that, he was managed to have a stent bilaterally. 112 00:17:22,670 --> 00:17:42,640 But during the. Well, he led a right side, was removed inadvertently, and then he had a red right in for to me. 113 00:17:42,640 --> 00:18:02,530 But above all, then he had he developed a bladder tumour, plus some positivity in which cytology from left G-Unit. 114 00:18:02,530 --> 00:18:07,480 So in a nutshell, he has a bladder atomosia size. 115 00:18:07,480 --> 00:18:28,310 Bless your throat tumour. And we have urged him to have laparoscopic radical or radical system. 116 00:18:28,310 --> 00:18:41,620 Again, he had surgery, the four hour plus radiotherapy, and this section itself was really tough in his case because of the fusion. 117 00:18:41,620 --> 00:18:52,650 For example, they don't realise that the U.S. was almost impossible and left side. 118 00:18:52,650 --> 00:19:02,840 This section was really tough. I totally obliterated with a scar tissues. 119 00:19:02,840 --> 00:19:14,710 Not. Well, we could have managed to find a left theory to. 120 00:19:14,710 --> 00:19:34,990 Fortunately. Yes, it is. 121 00:19:34,990 --> 00:19:43,090 That change in tissue here. Here you see an effort here to advance it. 122 00:19:43,090 --> 00:20:07,100 You know, it's really tough for us to find the correct plane all frozen. 123 00:20:07,100 --> 00:20:13,020 Well, until you see here, Blatter, we. 124 00:20:13,020 --> 00:20:23,400 Inadvertently open the bladder. So you may think care ability for him is out of question. 125 00:20:23,400 --> 00:20:41,290 And uh. You'll see here down below that upon all Scottish as our own. 126 00:20:41,290 --> 00:20:50,770 But I would like to show shear the thickness of the butter. Is very thin. 127 00:20:50,770 --> 00:21:08,810 Everything you see here very thin isn't. Well, this is a long, long, long surgery. 128 00:21:08,810 --> 00:21:22,790 And since we had a lesson about their delayed director of operation, we all forced him to have in the colostomy in advance at the same time. 129 00:21:22,790 --> 00:21:33,940 Rectal wall is ischaemic and adhesive as covered with scar tissue. 130 00:21:33,940 --> 00:21:56,690 All the way had to do at the time was cut, cut, cut. 131 00:21:56,690 --> 00:22:03,860 The developer. Yes. Yes, but you know. 132 00:22:03,860 --> 00:22:08,060 We estimate costs, I mean, at the same time. 133 00:22:08,060 --> 00:22:13,120 So. And nothing happened. Totally uneventful. 134 00:22:13,120 --> 00:22:24,370 So a letter could be removed. And this is a review in the world literature and culture. 135 00:22:24,370 --> 00:22:32,530 Well, a terrific bladder is nothing better than the condition of vasculature and caused by radiation therapy. 136 00:22:32,530 --> 00:22:45,940 So probably, you know, in the at least textbook statement, probably they may offer to have a augmentation of that of that bladder. 137 00:22:45,940 --> 00:22:52,240 I daresay L'AUGMENTATION option should should be a bad idea. 138 00:22:52,240 --> 00:23:00,100 There is no chance to get it healed. And he has a grade four contracted bladder. 139 00:23:00,100 --> 00:23:10,490 And here you see the H-e, all Scottishness. Well, the next one is illegal metastasis, as the you know, 140 00:23:10,490 --> 00:23:22,100 all the go metastasis itself is a condition between a localised disease and disseminated metastasis. 141 00:23:22,100 --> 00:23:35,000 And well, that the idea of illegal or isn't it a new adult at all and it's being increasingly diagnosed more recently because no one closer 142 00:23:35,000 --> 00:23:46,360 patient monitoring and then move to improve detection of limited diseases and emerging therapies that can prolong survival. 143 00:23:46,360 --> 00:23:55,060 Well, it's a said there is an other goal of metastasis, has some distinct biological differences, but I'm not certain about it. 144 00:23:55,060 --> 00:24:02,650 So first of all, we've got to prove whether it has a distinct biological differences. 145 00:24:02,650 --> 00:24:09,630 But they say all ego has a distinct biological differences. 146 00:24:09,630 --> 00:24:19,800 Well, here comes the case again open radical prostatectomy Gleason score nine three B seven out vertical invasion margin positive. 147 00:24:19,800 --> 00:24:26,940 And because of his pathology, he had adjuvant radiotherapy again six to eighty eight grace. 148 00:24:26,940 --> 00:24:29,700 And it was all right for a while. 149 00:24:29,700 --> 00:24:47,070 But he suffers from a gradually increasing PSA and the pelvic lymph node involvement was detected the side of right iliac artery and SRT. 150 00:24:47,070 --> 00:24:53,820 To that part, salvage radiotherapy to that part was applied for grace. 151 00:24:53,820 --> 00:25:00,430 Then PSA went down again, but then rise again. 152 00:25:00,430 --> 00:25:04,740 And the way I him to have an acclaimed pet. 153 00:25:04,740 --> 00:25:13,800 He shows here this this thing, and it was positive with Colin Pitt, who he took in a biopsy from that area. 154 00:25:13,800 --> 00:25:19,020 A biopsy turned out to be a Gleason score five plus four tumour. 155 00:25:19,020 --> 00:25:33,590 And since we do not have a specimen pet at home and we offered him to have a whole body MRI negative. 156 00:25:33,590 --> 00:25:38,450 Well, again, to nail a laparoscopic approach. 157 00:25:38,450 --> 00:25:43,790 You know, it is it is very bizarre for me. 158 00:25:43,790 --> 00:25:58,670 You know, she had in her heavily treated with radiotherapy before, as I said, but basically zero tissue reactions around. 159 00:25:58,670 --> 00:26:12,600 Didn't work. But I'm trying to say here is how. 160 00:26:12,600 --> 00:26:17,760 Radiation effect differs from individual to individual. 161 00:26:17,760 --> 00:26:24,830 You know, this raises a question about immune response with radiotherapy. 162 00:26:24,830 --> 00:26:32,730 It may well if some of you from radiation department problem, you can answer that question, that question. 163 00:26:32,730 --> 00:26:38,490 But I really am fascinated by it. 164 00:26:38,490 --> 00:26:47,620 Well, what I would like to show say here is how we can augment radiation effect. 165 00:26:47,620 --> 00:26:58,940 Well, anyway, there seems to be no tissue reactions at all in this case. 166 00:26:58,940 --> 00:27:09,680 Here you see a tumour. Two moms and we took that out. 167 00:27:09,680 --> 00:27:18,050 Well, well, after the surgery, the PSA went down to zero, almost zero. 168 00:27:18,050 --> 00:27:23,600 But that pathology shows a Gleason score five plus four, 169 00:27:23,600 --> 00:27:35,420 but unfortunately he had 1mm margins and PSA went up again at zero point seven three weeks and 019 at three months. 170 00:27:35,420 --> 00:27:41,450 And one year later, he developed disseminated metastases. 171 00:27:41,450 --> 00:27:53,130 So. We did a search in the world literature, I extended a salvage lymph node dissection. 172 00:27:53,130 --> 00:28:04,530 Well, the only predictor they could find was the Gleason score sixty seven versus eight to 10 since it had high Gleason score. 173 00:28:04,530 --> 00:28:08,010 Nine. Probably we cannot. 174 00:28:08,010 --> 00:28:13,470 We couldn't do rely solely on all the usual methods of sex to me. 175 00:28:13,470 --> 00:28:21,960 We should apply something. But then he was well, he didn't want to have 80 at the same time. 176 00:28:21,960 --> 00:28:28,630 So sorry for him. But this case provide food for thought. 177 00:28:28,630 --> 00:28:37,330 And at least in the world literature, a five year biochemical control rate is around 30 percent. 178 00:28:37,330 --> 00:28:46,360 And especially with a lower grade prostate cancer recurrence. 179 00:28:46,360 --> 00:28:54,670 Well, all think metastasis, a tumour of a purpose to control cancer and then to slow down any further metastasis. 180 00:28:54,670 --> 00:29:04,180 And of course, while they say avoiding and delaying the toxicity associated with a systemic therapy that is 80 and chemo, 181 00:29:04,180 --> 00:29:15,130 but I believe I myself have an a bias. This endpoint itself is a tumour in a very elusive and very weak endpoint. 182 00:29:15,130 --> 00:29:23,030 We should think about how we can control cancer. 183 00:29:23,030 --> 00:29:34,170 Well, another case here, a complicated surgery. Basically, it had again, a prostatectomy last SRT. 184 00:29:34,170 --> 00:29:46,810 And because of his advanced bladder tumour will offer him to have an assistant to me. 185 00:29:46,810 --> 00:29:52,390 Trusts peritoneal view of a pelvic floor. 186 00:29:52,390 --> 00:29:58,240 And here you see severe adhesion of ileum. 187 00:29:58,240 --> 00:30:04,410 At first, I thought this this that this section should be easy. 188 00:30:04,410 --> 00:30:11,030 But it was not. 189 00:30:11,030 --> 00:30:26,810 Again, I myself a bit wondering why such reaction tissue reaction changes differs from patient to patient, from individual to individual. 190 00:30:26,810 --> 00:30:37,830 Some things should be there. Well, the whole structure covers a bladder. 191 00:30:37,830 --> 00:30:44,430 That this section was really tough. This part was all right. 192 00:30:44,430 --> 00:30:54,960 We can dissect it. Yes, this year here. 193 00:30:54,960 --> 00:31:04,480 Covered with Scottishness are all all covered with scar tissue. 194 00:31:04,480 --> 00:31:15,310 Well, we could have managed to dissect. Anyway, and the rest of the procedure was also tough and bladder rectal wall. 195 00:31:15,310 --> 00:31:39,250 And the same story, but we can manage it. Motor. 196 00:31:39,250 --> 00:31:42,850 Cancer or colon cancer, testis cancer, kidney cancer? 197 00:31:42,850 --> 00:31:51,460 This statement is from the literature, but more recently, I heard in a randomised controlled trials with colon cancer. 198 00:31:51,460 --> 00:32:00,070 Aside to the surgery, the effect efficacy of a reduction in colon cancer has become in question. 199 00:32:00,070 --> 00:32:09,340 I may be wrong, and the role of surgery in metastatic prostate cancer is also not yet established. 200 00:32:09,340 --> 00:32:16,910 But this concept has been visited by acts of the Heidelberg from Germany. 201 00:32:16,910 --> 00:32:28,310 And a couple of papers in the world literature has like a retrospective, though they showed some advantage with as a sector. 202 00:32:28,310 --> 00:32:37,160 I mean, I said the reduction of the tumour from the tumour and are at all the prospective case control studies, 203 00:32:37,160 --> 00:32:53,700 but they didn't find any difference at all. In horror trial, they used primary a primer radiotherapy to the prostate plus 80 versus 80. 204 00:32:53,700 --> 00:33:07,860 They didn't show any difference in terms of overall survival, and averting a subgroup analysis shows some at some hint, some suggestion when. 205 00:33:07,860 --> 00:33:20,100 And the tumour volume is low. There may be some benefit a stampede trial, the same 80 plus radiotherapy versus 80 tell all. 206 00:33:20,100 --> 00:33:30,610 There seems to be some difference. A lot of tumour burden. The cases that we've got to be very careful interpretation, I believe. 207 00:33:30,610 --> 00:33:33,130 Here comes my case, six years old. 208 00:33:33,130 --> 00:33:47,050 Here's a general surgeon himself, and well, well, I'm biased about general surgeon general surgeon mentality is take it away, very simple and brave. 209 00:33:47,050 --> 00:33:54,310 And he was at that time just [INAUDIBLE] bent, [INAUDIBLE] bent to remove it. 210 00:33:54,310 --> 00:34:01,420 And it was way high. 182 Gleason score of five plus for 12 out of 12, of course positive. 211 00:34:01,420 --> 00:34:12,750 He had pelvic lymph nodes, swelling and plus a solitary bone metastasis. 212 00:34:12,750 --> 00:34:19,110 Well, after a long discussion, I I myself was a bit reluctant, 213 00:34:19,110 --> 00:34:30,000 then I offered him not to have an a combined blockade by my plus agonist, plus the ATX, the Texel six courses and his piece. 214 00:34:30,000 --> 00:34:40,230 I went to zero almost. And Mara, appearance tumour just disappeared. 215 00:34:40,230 --> 00:34:53,700 Well, at least complete remission on imaging studies, but pathology, this show a remnant of tumour iglesias growth. 216 00:34:53,700 --> 00:35:06,210 Interestingly, four plus three is seven and but I mean, obviously invasion margin positive plus another involvement. 217 00:35:06,210 --> 00:35:12,280 Well, this case also provided food for thought. 218 00:35:12,280 --> 00:35:21,460 Well, in the case of you'll see out of the euro or the cancer doctor, 219 00:35:21,460 --> 00:35:34,690 Professor Harry her from Memorial Sloan Kettering once stated this document and well, a situation is a bit different. 220 00:35:34,690 --> 00:35:40,570 His situation is for a surgical consultation for Metastatic QC. 221 00:35:40,570 --> 00:35:50,920 But I think we can use the analogy in the case of the reductive surgery in prostate cancer. 222 00:35:50,920 --> 00:36:01,150 So if we apply this surgery, no one must be technically feasible feasibility there. 223 00:36:01,150 --> 00:36:06,730 And with a modern technology, we can do at least not perfect. 224 00:36:06,730 --> 00:36:14,370 Maybe. But then we can. We can respect, remove the tumour technically feasible, that's for sure. 225 00:36:14,370 --> 00:36:28,810 But unfortunately, surgery alone slavish. Is considered to be nearly zero, so zero a possibility with Sergeant Lee along. 226 00:36:28,810 --> 00:36:37,330 Of course, a systemic chemotherapy first and then well in metastatic U.S. cases, systemic chemo first. 227 00:36:37,330 --> 00:36:43,840 And if he has or she has see our complete response, then I go for it. 228 00:36:43,840 --> 00:36:58,100 That's the whole concept of that idea to say if we do not have any adjuvant or adjuvant therapy together with site reduction. 229 00:36:58,100 --> 00:37:05,690 That's a sort of nuts and a good idea to go for it. 230 00:37:05,690 --> 00:37:16,760 So CO2 reduction itself doesn't cure that patient, though it is feasible technically and a subtle reduction, plus something should have been needed. 231 00:37:16,760 --> 00:37:29,850 That's my my take. So this is an example that to trial shows some advantage with abiraterone plus 80 versus 80 alone. 232 00:37:29,850 --> 00:37:39,460 Well, we just follow him with a abiraterone based on this Latitude trial. 233 00:37:39,460 --> 00:37:47,620 Well, this cartoon illustrate a prototype of DaVinci Machine. 234 00:37:47,620 --> 00:37:55,330 Interestingly, it was depicted illustrated in 1921, almost 100 years ago. 235 00:37:55,330 --> 00:38:05,560 Well, you know, it may take another couple of years, at least 10 years, at 20 years or 50 years, but we are moving into the right direction. 236 00:38:05,560 --> 00:38:13,160 But we've got to think about what the last surgery has in the future. 237 00:38:13,160 --> 00:38:20,430 Better than, I dare say, which surgeons should be more than I. 238 00:38:20,430 --> 00:38:29,990 I'm no wiser to incorporate surgical technique into future treatment. 239 00:38:29,990 --> 00:38:43,400 With yourself. Well, again, the techniques are all that it's feasible, but still certainly alone is not good enough and sufficient. 240 00:38:43,400 --> 00:38:57,400 That's my take. Well, that's all, and this is a Tokyo tower, just like the Eiffel Tower in Paris and decorated in colour for a. 241 00:38:57,400 --> 00:39:01,990 Well, ready to welcome Summer Olympic Games next year. 242 00:39:01,990 --> 00:39:09,255 All of you are welcome. Thank you very much.