I think it's just sort of.
This money saga is about salvage options for people who had already definitive therapy for prostate cancer, as shown in here.
There has been increasing use of a prostatectomy radiotherapy a for a locally advanced and very high risk of prostate cancer worldwide.
Well, because of that, there are certainly is a increasing needs for a therapy.
But when we apply or indicate salvage therapy, we've got to think a lot of things.
But at least in theory, it says it has a well, it has to deal with the recurrent tumour.
Expectant management option won't be enough. Well, castration.
So expect the management may not apply, certainly to recurrent diseases.
So basically, we should deal with high risk patients high-risk diseases.
But in world literature, salvage therapy options,
this is from a paper urologic oncology and only a two to three percent of patients who present with recurrence after radiotherapy,
for example, receive local salvage therapy.
And ninety seven to 80 percent managed, usually managed with observation or a politician with 80.
Well, forty nine percent of observation and 36 percent with ADT and only one point five percent with definitive therapy,
including brachytherapy, talvez brachytherapy and prostatectomy. So now I would like to introduce some complicated surgeries after a prostatectomy.
Well, before I start, I would like to know how many of you know, urologist.
Yes. OK, well, thank you very much for being here.
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.
But at the same time, technically really demanding a biologically and technically.
So that's an high risk. Well, first of all, I would like to mention about I talk about a prostatectomy.
You know, oh, well, sort of an interesting situation.
Prostatectomy. After prostatectomy.
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,
I don't mean England diagnosed in Country X initial PSA 13 and Gleason score six.
Only what one out of six calls a positive accuracy, meaning early stage prostate cancer.
He underwent laparoscopic prostatectomy in that country and but because of a rising PSA after surgery,
he visited me two years later and PSA at that time was one point five percent.
But incontinent and multi parametric MRI.
That's a standard test for prostate cancer shows like this thing?
Something in their dorm, the bladder and, well, similar vessels like structures still remains and a side view of the prostate.
I mean, pelvis shows prostate and seminal vessels.
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.
And the prostate volume was very small. Six point zero.
Well, he ASPCA went up further and actually, I contacted the doctor in charge in that country and well,
I asked him to send me another pathological information.
And well, interestingly, that documents chose a perfect PETA Non Gleason score, six and margin negativity, et cetera, et cetera.
So I was just wondering why and well, because of his age, we had a long, long,
long discussion with him and he opted for went for prostatectomy as selfish.
Again, his PSA looked like this. Well, I hear you say some videos during his surgery laparoscopic again.
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.
A laparoscopic most of the times and but in a posterior approach.
Well, this is to identify it correctly, identify seven of vesicles.
I usually use anterior approach, but in his case, I opted for the posterior approach.
But during that surgery, I didn't notice any any adhesion at all.
Well, probably I can use this mouse.
But how can I proceed?
Well, this video clip is a bit redundant, so I'd like to.
Oh, here. Most. If.
Well, if I can have a technical assistance. Yes, move faster.
Not enough to do that, anybody else? Makes sense because they know that.
So. Well, I was actually in my mouth.
You just won't see this. You can't miss a mouth that if is your present, you can't.
You can't. Yeah. And how? It is here that it hasn't.
Oh, yes. OK, OK.
All right, well, thank you very much. Well, anyway, you know, all.
No. Well, after a transacting the bladder neck and then.
Yes, it's a mess in here. I think that's a peripheral zone, remaining peripheral zone.
I'll try to find a correct plane in between the bladder wall and the Paracha ozone.
And here we have a. I mean, obviously again.
And back to the V.A. board, other than again.
And then. We change to find the plane again.
Well, the difficulty of the surgery. The surgery is sort of a surgery is a we cannot rely on the landmark and anatomical landmark,
but we can manage to find the correct plane in between the bladder wall and the peripheral zone.
Here you see a whole peripheral zone. Then we could dissect and find a seminal vesicle.
There you go. Well, the risks of the procedure is, say, an eventful or.
Yes, except the part of the Apex Apex was very adhesive.
Certainly, they did something there. It's no.
I hear. Oh.
Doesn't work very well. Sorry for that. I'm not used.
Well, what I would like to show here is a removal of the prostate and recovery, but four days later,
unfortunately, he developed an erectile perforation and leading to peritonitis.
And because of the ischaemia caused by dissection, well, perforated the rectum.
I think, well, probably you are you aware of A. Part of the withdrawal, a stamp is gone.
That's why he has a. Incontinence, but in a first interview, we could save him and well,
the lesson I got we had at that time was I wish I should offer him to having a colostomy in an advance.
But well, my point here is this sort of a surgery is technically at least technically feasible.
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,
and sometimes we encounter the advanced bladder tumour.
A couple of years later, after a prostatectomy, and in this situation, we indicated that it's an other topic bladder construction.
Sixty seven years old, and he is very motivated to have isotopic letter.
And before such surgery, he was totally continent.
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.
And if his not just to forget about it and their there is recommended.
Since he, the patient himself had a total continent.
So it continues and we proceed at.
For a steward of. The surgery itself is totally uneventful and well,
she had previously 80 years ago laparoscopic prostatectomy, but we didn't encounter any adhesions at all.
You'll see a rectal wall very easily dissected.
Well, this is down there, not really as much. But of course, I don't doubt the.
As you see here, there's no scar formation told the ABC, it looks like this and very.
Well, if probably you cannot imagine he had there was this.
Violated are being violated with this place.
Well, I'd like to take any questions during procedure and during the videos, if you like.
And in the well, in the well, technically we.
When we dissect the apex, we what do we call lateral approach procedure is conducted.
This is a we insert the camera from the port down below that are right down below pelvis.
So this way we can have a. a very clear view of the side of the urethra like this.
And this enables us to preserve the lengths of the Earth as long as possible.
Anyway, the surgery went at an eventful, and he didn't the other with a rectal injury at all.
So this could be done. Well, about an hour after the surgery, he had an estimated more structure,
but after incision, he's just fine and totally continent and no recurrence since then.
Already a couple of years, a three years and maybe. Just fine.
Well, our next case, I would like to show here is a constructive letter and two more.
Sixty nine years old, initial years, sixty point two, Gleason score pretty high, 10.
Five out of eight cause positive clinical eighty three.
He had open prostatectomy and extended lymph node dissection over 10 years ago and because of his pathology,
and he underwent adjuvant radiotherapy, a sixty seven degree as grace.
Well, he had multiple complications later on.
And the structure and the structure and the radiation cystitis necessitating multiple sessions of hyperbaric
therapy and also a contracted bladder capacity less than 100 and also repeated pubic osteomyelitis.
And because of that, he was managed to have a stent bilaterally.
But during the. Well, he led a right side, was removed inadvertently, and then he had a red right in for to me.
But above all, then he had he developed a bladder tumour, plus some positivity in which cytology from left G-Unit.
So in a nutshell, he has a bladder atomosia size.
Bless your throat tumour. And we have urged him to have laparoscopic radical or radical system.
Again, he had surgery, the four hour plus radiotherapy, and this section itself was really tough in his case because of the fusion.
For example, they don't realise that the U.S. was almost impossible and left side.
This section was really tough. I totally obliterated with a scar tissues.
Not. Well, we could have managed to find a left theory to.
Fortunately. Yes, it is.
That change in tissue here. Here you see an effort here to advance it.
You know, it's really tough for us to find the correct plane all frozen.
Well, until you see here, Blatter, we.
Inadvertently open the bladder. So you may think care ability for him is out of question.
And uh. You'll see here down below that upon all Scottish as our own.
But I would like to show shear the thickness of the butter. Is very thin.
Everything you see here very thin isn't. Well, this is a long, long, long surgery.
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.
Rectal wall is ischaemic and adhesive as covered with scar tissue.
All the way had to do at the time was cut, cut, cut.
The developer. Yes. Yes, but you know.
We estimate costs, I mean, at the same time.
So. And nothing happened. Totally uneventful.
So a letter could be removed. And this is a review in the world literature and culture.
Well, a terrific bladder is nothing better than the condition of vasculature and caused by radiation therapy.
So probably, you know, in the at least textbook statement, probably they may offer to have a augmentation of that of that bladder.
I daresay L'AUGMENTATION option should should be a bad idea.
There is no chance to get it healed. And he has a grade four contracted bladder.
And here you see the H-e, all Scottishness. Well, the next one is illegal metastasis, as the you know,
all the go metastasis itself is a condition between a localised disease and disseminated metastasis.
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
patient monitoring and then move to improve detection of limited diseases and emerging therapies that can prolong survival.
Well, it's a said there is an other goal of metastasis, has some distinct biological differences, but I'm not certain about it.
So first of all, we've got to prove whether it has a distinct biological differences.
But they say all ego has a distinct biological differences.
Well, here comes the case again open radical prostatectomy Gleason score nine three B seven out vertical invasion margin positive.
And because of his pathology, he had adjuvant radiotherapy again six to eighty eight grace.
And it was all right for a while.
But he suffers from a gradually increasing PSA and the pelvic lymph node involvement was detected the side of right iliac artery and SRT.
To that part, salvage radiotherapy to that part was applied for grace.
Then PSA went down again, but then rise again.
And the way I him to have an acclaimed pet.
He shows here this this thing, and it was positive with Colin Pitt, who he took in a biopsy from that area.
A biopsy turned out to be a Gleason score five plus four tumour.
And since we do not have a specimen pet at home and we offered him to have a whole body MRI negative.
Well, again, to nail a laparoscopic approach.
You know, it is it is very bizarre for me.
You know, she had in her heavily treated with radiotherapy before, as I said, but basically zero tissue reactions around.
Didn't work. But I'm trying to say here is how.
Radiation effect differs from individual to individual.
You know, this raises a question about immune response with radiotherapy.
It may well if some of you from radiation department problem, you can answer that question, that question.
But I really am fascinated by it.
Well, what I would like to show say here is how we can augment radiation effect.
Well, anyway, there seems to be no tissue reactions at all in this case.
Here you see a tumour. Two moms and we took that out.
Well, well, after the surgery, the PSA went down to zero, almost zero.
But that pathology shows a Gleason score five plus four,
but unfortunately he had 1mm margins and PSA went up again at zero point seven three weeks and 019 at three months.
And one year later, he developed disseminated metastases.
So. We did a search in the world literature, I extended a salvage lymph node dissection.
Well, the only predictor they could find was the Gleason score sixty seven versus eight to 10 since it had high Gleason score.
Nine. Probably we cannot.
We couldn't do rely solely on all the usual methods of sex to me.
We should apply something. But then he was well, he didn't want to have 80 at the same time.
So sorry for him. But this case provide food for thought.
And at least in the world literature, a five year biochemical control rate is around 30 percent.
And especially with a lower grade prostate cancer recurrence.
Well, all think metastasis, a tumour of a purpose to control cancer and then to slow down any further metastasis.
And of course, while they say avoiding and delaying the toxicity associated with a systemic therapy that is 80 and chemo,
but I believe I myself have an a bias. This endpoint itself is a tumour in a very elusive and very weak endpoint.
We should think about how we can control cancer.
Well, another case here, a complicated surgery. Basically, it had again, a prostatectomy last SRT.
And because of his advanced bladder tumour will offer him to have an assistant to me.
Trusts peritoneal view of a pelvic floor.
And here you see severe adhesion of ileum.
At first, I thought this this that this section should be easy.
But it was not.
Again, I myself a bit wondering why such reaction tissue reaction changes differs from patient to patient, from individual to individual.
Some things should be there. Well, the whole structure covers a bladder.
That this section was really tough. This part was all right.
We can dissect it. Yes, this year here.
Covered with Scottishness are all all covered with scar tissue.
Well, we could have managed to dissect. Anyway, and the rest of the procedure was also tough and bladder rectal wall.
And the same story, but we can manage it. Motor.
Cancer or colon cancer, testis cancer, kidney cancer?
This statement is from the literature, but more recently, I heard in a randomised controlled trials with colon cancer.
Aside to the surgery, the effect efficacy of a reduction in colon cancer has become in question.
I may be wrong, and the role of surgery in metastatic prostate cancer is also not yet established.
But this concept has been visited by acts of the Heidelberg from Germany.
And a couple of papers in the world literature has like a retrospective, though they showed some advantage with as a sector.
I mean, I said the reduction of the tumour from the tumour and are at all the prospective case control studies,
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.
They didn't show any difference in terms of overall survival, and averting a subgroup analysis shows some at some hint, some suggestion when.
And the tumour volume is low. There may be some benefit a stampede trial, the same 80 plus radiotherapy versus 80 tell all.
There seems to be some difference. A lot of tumour burden. The cases that we've got to be very careful interpretation, I believe.
Here comes my case, six years old.
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.
And he was at that time just [INAUDIBLE] bent, [INAUDIBLE] bent to remove it.
And it was way high. 182 Gleason score of five plus for 12 out of 12, of course positive.
He had pelvic lymph nodes, swelling and plus a solitary bone metastasis.
Well, after a long discussion, I I myself was a bit reluctant,
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.
I went to zero almost. And Mara, appearance tumour just disappeared.
Well, at least complete remission on imaging studies, but pathology, this show a remnant of tumour iglesias growth.
Interestingly, four plus three is seven and but I mean, obviously invasion margin positive plus another involvement.
Well, this case also provided food for thought.
Well, in the case of you'll see out of the euro or the cancer doctor,
Professor Harry her from Memorial Sloan Kettering once stated this document and well, a situation is a bit different.
His situation is for a surgical consultation for Metastatic QC.
But I think we can use the analogy in the case of the reductive surgery in prostate cancer.
So if we apply this surgery, no one must be technically feasible feasibility there.
And with a modern technology, we can do at least not perfect.
Maybe. But then we can. We can respect, remove the tumour technically feasible, that's for sure.
But unfortunately, surgery alone slavish. Is considered to be nearly zero, so zero a possibility with Sergeant Lee along.
Of course, a systemic chemotherapy first and then well in metastatic U.S. cases, systemic chemo first.
And if he has or she has see our complete response, then I go for it.
That's the whole concept of that idea to say if we do not have any adjuvant or adjuvant therapy together with site reduction.
That's a sort of nuts and a good idea to go for it.
So CO2 reduction itself doesn't cure that patient, though it is feasible technically and a subtle reduction, plus something should have been needed.
That's my my take. So this is an example that to trial shows some advantage with abiraterone plus 80 versus 80 alone.
Well, we just follow him with a abiraterone based on this Latitude trial.
Well, this cartoon illustrate a prototype of DaVinci Machine.
Interestingly, it was depicted illustrated in 1921, almost 100 years ago.
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.
But we've got to think about what the last surgery has in the future.
Better than, I dare say, which surgeons should be more than I.
I'm no wiser to incorporate surgical technique into future treatment.
With yourself. Well, again, the techniques are all that it's feasible, but still certainly alone is not good enough and sufficient.
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.
Well, ready to welcome Summer Olympic Games next year.
All of you are welcome. Thank you very much.