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Yeah. Thank you. Hello, everybody. Um, can I just confirm that you can hear me? I'm sure if you can use the chat function. Yeah. More importantly, can you see my screen? Hello? Uh, have someone in the chest. Yeah. Ben said that he can hear me. I'm just going to allow a few more people to join, and we'll get cracking very soon. Uh, we've got a few more people now. Thank you very much. Everybody for coming. I hope the sound is of good quality. Do please let me know if you like anything change during the presentation. And do please also feel free to ask questions during the presentation as well. Um, for those who don't know me, my name's Charlie currently work in Manchester. I work in urology, and my main interest for my career going forward is, uh, cancer and surgical cancer. So the way we treat cancer surgically, um, prostate cancers. One of the main things that I, uh, may end up doing in the future. Um, as well as our session last week, which is on renal cancer, is something that I'm also very much considering um and yes, our session today was made by myself alongside one of my consultants, Mr Marmo. He, uh, and yes, without further a do we will jump into it. And before, as we always start, we always start with a case. And this is of Bill, who is an 85 year old gentleman who presents to you, complaining of incontinence and knocked Iria. He does not appear to be in urinary retention, and he's not in any pain. His urine dip is no shows, no acute disease. He's also stated, though, that he stopped leaving home as he's afraid that he'll have an accident. His many comorbidities, including COPD, hypertension and end stemi that occurred three years ago, and a T. I. A. Amongst many other things. He only drinks two cups of tea a day, and you perform a digital rectal examination during which you can feel a nodule on one side of the prostate. He expresses fear of a prostate cancer, and his brother suffered from this, and he's keen to avoid surgery. You reassure him and you send a two week wait referral to urology. I hope that cases clear. It touches upon a few things that are key to our presentation are learning. Objectives are to include an understanding about prostate cancer. Realize the challenges associated with prostate cancer, and it's diagnosis and management. Understand how it's diagnosed, staged and graded. Realize how staging and grading relates to management and understand the basic principles of surgical management. Prostate cancer. What a bit more detail than what you might learn in medical school and what that might involve. Recognize why non operative measures may be chosen and appreciate these non surgical manage management strategies. I will say prostate cancer to me, seems like the cancer where that has the most options for patient's with respect to its management and it it gets quite nitty gritty. I will say we will only be focusing on localized prostate cancer. Disease will not open the whole Pandora's box of metastatic disease today just because that is not related to surgery. In general, metastatic prostate cancer is not managed surgically. Prostate cancer is the most common cancer amongst men in the UK, and it's the third most common overall with breast cancer and lung cancer. I believe being more common than prostate cancer. Overall, it is strongly associated with age, and it is also strongly associated with having an Afro Caribbean ethnicity. Many cases do not present with symptoms during the early stages, and the classic symptoms employed avoiding lower urinary tract symptoms. Management of prostate cancer varies, and it depends on many factors, as I've said before. And the survival outcomes for prostate cancer also may vary significantly, with some patient's being able to live with prostate cancer and have it until they die, perhaps of something else or others where it is the main issue that is leading to a poor prognosis. They're roughly 1.4 million diagnoses of prostate cancer made worldwide, so it's a huge issue, and that's not including the patient's living with it already. As I said, it's got more common in men who are from Africa Caribbean heritage. However, age has the biggest impact on risk. For example, the prevalence in under 30 year olds is just 5% and this increases with an odds ratio of 1.7 every single decade of life. It's prevalence by the age of 80 or above is 59%. That's a huge proportion of the population of men who are aged 80 or above. There is also a higher degree of geographic variability and you can see it's actually in countries where Africa Ribhi in people are in the minority in the population. Ask my consultant how this can be and he said, two things. A. There's other risk factors, such as the age and the obesity that are seen in these countries but also lets you know, appreciate the fact that diagnosis is better in a lot of these places in the world. So Europe, Australia, North America than it is in other parts of the world, which is very unfortunate. As with all surgical specialties, we need to appreciate anatomy, and the prostate is a very small Normally it's a walnut sized organ and is placed immediately inferior to the bladder, neck and anterior to the rectum. It houses the prostatic urethra, so that's the one of the first part of our male urethra. It you can see in this image and it normally happens if you have cancer in the peripheral zone. So that is that purple bit here on this image, and I should also orienting orientate you by saying that this left hand side of this image is the posterior side, and this side here on the right hand side is the anterior side, so the peripheral zone is largely a posterior structure because it's posterior nodules can be felt during the D R digital rectal examination, whereby we put our finger through the rectum, which is posterior to the prostate benign prostatic hyperplasia, which is one of the main differentials. Whenever you have any issues with the prostate, um tends to go in the transitional zone. Transitional zone occurs here in this green bit, Um, so it's quite central. Most prostate cancers are adenocarcinomas, so what that means is it derives from glandular epithelial tissues. That's what an adenocarcinoma means, and that's because the prostate is itself a gland. But other types that are much rarer include neuro endocrine tumours and ductal carcinoma as well grading. So what is grading guys? Does anyone want to? I'm not sure if you can shout out, but if in the chat can anybody tell me what cancer grading is? Anyone in the chat? Who wants to just offer offer a vague idea of what grading Is this a very friendly session? You've come in your own time, so I'm very grateful for you coming. That's all right, Um, so cancer grading and this is for all cancers is looking at the histological May ship mation. Yeah, has how severe the cancer is. That's true to an extent, yes. So the higher the grade of the cancer, the more sort of severe, advanced or dangerous the cancer, uh is, and so that is true. However, we have staging and grading, and both of them, higher stage and grade suggests severity of cancer. The grading of the cancer is the histological features. So how it looks down the microscope. That way you can tell how aggressive it is. And in prostate cancer, it's the only cancer where we use the Gleason score. And the Gleason score looks at how differentiated the tissues are. So how similar is the tissue in this cancer to normal tissue? And it requires a biopsy in order to to assess. And so, in all cases of prostate cancer bar a few exceptions. They should have a prostate biopsy, the less differentiated I, either less similar to normal tissue. It is the worst prognosis, and we score people on a scale of 1 to 5, and then in the Gleason score, what you do is you take biopsies from multiple areas and you add up the two areas with the highest Gleason score to get a score out of 10. So five plus five being the worst as a 10. And so if you, for example, have one area that's scoring a four on the Gleason score and one that's scoring a three, then that would be seven. But of course you can have three plus four, which would also be seven. And what you can see in this table here is a categorization of the risks. And what we do is we have the i s u P Grade grouping. So Grade one being the lowest three plus three grade to being intermediate alongside Grade three. Being intermediate, that's three plus four or four plus three. So why does four go before three Sometimes and three go before four? Well, the first number is the area where which is most common, so if it is a three plus four, that means the grading is mostly three. But there are some areas of four, whereas a score or four plus three suggests that is mostly four. But there are some areas of three and So that's why three plus four is better than a four plus three and then so on and so forth. Four plus four being high risk and then even higher risk grade five being, um, anything where it's five plus four or five plus five if you have so you you you know you may notice that we start with three plus three equals six, and that's because anything less than six is very unlikely to be prostate cancer. And so we don't normally include these patient's. So that's why it starts from six. And it finishes at 10, even though in theory you can get one plus one, which is two. But these patient's will not be typically diagnosed with prostate cancer, and so we don't really consider them when doing our assessments. It should be noted that the Gleason score being so unique is interesting because most cancers use very similar features under the microscope, such as your how quickly your cells are undergoing mitosis, um, and things like that. But prostate cancer just has to be a little bit different, as it is in quite quite a few other ways. So that's why we use this Gleason score and onto are staging. And so we discussed last week we used the T n M system for cancer staging, so t being the tumor size n being the presence or absence of lymph nodes, m being the presence or absence of metastases that are further away from the original cancer when it comes to T. As you can see from all of these boxes, it's fairly complicated. And so you have t 1234. But within that you have t one A. B c and so on and so on and so on. I'm not going to go through all of these details. I think it's quite a lot. But you know, in in essence, t one cancers usually are found, incidentally, so sort of finding them by accident. T one c being through a raised P S, a. T two. These are cancers you can feel on digital rectal examination, so t one you can't feel them by and large on digital rectal examination, if you can, it's usually a T two t three. That's where you have extension outside of the prostate itself into surrounding structures and t three c being into the seminal vesicles and then t four. It is invading into the bladder into the external sphincter or involvement of peri prostatic tissue. We often use our prostatic MRI scans to assess the tea and so prostatic MRI. It's a very useful tool. It's fairly modern, and we use that to have a look at the prostate radiologically. Okay, so I'm just going to go back to slide. Um, and then, you know, we we often sometimes use transrectal ultrasound scan to affect assess T. However, that is actually no better according to studies than our digital rectal examination. So Transrectal ultrasound scan used to be the way to assess tea, but it's been since replaced by prostatic MRI scans and prostatic MRI is commonly the first test used. If we suspect prostate cancer in any patient, n and M. A much more simple, it's simply Do you have lymph node involvement? Yes or no? If you do, then it's N. One. If you don't end zero m, do you or do you not have distant metastases? If you don't, then it's M zero. If you do, it's M one and exactly where it is. Depends whether you get a one a one B or one c. Prostate cancer is one of the few cancers that can spread to bone, and that's the most common site of metastases, So that will give you an M one B and M one A is only spread to distant lymph nodes. And so you have the local lymph nodes, your obturator nodes, your iliac nodes. If it's gone to, for example, the para-aortic nodes, that would be a distant metastases, whereas spread to the, uh, inguinal lymph nodes or the iliac pelvic lymph nodes. This is local or is considered local, so that would not lead to a M score, but instead would lead to an end score N for node M one C is spread anywhere else, for example, to the lungs. So we spoke about few of these already Pelvic MRI scan biopsy. Um, but there's other investigations as well. One of the most famous sort of investigations patient's always ask about it is the P S. A. And I think patient's often think about the P S. A because A. It's a blood test. So it's nice and easy to do but be they think often that is okay. If it's high then I have cancer, Then I can get treated. If it's low, then I don't have cancer. It's not strictly true, and we'll talk about it in a little while. Unfortunately, it's a a useful biomarker, but it is not entirely diagnostic. It varies with patient's age, and it also varies depending on whether you've done a few things, such as exercise. If you've had intercourse, if you've had digital rectal examination, and then if you suspect a patient has metastases, then you put them in the high risk group generally. And these patient's should have a bone scan. And this is a type of nuclear medicine scan to assess with if they have bony metastases, which might not be seen on other investigations. And a CT is also indicated as per the current guidelines. But the evidence for the use of CT is less strong than for the evidence of bone scans. So a lot of patients will have a CT scans. Some of them won't. In short, CT scan, in theory, should pick up on metastases that a bone scan won't, for example, to the to the lungs or to anywhere else. Small occasions. Bone scans may miss a bony metastases as well that might be picked up on CT. So more details about PS A then as well. So PSA test, as I said, is often asked for by patient's at the G P. And generally speaking, the advice is to offer a patient a P S, a test if they ask for it. If you ask for a PS PSA test and you are someone who is in a few risk factors for prostate cancer, then fair enough you should be able to have one. Hopefully, it's low. And although that doesn't rule out prostate cancer, it helps put a lot of people's minds at ease. If your PS PSA is very high, such as 40 your chance of having metastatic prostate cancer is quite high. If it's above 100 you almost certainly have metastatic prostate cancer. So in certain contexts are you when it's very high? Actually, that is very suggestive of metastatic prostate cancer. Um, and so it is quite a useful test mhm. Unfortunately, however, it has to be taken with a pinch of salt when it's in the normal range. So what is the normal range? Well, it depends on the age of the patient. Those who are above 40 usually have a P S a above 2.5. And this changes with age, as you can see in this table, if it's outside of the range age adjusted range, I should say this doesn't necessarily mean the patient has prostate cancer as a raised PSA can be suggestive of a number of things, for example, in benign prostatic hyperplasia. But in addition, a low P s a or a low for your age. Priess A doesn't rule out prostate cancer at the same time. And that's why it's not a silver bullet, as some patient's may believe. And it's important to counsel patients who ask for a P S A on this matter. And so, in other words, actually, you can probably say that the sensitivity and specificity of PS PSA are not good enough to be diagnostic when used on its own. And those are a list of things that can be raised in. Does anyone know what the PS PSA stands for? If you don't mind just saying in the chat, I'll give you a clue. The P stands for prostate. Yeah, well done, Ben Prostate specific antigen. Um, and as you can see, it's maybe not that specific because it's not specific for prostate cancer. So not the most helpful name. Perhaps, but it is, um, it is useful in disease surveillance. And so if you are known to have prostate cancer, if you've been shown to have rising levels of your PSA, then it's useful to monitor the disease to see if a patient might be progressing. In addition, if you've had treatment, you should expect the PS PSA to go down, and so that should be checked as well. If it's not going down after treatment, then you may have a metastasis somewhere that we haven't yet diagnosed. So in the context of known prostate cancer for disease surveillance, it's it's much more useful than in a primary diagnosis. Thanks, Mohammad, for saying that as well. Yeah, you're right. Prostate specific antigen. So how do we use a P S? A. How do we use cancer staging And how do we use the cancer grading? Well, there's a fairly modern tool that we use now, and it's called the Cambridge Prognostic Group. Score. C P. G. Score. Um, it is quite new, developed by the University of Cambridge. And it is a score ING system based on a 1 to 5 scale for patient's with prostate cancer, and it includes all of the information that we've talked about. So the state, the T stage, how big it is P s a level and the grading under the microscope using the Gleason score. And anyone can access their calculator. Um, online. I've had to do so for some projects where I've needed to calculate patients' Cambridge prognostic Score group. And if you're in the first two groups, I group one Group two, then that can be considered a low risk patient in Group three. That is an intermediate risk patient. And if you're a Group four or Group five, then you are high risk patient. And when I say high risk, high risk of disease progression, high risk of having metastases. And this particular group score is not used for patient's with the P S. A above 100 and it is not used for those with no metastases already. So now that's how we use these together in the context of many things together to make a judgment on how risk how likely a patient is to have advanced disease and have, um, disease that is aggressive and likely to progress for my slide. Oh, technically. Okay. Um, I think we're back. Yes. And so when I was researching this, I came across this term again and again and again. And it's clinically significant. Prostate cancer. You might think, Hey, well, I have cancer. Surely that's clinically significant by default. Well, not necessarily actually, again prostate cancer, as it always seems to do bucks the trend because you can have prostate cancer but actually have it not really affect your life particularly, and not require much treatment whatsoever. And so this term, clinically significant prostate cancer is prostate cancer that has the potential to cause major complications and death non harmful cost. Eight cancers I those which are so mild or are very unlikely to become aggressive before the patient passes away are very common and often have been overtreatment treated, which has been criticized. And now we're trying to adjust our treatment. As such, many people define clinical significance as having a Gleason score of seven or higher, and, um, many insignificant cases may only be managed with watchful waiting. As with all surgical specialties. We need to think about the patient's co morbidities. We need to think about the patient as a person rather than a set of investigations and numbers and things. Let's say, for example, we have a 90 year old man. His life expectancy due to a number of comorbidities, is only about one or two years, and he has mild. Prostate cancer is low risk. We're very unlikely to take this person to theater and do an operation A because of his comorbidities and his frailty, but also his prostate cancer, the time taken for the prostate cancer to become aggressive and, um, Patasse to size and cause any clinical issues that time is greater and probably much greater in this case than this patient's life expectancy. So it's important to consider. And with that, prostate cancer has really good survival outcomes compared to a lot of cancers, particularly lung cancer. For example, uh, and many patients die with prostate cancer, and not because of it. In England, for example, we have 85% 5 year survival rates and 80% 10 year survival rates overall, such all patient's included. If you're a low risk patient, you're 95 you have a 95% chance of having a five year survival rate. Unfortunately, for those who have high risk prostate cancer, this dropped to 50%. As with all cancers, therefore, it's been shown earlier. Stage and lower grade tumors have better outcomes. So if you can get that diagnosis nice and early, then we're on to a winner. Hopefully, a lot of patient's also have complications. Complications? We've mentioned lower urinary tracts. Symptoms. Um, so your frequency, your urgency nocturia incontinence. If you have a bony metastases that commonly causes pain, you may get hypercalcemia, and that can be an emergency medically, Um, and if you have a metastases in the lungs, that can potentially affect your lung function. So we need to consider that in those more complex cases. And as I've mentioned, prostate cancer seems to have so many different types of options, and so many of them are valid in their own way. And so realistically we have to consider patient's in their whole context. We have to also consider their wishes, and then we also have to consider our particular recommendations. For particular patient's. This can be very, very difficult indeed, of course, being a surgical teaching series, we won't focus on a few of these, such as chemotherapy breaky therapy. We won't focus on watchful waiting. Um, and we won't focus too much on external beam radiotherapy or androgen deprivation. The main one will focus on is radical prostatectomy. But we're also going to talk a bit about active surveillance and a small amount about radiotherapy as well. Is anyone unclear as to what any of these terms mean? I'm happy to explain them now. Some of them will will go through in a little bit. Uh, May has asked, What is breaky therapy? It's a very good question, So Breaky therapy is a type of radiotherapy, but in this instance, we take a radioactive substance and place it inside of the area where there is the cancer. We've placed it inside the body, and then it exerts local radiation to the cancer over a period of time. Patient's usually stay in the hospital in a breaky therapy unit whilst this is occurring so as to not expose other people to the radiation. And then after a period of time, this radiation runs out, the breaky therapy may be removed or it may be left in place. And that's why I call in this little excellent here. External beam radiotherapy sat xrt is radiotherapy, and that's because that's the classic radiotherapy that you think of. You get a laser, you fire radioactive beams at it and then that Fry's the cancer. Breaky therapy does a similar thing, but in a slightly different way. Does anyone know what androgen deprivation might mean? If not, that's okay. Uh, because I appreciate there's quite a few big words, but essentially, we all know what estrogens are. Estrogen is a hormone present in both males and females, but in females, it regulates the menstrual cycle to a large extent and needs to a lot of other, um, a lot of other functions, too, whereas androgens uh, your testosterones and, um your testosterones, uh, their functions in the body such as male fertility, uh, and other such things. So prostate cancer is very sensitive to the effect of testosterone and dihydrotestosterone. And so if you deprive patient's of their androgens, I get rid of the production of testosterone and that can slow the progression and development of prostate cancer. And so we try and inhibit that we do that through chemical castration by the administration of agents such as God's Real in um so that is generally for patient's who have metastatic prostate cancer. It's usually the first treatment that they have, and that is to slow the effects of the prostate cancer. A lot of patient's become resistant to this over time, and so then they need chemotherapy. After that, I told you it was complicated, didn't I? Prostate cancer, Um, and that's just for certain groups of patient's this breaky therapy and driven decorations so and so forth. We're not going to go into any more detail onto those those so onto what we are going to focus on, which is radical prostatectomy, first of all, and the goal of radical prostatectomy is to cure the cancer and preserve as much pelvic function as possible. So radical whenever you hear radical in terms of cancer surgery and you're getting rid of the whole thing, you're getting rid of the prostate, the seminal, seminal vesicles and some of the surrounding tissue at the same time. And that should hopefully cure the cancer outright the bladder afterwards. Because if you remember and you can see here the bladder and the prostate connect together the parts of the your urethra. The bladder needs to be reconnected to the urethra. Uh, and this is this procedure is mostly performed robotic lee or laparoscopically, I should say, Actually, where I work, almost all of them are performed with robotic assistance nowadays, and radical prostatectomy is indicated in low risk patient. So your C P. G. S one and two and intermediate patient's with local disease again, No point doing in the metastatic patient's. This has equal survival outcomes over 10 years as active surveillance and radical radiotherapy. So there is no significant difference between the use of radical prostatectomy versus active surveillance. I e. Just monitoring the disease and radical radiotherapy over a period of 10 years. If the patient is low risk and has local disease, which for me just seems very odd, you think surgery would actually be much better. But in actual fact, it has equal outcomes. What I will say is that surgery and radiotherapy are better at preventing disease progression and developing metastases after 10 years. But surgery and radiotherapy have equal outcomes in this respect, of course, with surgery and with radiotherapy you're more likely to get complications than with active surveillance because this doesn't involve an intervention. And so again, you need to think are the potential complications of this procedure better than, um uh, doing nothing at all? If we think probably this patient isn't going to develop metastases. If we have a strong suspicion of that, or if the patient wants surgery already, oh, therapy, then we would offer them if they have local disease and, uh, of low to intermediate risk. And actually, if they're low risk most of the time, most patient's will be best off having active surveillance. I e. Checking up on them, regularly, doing many investigations, seeing if they're still in that low risk group. If they progress to the more intermediate group, it's probably better to do radical treatment because they're more likely to progress to having high risk disease. And when they're in between, I either low risk. But the Cambridge Prognostic group score is, too. You can discuss either option, and it depends on the patient sensibilities as to what they go for. And so what's the difference between watchful waiting and active surveillance? Both of them involve monitoring the patient and both of them involve not actively treating anything well. The difference is watchful. Waiting is commonly offered where the disease is localized, but life expectancy is less than 10 years, whereas active surveillance. That's when we expect the life expectancy is to be above 10 years. We may intervene in the future. We may operate. We may do radiotherapy. But there is also the option of waiting because this patient's risk of developing high risk disease isn't that high. What techniques can we use? Well, I've mentioned most are done robotically where I work. Many are done laparoscopically. Um, open surgery was the original way of doing a radical prostatectomy, but is less common nowadays. Although I do remember seeing one case as a medical student, there are no clear differences between the complication rates of the two, however, robotic and laproscopic techniques are associated with shorter hospital stays, and the patient's are less likely to need a blood transfusion. The open technique nowadays is transperineal, and so that is involving a transverse cut in the lower abdomen. The original technique, however, was transperineal, and so that is going through the perineum. Transparent real root has many complications for the pelvic floor, however, and does not allow for pelvic lymph node dissection. And so it's kind of been replaced by the retropubic technique. I this one on the left, which itself is slowly but surely being replaced by the laparoscopic and robotic techniques on the image on my right. What you can see is that the prostate is removed either side from the bladder and the membranous urethra, which is the next part of the urethra before the, uh, spongy urethra. It is taken out, and you can see there that the bladder neck is reconnected to the membranous urethra just there in order to allow four continents to happen as a result, given that the prostate is located so close to the perineum, which is where a pelvic floor is, which is so important for our continents, given that is so close to the Penis as well, where the cavernosal nerves and the perennial nerve happens, I'm sure you can appreciate if we do cut any of these important nerves or vessels we may lead to urinary incontinence. We may also lead to sexual dysfunction as well, so those are the main issues with surgical treatment of prostate cancer. I've discussed this last week when we were discussing renal cancer, but in case anybody wasn't there, needs a bit of a reminder. Laproscopic surgery This is a minimally invasive technique. It involves placing keyhole cuts, so you you cut only for the placement of your trocars. These trocars then have wires inserted that you use in order to manipulate tissue. Make your cuts and exercise tissue. The incisions are very small. You put a laparoscope in. And so what is that? That is a camera that goes through the through the tummy wall that allows you to view the abdominal organs as well. In order to actually do what you need to do, you need to inflate the abdomen with an inert gas. So that's carbon dioxide. And the pressure that this gas exerts in the abdomen is 15 millimeters of mercury or less so normally 8 to 15 millimeters of mercury. Any higher is going to cause its own complications, as I'm sure you can imagine creating additional pressure in the abdomen, Um, and so that's important to appreciate. And that is true for all that scopic surgery, not just, uh, radical prostatectomy. And again, I mentioned this last week, but it's important to go over it again. When you do robotic surgery, you make similar size cuts. You insert the TRO cards, but instead of a surgeon operating by hand what you can see here, the equipment the surgeon goes away, you may be scrubbed or he may be described. He uses the robot, which is separate from the patient, as far away from the operating table and then through a computer system. Uh, the computer mimics the actions of the surgeon inside of the patient. But whilst the surgeons making quite big arm movements, the robot is making very small arm movements, and therefore you can do more precise surgery. Using this technique, It's really cool to see if you can get yourselves into the robotic theaters or even into a course where you can have a go on a, uh, pretend robot simulation. 100% recommend it. It's really fun. I really enjoyed it when I've done that as well mentioned, a few of these complications you can get. You can swap your uh, frequency and your urgency for incontinence. That's low pressure, uh, incontinence, because you might knick some of the cavernosal nerves you may get erectile dysfunction, which many patient's are very scared of developing. Preoperatively. You may get retrograde ejaculation. What's that? That is the ejaculation of semen into the bladder rather than down the way it should go. Rarely you can get fecal incontinence. It's not very common in prostatectomy, but it might occur because you're operating on the bladder neck that can stir nose and become narrower, creating maybe a stricture. Because you're removing lymph nodes, you can get lymphedema as per any sort of lymph node surgery, and it might even lead to shortening of the Penis. Which, of course, patient's should be counseled about beforehand. So what about high risk? We've spoken about low risk patient. What about high risk patients'? Well, again. Consider whether disease is whether the disease is local or metastatic in these patient's. You should not offer active surveillance unless the patient really is adamant that they do not want any treatment. If they do want treatment, they should get it. This usually should be radical. I either radiotherapy or prostatectomy if the patient has developed metastases, chemotherapy and androgen deprivation. Therapy is what is used, and the chemotherapy agent that I've seen most commonly used in what's recommended is called docetaxel. It's a pre and POSTOP as well. Uh, preop preparation should include pelvic floor exercises, prophylactic antibiotics, Uh, and, um, and these are to prevent infections to allow for the greatest likelihood of developing continents and not having incontinence during or after the surgery. Neo adjuvant adjuvant uh, androgen deprivation is not recommended, so that's a lot of big words. Neo adjuvant. What does that mean? That means chemotherapy or an agent Pre surgery and having that in the form of androgen deprivation or any chemotherapy is not recommended in prostate cancer in other types of cancer, you may see the administration of chemotherapy before the surgery, and that is to shrink the size of the cancer, making it easier to operate on patient also needs screening for disease recurrence. Uh, because the cancer can come back regular history. Taking regular P S A measurements. As I said, it's a very good, um, screening tool for surveillance of patients who are already diagnosed. Um, having a pet scan Post radical surgery is also important. Um, and I should say there's no evidence to suggest that salvage radiotherapy in patient's with no metastases, but they have high P s a is recommended, but this is still recommended in the literature, even though there's not huge amounts of evidence to support it. So back to our patient's, that brings us almost to the end of our session. Um, I don't know, actually, before we go through our case again, I don't know if it's now is a good time to consider any questions at all. Does anyone have any questions? Give you a few moments? I do have some questions, Some MCQ style questions, Um, that I can get up on the screen as well. So whilst I'm doing that, uh, happy for you guys to think of any questions or anything like that, Make any comments? I'm just going to get these questions that I have on this screen as well. Okay. Yeah. Okay. Yeah. Mhm. Yeah. Okay. Okay. Do you get access to the slides? I'm happy for that. Um, normally, what I prefer to do is make a fat sheet. However, do let me know if you actually just prefer the slides. That's fine. Um, Ashok, um, I don't know if there's any other questions whilst I just get these slides ready? Hi, Charlie. Hey, Adam. How? Yeah. Sorry. Sorry. I came a bit late, mate, but that was that was a really good talk. Thanks so much. Hi, everyone. I don't for for those of you who I met, I'm Adam. I'm also in this, uh, series with Charlie. I'm one of the one of the teaching fellows in Birmingham. Um, so, yeah, thanks so much for the talk. I just wanted to ask a little bit about the lymph node dissection in radical prostatectomy. Is there a defined group of lymph nodes that are always taken? Is it Is it like an entire lymph node clearance in the pelvis? Or does that depend on the stage of the disease in the extent of spread? Uh, so great question That depends on a few things, some of which you mentioned. So it depends on whether the lymph nodes are involved or not. Um, And so, as we said, the patient could be n one or n zero the end zero. No evidence of cancer. Then we will not take out the lymph nodes to avoid lymphedema or any further complications. If, of course they are. We need to get rid of them. Now. Generally speaking, you can classify them as the pelvic lymph nodes. Um, so this includes things like the Obturator node. Uh, the internal iliac nodes, the inguinal lymph nodes as well. Uh, some lymph nodes can be particularly tricky. They can be stuck to the pelvic wall. Um, that can create a lot of issues. Um, so those are the ones that we tend to take? Uh, if, As I said, if a lymph node is outside of the local area, that's classic for prostate cancer that's considered a distant metastases. So Para-aortic nodes. That's the That's the main one. Uh, they are distant metastases rather than local metastases, so that patient would be not eligible for surgery. Cool. Thanks for clearing up. Thanks, mate. Anytime I see Ben's ask the question, Why is near adjuvant deprivation not recommended? Preop. And I'm going to give a a fairly political answer and say there's probably just simply not enough evidence to suggest that this would benefit patient's, um, in terms of the ins and outs of the sciences. I'm not sure, but essentially the point of neoadjuvant therapy would be to shrink a cancer if the cancer is very large e T T three or t four cancer, but the patient is still considered to be Cambridge Prognostic. Score fairly low. Intermediate, then that doesn't change a whole lot about their treatment. If the Cambridge prognostic score suggest that the patient is high risk, but they're still not metastatic, maybe other parts of their score is pretty good. So low Gleason score, for example. Then, actually, is this patient more at risk than, say, a small cancer that is very aggressive in its grading and has a high P s? A. It's hard to know which you'd rather, and that's why this is Cambridge. Prognostic score is so useful because it allows you to consider all of these three main factors for prognosis altogether. Fab. Um, so do continue to ask questions in the chat. Um, I have made some emcee cues, um, related to the talk. Does anyone know in which part of the prostate are we most likely to find cancer? Transitional zone, Peripheral zone, Central zone, anterior zone or the variables own? Yeah, And I'm feeling brave. That's not called Adam. Okay, a check. Well done, Ben. Yes. You're correct. The peripheral zone if you remember, that peripheral zone is also the posterior zone. So I like to remember it peripheral posterior and we in prostate cancer. What do we do? We do a digital rectal examination. The rectum is also posterior to the prostate. So we put do a digital rectal examination, which is prostate. Um uh uh, digital rectal examination to examine the prostate, which is posterior. And that therefore means it's in the other p, which is the peripheral zone. The one that people get confused with is the transitional zone and the central zone transitional zone is where BPH tends to occur. And the central zone that is it maybe an area of disease. But it is not the most common area for disease. The anterior zone again, it's not the most common area of disease. And, uh, the variable zone is something I made up Which of the following is the most accurate? A high P s a level is always associated with prostate cancer. A low P s a level rules out prostate cancer. The age of the patient maybe needed to interpret a PSA level. P s. A. Levels are not useful in prostate cancer surveillance or the P S. A level can only be raised in prostate cancer. Yeah, yes, Thank you, Mohammad. That's correct. The age of the patient maybe needed to interpret a P s a level. Remember that table I showed before younger patient's should have a lower the PSSA than your older patient's. So if you get a eight years rolled and they have a P S A of five, for example, that is not the same thing as a 40 year old having a P S, A or five and the 40 year olds more likely to have an issue with their prostate, or indeed have one of the factors that falsely elevate the prostate at the P s a level. Incidentally, if you're ever doing, um M. C. Q s. A general rule of thumb is, if something says always or never, it's probably wrong. Um, and that goes for things like rules out. So if anything is absolute, um, it's usually wrong. Not in all cases, but it usually is. Which of the following is the most accurate? Radical prostatectomy is superior to radical radiotherapy for localized prostate cancer. Radical prostatectomy is superior to active surveillance for localized prostate cancer. There is no difference between active surveillance and watchful waiting. There is no statistical difference in the oncological outcomes between active surveillance, radical prostatectomy and radical radiotherapy and radical prostatectomy is that more commonly leads to fecal incontinence than radiotherapy. Yeah, does anyone want to hazard again? You've got 100% as a group, so far, so I'm very happy. Yeah, that's true. I'm not sure anyone's feeling keen for this one, but if you remember, there is no statistical difference in the oncological outcomes between active surveillance, radical prostatectomy and your radical radiotherapy when it comes to localized low risk or intermediate risk disease. Uh, and that's been shown over a 10 year period, the survival outcomes over a 10 year period of very similar for these three in the low risk group. And that's why it's not superior any of these cases for localized disease. In the lower risk groups, active surveillance is more fear. Patient's who are who may have treatment in the future radically, whereas watchful waiting, are unlikely to have radical treatment in the future. Radical prostatectomy more commonly leads to urinary incontinence, whereas radiotherapy tends to lead to fecal incontinence. More commonly which of the following is the least accurate? I think this is the last MCQ Which the following is the least accurate? Um, open surgery is less commonly performed nowadays for prostate cancer. Robotic surgery involves surgeons being scrubbed in and next to the patient throughout the operation. Uh, laproscopic surgery is a minimally invasive technique. Radical prostatectomy always leads to regulate ejaculation. Uh, and not, uh, sorry. Uh, that should say never never leads to retrograde ejaculation. And not all hospitals have the capacity to perform robotic surgery. So which is least accurate? Bearing in mind that fourth one should say never, Not always. Anyone want to hazard a guess? Just before we wrap up, I'm going to post the feedback form in the group. I very much appreciate it. If you fill out the feedback form and following that, you can get a certificate and the slides. Um, but you can also answer this question as well, if you feel like it. Yes. Well done, Adam 0.2. Um, so robotic surgery does not involve the surgeon being scrubbed in and right next to the patient throughout the operation. Um, it's quite a strange thing to think about they operating at a sort of virtual reality headset that is controlling the patient, controlling the arms of a robot in real time, which is mimicking the surgeons movement. It's it's really quite a cool thing to see. So if you have the ability, um, try and see some robotic surgery before you do that, Do try and fill in a feedback form very much. Appreciate. If you could fill this out, it's essential for our growth as an organization. If we want to continue doing the series, need to learn and get better. But we also need to justify ourselves. Is this something that is, uh, providing a good service for students and junior doctors around the world? And, yes, thank you very much for coming. Happy to take any more questions for the remaining last few minutes. I hope you enjoyed. All right, that's our our, um, up. I'll leave the link to the feed back format for a few more minutes. Uh, if there are no more questions after a few more minutes, happy to say goodbye. We hope to see you all next week. Um, Adam will be delivering the session. Um, sure to be absolutely fantastic. Adam is a great teacher currently teaching in Birmingham. Very much interested in surgery. Um, and yes, thank you very much for coming. Yeah. All right. Cheers, guys. Have a good rest of your evening. Mhm.