AUA2021 Day 3 eNews - 091221

SUNDAY • SEPTEMBER 12, 2021 • AUA2021 DAILY NEWS 11 New approaches to metastatic hormone-sensitive prostate cancer, castration-resistant prostate cancer N ew trials and new treatment approvals are changing the ways clinicians approach the androgen axis for the treatment of metastatic hormone-sensitive prostate cancer and nonmetastatic castration-resistant prostate cancer (CRPC). The changes have been so dramatic that the AUA has updated its guidelines, which had been amended as recently as 2018. “The management of men with advanced and castration- resistant prostate cancer is an ever-changing landscape,” said Michael S. Cookson, MD, MMHC, professor and chair of urology at the University of Oklahoma College of Medicine and chief of urology at the Stephenson Cancer Center in Oklahoma City. “The last decade has seen an explosion in both the evaluation and the management of men within these disease states.” Recent years have also seen a dramatic increase in the number of patients with advanced prostate cancers, he continued. Advanced prostate cancer can easily account for 25% and more of the practice for urologists and advanced practice providers. The increase in patients, combined with increasing treatment options, makes it imperative for all clinicians to keep current in this rapidly changing field. Dr. Cookson will direct a course exploring the practical and clinical implications of the “Updated 2020 AUA Guidelines on Metastatic Hormone Sensitive (HSPC) and Castration-Resistant Prostate Cancer (CRPC)” on Sunday. The faculty for the course are David F. Jarrard, MD, professor and John P. Livesey chair in urology at the University of Wisconsin in Madison; William Thomas Lowrance, MD, MPH, MBA, chair of the AUA Advanced Practice Guidelines and a urologist in Easley, South Carolina; and Adam S. Kibel, MD, Elliott Carr Cutler professor of surgery and chief of urology at Harvard Medical School and Brigham Health in Boston. They will highlight new therapeutic options that have been incorporated into evidence-based guidelines, the growing role of genetic testing, new developments and future research needs. Attendees can expect a thorough, clinically focused review of new data and novel antiandrogen treatments for men with nonmetastatic CRPC, Dr. Cookson said. Genetic testing is moving from an interesting option to a clinically useful tool for many men with metastatic and CRPC. “This course will include the role of genetic counseling in germline testing and the precision-based and image-guided therapeutics linked to the findings based on the latest clinical trial data,” he said. Advances in evaluation and treatment are not restricted to a few patients or cancer types and states. For patients with newly diagnosed prostate cancer with low-volume metastases, evidence now suggests that radiation therapy to the primary tumor can improve survival when combined with standard of care systemic therapy. That standard of care has also evolved. Androgen deprivation therapy combined with docetaxel chemotherapy or a novel androgen axis therapy has become the starting point for many men. For men with CRPC, prior treatment, location and burden of disease and degree of symptoms have emerged as important factors in management decisions going forward. Course instructors will highlight some of the nuances of second- and third-line therapy. “The course will include treatments for men with newly diagnosed metastatic prostate cancer as well as those with castration-sensitive disease,” Dr. Cookson said. “We will cover the use of precision-based treatments, including PARP inhibitors and the germline and somatic testing that is imperative in preparation for treatment. There are novel therapeutics, theragnostics, linked to PET imaging. This is the most up-to-date information for the practicing clinician.” Retzius-sparing robotic radical prostatectomy debated The pros and cons of Retzius-sparing robotic radical prostatectomy were presented in Saturday’s Crossfire, with a video demonstration of a new alternative surgical technique. R etzius-sparing robot- assisted radical prostatectomy is a surgical technique developed to promote early continence recovery and functional outcomes following prostatectomy. The surgical technique approaches the prostate from a small space below the bladder to minimize surgical trauma and preserve normal pelvic anatomy. Should you add this technique to your surgical repertoire? That’s debatable. In Saturday’s session, “Crossfire: Controversies in Urology Debate: Retzius- Sparing Robotic Radical Prostatectomy,” Aldo Bocciardi, MD, director of the Urology Department at the Niguarda Ca’ Granda Hospital in Milan, and Ashutosh (Ash) K. Tewari, MBBS, MCh, chair, Milton and Carroll Petrie Department of Urology, Mount Sinai Health System and professor of urology at the Icahn School of Medicine at Mount Sinai, presented the pros and cons of this innovative method. Citing unpublished data submitted to European Urology involving a study with 320 patients, “Retzius-sparing robotic radical prostatectomy is associated with faster and higher urinary continence recovery in the short term and also in high- risk prostate cancer settings,” Dr. Bocciardi said. The overall advantages of Retzius-sparing robotic radical prostatectomy include early continence recovery and oncological results comparable to anterior robot-assisted radical prostatectomy. “The procedure is faster, there’s less bleeding, lower risk of hernias, it’s still possible for cistocath placement and it’s standardized,” Dr. Bocciardi said. “I hope Retzius-sparing robotic radical prostatectomy will become popular all around the world.” “Retzius-sparing robotic radical prostatectomy requires us to work in a very small space, which forces us to use more cautery,” Dr. Tewari countered. In addition, the surgical technique lacks a lateral aiming point when dissecting the lateral pedicles of the prostate. “There’s also an inability to look into the bladder, after bladder neck division, to verify the position of the ureteric orifices, and there’s an inverted relationship between the bladder and prostate during dissection and reconstruction,” he said. Dr. Tewari presented an alternative structure-sparing “Hood” robotic radical prostatectomy technique, with anatomical dissection demonstrated on video. “The Hood is made up structures. It’s not prostate, but it’s embedded within the prostate,” Dr. Tewari said. With the Hood technique, median lobes, sub-trigonal benign prostatic hyperplasia and ureteric orifices are handled under imaging. “There’s no worry about ureteric injury,” Dr. Tewari said. The technique can be performed with all sizes of prostates transperitoneally, extraperitoneally or transvesically, with a subserosal tunnel or wider access if lymph node dissection is needed. “The alternative technique also allows for sparing the bladder neck or reconstruction based on oncological and anatomical determinants,” Dr. Tewari said. Another advantage: The Hood technique is versatile in modifying planes of dissections by partial thickness or unilateral hood creation to accommodate tumor location. “With this alternative technique to Retzius-sparing robotic radical prostatectomy, we can achieve almost similar outcomes coming from the front of the bladder, which is easier and more anatomical for most robotic surgeons,” Dr. Tewari said. “And for the majority of robotic prostatectomy surgeons, the technique is easy to adapt.” Moreover, he said, citing the literature, “at about four weeks post-surgery, 91% of patients are continent.” AUA Guidelines on Advanced/ Metastatic/Castration Resistant Prostate Cancer Sunday, Sept. 12 7:00 – 9:00 a.m. PDT David F. Jarrard, MD Michael S. Cookson, MD, MMHC Adam S. Kibel, MD From left, Ashutosh (Ash) K. Tewari, MBBS, MCh, and Aldo Bocciardi, MD