- Speaker #0
This podcast is created by Coelis. Now, the use of focal therapy is not yet common, but a lot of doctors and patients are very keen to embark on focal therapy.
- Speaker #1
Welcome, aficionados of all things prostate, related to another episode of Prostatalk. I'm your host, Thomas. and today we are delving into the nitty-gritty world of prostate biopsies and focal therapies. Joining us is none other than the estimated Dr. Peter Chiu, a trailblazing pioneer on focal therapy in Asia and driving force behind the evolution of urological practices for prostate care. With his innovative approaches and unwavering dedication, Dr. Peter Chiu is worshipping the landscape of prostate treatment across the world. Now, when it comes to targeting in the diagnosis and treatment of prostate cancer, Dr. Peter Chu is a true marksman, and he will tell us, hitting the bull's-eye is not just for harkering tournaments, it is also essential for improving the everyday lives of the patients. So, let's aim high, but not too high, we are talking about prostates, and learn how precise targeting is key to hitting the mark in prostate care with Dr. Peter Chu. Hi, Dr. Chu. We are really pleased to welcome you. So today we are currently live from the 2024 AUA annual meeting in San Antonio, Texas for an amazing edition. How are you today?
- Speaker #0
So thank you, Thomas. I'm doing very well and I'm very happy to be coming back to the AUA again.
- Speaker #1
Before to begin, could you please introduce yourself to our listeners?
- Speaker #0
Well, I'm Peter, Peter Chu from Hong Kong, and I work in the Chinese University of Hong Kong. And my research and practice focus is mainly on prostate cancer and mainly on image-guided prostate biopsies to novel treatments like focal treatments, and I also do robotic surgery.
- Speaker #1
So in order to prepare this interview, I have made my little research, and I have seen that your studies focus on prostate cancer with a particular emphasis on exploring novel treatment options. Am I right?
- Speaker #0
Yes, there are lots of new treatments coming up and my interest in recent years would be on focal therapy for prostate cancer. And that includes my trial cases in microwave ablation and also high-intensity focus ultrasound and some cryotherapy too.
- Speaker #1
I've had the opportunity to participate in many congresses and conferences across Europe and few in the US. Unfortunately, I haven't yet had the chance to attend any in Asia. As a result, my understanding of the situation regarding focal therapy in Asia is a little bit limited. So, Dr. Chu, could you provide insight into the current situation there, including any guidelines of emerging trends, please?
- Speaker #0
We do not have very unified Asian guidelines, but the emerging trend is that minimally invasive treatment is getting more and more popular. Now, the use of focal therapy for prostate cancer in Asia is not yet. common, but a lot of doctors and patients are very keen to embark on focal therapy because focal therapy gives the patient much less morbidity, but at the same time, a lot of patients can be treated with the prostate cancer. So in some countries like Japan, some focal therapies is approved, but in most other countries, there's actually no formal approval. And a lot of these focal therapies are done under trial settings. So I would say there's a lot of interest, but it is not yet very common.
- Speaker #1
Interesting. Let's go back to your daily practice now. Are you performing transpirineal prostate biopsy or transrectal biopsies and why?
- Speaker #0
In my hospital and in my personal practice, I have been doing transpirineal prostate biopsy since 2019. So since five years ago, I have not done one transrectal biopsy. And there are a few reasons. One is obviously less infection. with a transperineal biopsy. Secondly, as we are doing more focal therapy and we need to plan for focal therapy and transperineal biopsy and with the targeted and systematic biopsies gives us an excellent mapping on transperineal route, much better than transrectal in my opinion. So it would actually make us easier to choose suitable cases to do focal therapy.
- Speaker #1
According to you, What are the main advices you can provide to a physician who wants to switch from transrectal to transparent prostate biopsies?
- Speaker #0
I think this is a major change from transrectal to transperineal as we did more than five years ago. But this is not something difficult. So you need some to learn. There is some learning curve, you know, in transperineal biopsy, both in a freehand manner and also in MRI ultrasound fusion platforms. In a way, the softwares are similar. The way you do it is slightly different. And also you need to determine whether in your setting, you do it under local anesthesia or under general or monitor anesthetic care. So these are all the considerations that you need to have. And also that you need to have slightly different equipments, particularly the ultrasound probe in doing a transperineal biopsy. But overall, I think it is a very nice experience. And I don't think it's that difficult to change to a transperineal biopsy.
- Speaker #1
And how the equipment and... especially the ultrasound probe, it's important for transperineal biopsies.
- Speaker #0
So for transrectal, it is usually an N-firing probe. To use the same probe for transperineal would be quite challenging. So a side-firing probe would make your life much easier. And all of the transperineal MRI ultrasound fusion platform, including the coalescent one, would be a side-firing ultrasound probe.
- Speaker #1
I have no doubt that... this information will be helpful. From what I understand focal therapy is typically performed via the transpirineal route correct? This aspect could serve as a compelling argument for doctors who wish to provide the patients with multi treatment options. Wouldn't you agree?
- Speaker #0
Yes so with all the needle based ablations not only in microwave but cryotherapy or even IRE All of them were done on the transperineal setting, except for HIFU, which it is actually a transrectal transmission of ultrasound energy to the prostate. But most of them would be done with the transperineal route. And that is why I mentioned that doing a transperineal biopsy is sometimes similar to the way we do transperineal route of focal therapy, particularly in... microwave or cryotherapy, it's actually very similar to how you do a fusion guided transperineal biopsy.
- Speaker #1
So you mentioned IFU and microarrays, what kind of treatments are you performing now?
- Speaker #0
Different focal energies are suitable for different tumor locations. So for example, for very posterior lesions next to the rectum, HIFU would be a good option. Whereas for tumors that are further away, like anterior, particularly antero-lateral, cryotherapy or any needle-based ablations like microwave or IRE would be more suitable. For tumors that is next to the prostate urethra or anterior to the prostate urethra are those which are very challenging for cryotherapy. And in my personal experience, microwave ablations are particularly good in that locations. So in a way, microwave ablation can cater for most locations, except for the small region of the tumours that is just anterior or next to the rectum.
- Speaker #1
So about targeted microwave ablation, could you explain to us what does it consist concretely?
- Speaker #0
Right, so we're talking about targeted and microwave ablation. So these are two things. First thing is the targeted. Targeted, we use MRI ultrasound fusion technology. on the organ-based tracking mechanism, just like what we do in fusion biopsy. And the second, obviously, is the microwave ablation. We use a single microwave needle inserted transparently into the prostate, and we do it one by one, usually with the guidance of the mini-grid, which is attached to the side-firing transrectal ultrasound probe, exactly the same as we do fusion biopsy. So these are the components of the microwave ablation and each microwave ablation lasts for around five minutes and usually for one lesion we need about between three to five ablations to cover the tumor and margin. So each ablation five minutes and overall the ablation time are usually within 25 minutes for each case.
- Speaker #1
So it's quite a... fast to treat this kind of lesion with microwave ablation. In fact,
- Speaker #0
you're right, because compared with HIFU or cryotherapy, microwave ablation is a much quicker treatment. probably less than half of the time that you need for other treatments. So this is another advantage of doing microwave ablation.
- Speaker #1
Great. This is why you decided to offer it to your patients?
- Speaker #0
Yes, I think because for microwave ablation, I think the direct comparison which is more commonly done, the alternative, would be cryotherapy. For cryotherapy, it is actually a well-proven focal energy, but there are also challenges when we apply it. First, we cannot apply it near the urethra because the urethral warmer will stop the cryo from killing tumor cells around the prostate urethra and the warmer and for the anterior central midline tumors it is also quite challenging for the cryo on the other hand cryotherapy requires the gas which is sometimes a problem because it is less convenient to prepare for the gas and also sometimes the gas isn't in is inadequate for one case or maybe it is a bit too much for one case or two cases. So this is another challenge. And thirdly, for the cryotherapy, because there is a risk of harming the urethra. So for routine, we put in the urethra warmer via cystoscopy, and this is another step which makes the treatment time longer. So in a way, I think tachycardia microwave ablation is as good as cryotherapy in killing prostate cancer cells, but it is much more convenient. quicker, much reproducible and to me I think it is a very convenient and nice way of treating prostate cancer.
- Speaker #1
And do you have any feedbacks from your patient or could you see a specific impact?
- Speaker #0
For almost all of my patients they are actually discharged from the hospital around six hours after the operation. I typically put in a catheter to put in for a few days and they actually come back a few days later or within a week to take off the catheter and most of them would you know pass urine quite well so for the recovery wise most patients actually feel very good and they do not have you know major complications even in the first week besides the discomfort of the follies catheter otherwise the patient just feel very very good a little bit of urinary frequency in the first one to two weeks maybe very minor hematuria in a few cases but overall no major complications so far.
- Speaker #1
How do you determine which treatment options to offer a patient and do patients have the freedom to choose one option over another based on their preferences or their research?
- Speaker #0
I think for focal therapy the choice of the energy heavily relies on first the experience of the user, the availability, the cost and also last but of course on the least but a tumor location. So in some hospitals where only one energy is available, then the doctor or the patient wouldn't have a choice for an alternative. But in my hospital, I'm very fortunate that I have three different energies that the patient can choose from. And therefore, I can actually choose according to the patient's need and the tumor location. So I can actually select the most suitable treatment option for them.
- Speaker #1
It seems like you are now leading a trial in Asia for the use of targeted microwave ablation for prostate cancer, right? What are the objectives?
- Speaker #0
Yes, it is very exciting. I've completed 30 cases of targeted microwave ablation, TMA, for 30 patients in the past few years. And now we're embarking on not a single center, but now a multi-center trial on targeted microwave ablation involving... a few Asian countries and regions like Hong Kong, Malaysia, Philippines, and a couple of more centers we'll be coming up to. So we hope to do a bigger trial.
- Speaker #1
We can't wait to follow the results. Before we end this episode, what would you say to convince physicians to perform focal therapy?
- Speaker #0
To me, a different treatment option for prostate cancer, for localized prostate cancer, they each have its role. So for me, I also do robotic prostatectomy. So in my counseling of the patients, prostatectomy, radiotherapy, and focal therapy, I will actually talk to them like one by one with the pros and cons, explain each of them in detail. So I would not push them into focal therapy. Some of them actually come to me because they want to do focal therapy, but for suitable cases, I would arrange for them. But some of the cases which are actually not very suitable for focal therapy, I would actually advise them to do radical treatment instead. Whereas some patients who come for robotic surgery, I would actually talk to them, oh, you may be suitable for focal therapy. So we talk about the advantages and disadvantages of vocal therapy and let them you know choose for themselves so i think you know to have the information of every single treatment option is important for the patient perfect thank you again so dr fitzschuh for this precise input and for your time and
- Speaker #1
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