Wonderful content
At 3:00 p.m. on April 8, 2020, the first session of "cloud class", a series of urological expert lectures on "Taihu Lake bleeding" jointly sponsored by the urology branch of Jiangsu Medical Association, the urology department of Wuxi Second Hospital Affiliated to Nanjing Medical University and Shenrui biology, was successfully opened!
During this special anti epidemic period, we have the honor to invite a group of academic celebrities in the field of Urology, who are hot in the heart, to preach for the audience and friends.
In the first phase of "Taihu Lake secretion", Professor Chen Ming, urology department of Zhongda Hospital Affiliated to Southeast University, Professor Ren Shancheng, urology department of Changhai Hospital Affiliated to Naval Military Medical University, Professor Huang Yuhua, urology department of the Second Affiliated Hospital of Suzhou University and Professor Feng ninghan, urology department of the Second Affiliated Hospital of Wuxi Medical University, served as the chairman of the meeting. Professor Feng ninghan, urology department of Wuxi Second Hospital Affiliated to Nanjing Medical University, presided over the meeting, Professor Ren Shancheng, urology department of Changhai Hospital Affiliated to Navy Medical University and Professor Wei Xuedong, urology department of Suzhou University Hospital, served as sharing guests. Professor Xu Bin, urology department of Zhongda Hospital Affiliated to Southeast University, Professor Wu Jianping, urology department of Zhongda Hospital Affiliated to Southeast University, Professor Xu renfang, urology department of Changzhou First People's Hospital, Professor Ma Limin, urology department of Nantong University, Professor Zheng Bing, urology department of Nantong first people's Hospital, Professor Zuo Li, urology department of Changzhou Second People's Hospital, Wuxi Second Professor Dong Jian, Professor Xu Xinyu, Professor He Xiaoliang, urology department of Xishan people's Hospital, Wuxi, and Professor Wan Enming, urology department of Huishan people's Hospital, Wuxi served as guests. 01
In the first part of the meeting, Professor Ren Shancheng of Urology Department of Changhai Hospital Affiliated to Naval Military Medical University gave a special lecture entitled "prostate cancer single hole robot operation".
Professor Ren shared his experience since he completed the first single hole robotic radical prostatectomy in Asia in July 2018. He has successively completed a variety of surgical procedures such as single hole extraperitoneal, single hole perineum and single hole bladder. At present, more than 100 cases have been completed. The results of these clinical operations are internationally recognized and published in Asian Journal of Urology and urological internationalism. Professor Ren introduced the specific operation steps and key points of each operation in detail, especially pointed out that each operation has its unique advantages and applicable population. It is suggested that urologists should master more operative methods, choose the most appropriate scheme according to the patients' characteristics, requirements and disease stages, so as to achieve the purpose of precise surgery. Professor Ren's wonderful speech was highly recognized and praised by online experts. After the explanation and case sharing, Professor Ren and many big guys had a wonderful discussion on many problems in the process of robot surgery.
Discussion summary of 20200408 single hole robot surgery
Ma Limin: the biggest difficulty encountered in the operation of a single hole robot is the "fight" of the mechanical arm?
Wu Jianping: during the operation of a single hole robot, the mechanical arm will "fight". It is suggested that the action range should not be too large during the operation. The two mechanical arms and the lens should closely follow each other. The "fight" of the mechanical arm will significantly prolong the operation time.
Ma Limin: is there any special requirement for "trocar" in single hole robot surgery? The distribution of trocar is three mechanical arms and one auxiliary arm. The auxiliary arm is at the front, the lens arm is at the tail, and two mechanical arms are at the middle. Will this way "fight"? If so, what's the best way to avoid it?
Ren Shancheng: during the operation, the phenomenon of mechanical arm "fight" exists. At present, the urology department of Changhai Hospital can avoid more than 5 times of mechanical arm "fight" during the operation. In the actual operation process, the chance of "fighting" is much smaller than that of "fighting" through the abdominal cavity. At the beginning of robotic single hole surgery, patients with prostate size not particularly large were selected. At the beginning of the operation, do not make a longitudinal incision, but a transverse incision. A 4-5 cm incision is made in the transverse direction 5 cm above the pubis. "Port" shall be 100 square cm, and try to lean to the side when placing "trocar", and four operation arms shall form a diagonal. The depth of placing "trocar" will affect the "fight" of the mechanical arm, and the placement position should be just such that the end of "trocar" is located at the bottom layer of the skin. The depth of arm 1 and arm 2 should be adjusted, not the relative distance. During the operation, the range of action is smaller. Both arms 1 and 2 move together, and the distance cannot exceed 2cm. To use a 30 ° lens, always face up during operation.
Xu Renfang: will it be more difficult to clean lymph nodes with a single hole robot through the perineum?
Ren Shancheng: it will be difficult, but not impossible. Two cases of perineum lymphadenectomy abroad were performed with XP. We use Xi system, unless there is a terminal bend of 5mm. The advantage of transperineal route is not lymphadenectomy, but urination and sexual function maintenance. At present, all the patients I choose do not have lymph node dissection.
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In the second part of the meeting, Wei Xuedong, Professor of Urology, Affiliated Hospital of Suzhou University, provided the classic cases of prostate cancer management.
20200408 medical history
The patient, male, 71 years old, complained of progressive dysuria for one year and PSA elevation for three days. Plain CT scan showed that the prostate was enlarged, irregular in shape with abnormal enhancement, and prostate cancer was to be discharged. The shape of bilateral seminal vesicles was normal, the density was even, and the angle of vesical seminal vesicles was sharp. CT scan showed that the localization of the left acetabulum was active and the metastasis was possible. PSA 26.9 ng / ml, f-PSA 2.68 ng / ml, puncture pathology Gleason 4 + 5, ct2c-3an1m1b, the treatment plan successively carried out endocrine therapy, abiolone therapy, chemotherapy, gene detection, radiotherapy, etc., endocrine therapy for 11 months, PSA decreased to 0.701 After 12 months, PSA began to rise gradually. After the replacement of endocrine therapy, PSA gradually increased to 5.827ng/ml, and MR showed left ischial metastasis. After 11 months of treatment with abiolone, PSA decreased to 1.73ng/ml, and then increased to 4.98ng/ml, The effect was not good; after 4 months of chemotherapy with docetaxel and cisplatin, PSA decreased to 4.47ng/ml at the lowest level, and then increased to 5.54ng/ml. At this time, the patient underwent gene testing, and the test results showed that TMB 57.9%, MMR -, MSS, chemotherapy -, target -, the drug suggests that PD-1 mAb, target drug (olapani), and related chemotherapy drugs are less likely to benefit. The follow-up treatment plans try to use fixed-point radiotherapy, endocrine therapy, and chemotherapy plans (cyclophosphamide, etoposide, and estrogen) and the treatment effect is not good.
In the case discussion, the guests discussed whether local treatment should be actively carried out for oligometastatic prostate cancer, whether drug should be stopped when the PSA of DP regimen chemotherapy was not significantly decreased for three months, how to grasp the timing of radiotherapy to affect the disease process and gene detection, whether gene detection is applicable to the population, the selection of gene detection products, and the guidance of gene detection results on patients' treatment, including targeted drug use , chemotherapy, immunotherapy and clinical benefits of patients were discussed. Summary of case sharing discussion
Xu Bin: CEE chemotherapy program, under what circumstances should patients consider using CEE program? Huang Yuhua: with regard to the CEE scheme, Su Fuyi urology department has tried different combinations of drugs. Including the effective rate of estrogen for some patients is not high; cyclophosphamide can also be used alone, some effective; VP-16 can also be tried, in the late stage of patients' disease, there are not many effective chemotherapy drugs. Even if the gene test suggests a particularly effective chemotherapy drug, the actual use effect is limited. After consulting the literature and trying to use the combination of drugs, we got a better effect, because the side effects are large, we did not continue to try to use. The feasible plan of this patient includes cab, abitron and DP, but only enzalutamide has not been used. After all the above schemes are tried, the combination chemotherapy is started. Ma Limin: this case gives us a good hint, that is, how to choose the treatment plan for mhspc patients. At present, for the treatment of mhspc, we have ADT as the basic treatment, in addition to radiotherapy, DP chemotherapy, new endocrine therapy. What treatment should be done first, ADT + chemotherapy, ADT + radiotherapy or ADT + new endocrine therapy? How does sequential therapy work? What is the treatment sequence? These are under study. Through case analysis, we found that some cases were successful. Gene analysis showed that PARP inhibitor and PD-1 / PD-L1 were not used in this patient. He Xiaoliang: almost all the treatment schemes at this stage have been used in this case. The PSA will come down a little every time you change the usage plan. Among them, the first stage of the use of cab program, followed by ADT treatment. At the beginning of the disease, is cab better or ADT more suitable? Huang Yuhua: is the cab scheme better or the ADT scheme better. In patients with higher malignancy and tumor burden, cab is better than ADT. But it also needs to be treated in a specific way. At present, there is also evidence that ADT + abitrone is better than cab. In this case, if ADT + abitrone was selected as the initial treatment, the treatment effect might be better. Zuoli: for patients treated with cab regimen and / or ADT regimen, PSA is decreasing but testosterone level is not ideal. The testosterone level of this patient reached castration level but did not reach below 0.7nmol/l. Attention should be paid to such patients. According to statistics, if testosterone does not drop to 0.7nmol/l within 6 months after treatment, such patients will progress to CRPC within 2 years. However, if the testosterone level drops below 0.7nmol/l within 6 months, the patients may not progress until 48 months. In this case, after nine months of cab treatment, the testosterone level still did not reach below 0.7nmol/l. Intervention is needed, early use of abitrone, or direct use of chemotherapy regimens during the CPRC phase. Above, is the testosterone level management to give me the hint. Feng ninghan: this case is very typical. The median survival time is more than 40 months. It is suggested that gene testing, including ar-v7 testing, should be carried out as early as possible for such patients. Gene testing may be more useful for drug therapy. The basic scheme of the patient has been tried. Can we try to use PD-1 / PD-L1 at present? Huang Yuhua: PD-1 / PD-L1 treatment is not recommended for this patient at present. However, it has been reported that it may be better to artificially increase mutation load through radiotherapy and then receive PD-1 / PD-L1 treatment. In addition, we have done some clinical research on testosterone level management. Testosterone level, compared with PSA minimum and time to reach the minimum, is an independent factor. Now there are research teams building models to predict resistance and time to progress. If it can be achieved and early intervention, the treatment effect for patients will be better. Xu renfang: in this case, gs9 points of the patient, oligo metastasis and suspected lymph node metastasis, and 12 systematic punctures were all positive. For such patients, it is a good result to be able to achieve a 5-year life cycle through a series of treatment. Just now, you have discussed several schemes. I think that the patient has reached this stage, and the follow-up treatment may not be able to prolong the survival period of the patient. Zheng Bing: