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Robotic Surgery for Prostate Cancer Christopher Amling, M.D. Terry Page Webcast December 15, 2011 Please remember the opinions expressed on Patient Power are not necessarily the views of Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that’s how you’ll get care that’s most appropriate for you.

The Progression to Robotic Surgery Andrew Schorr: Robotic surgery allows surgeons to operate with greater precision to treat prostate cancer leading often to fewer complications and hopefully a quicker recovery. We'll learn more from an expert who has performed more than 750 of these procedures. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by the Knight Cancer Institute at Oregon Health and Science University. I'm Andrew Schorr. When you think about cancer, certainly as a man when I think about cancer I think about prostate cancer. My father, unfortunately, while he lived with it for many years he died from the complications of prostate cancer. Many men will develop prostate cancer over years and die with it rather from it, but some of us we need treatment, and surgery has always been right up there, up front. So are there ways of doing surgery that might have fewer complications, a quicker recovery. And that brings us to a discussion of robotic surgery, and a leader in the field and certainly a leader in urology is Dr. Christopher Amling. He's the division chief of urology at OHSU in Portland, Oregon. Dr. Amling, thank you so much for being with us. Dr. Amling: Thanks for having me.

I appreciate the invitation to be here.

Andrew Schorr: Dr. Amling, so robotic surgery, we've talked about it increasingly now in surgery. When it comes to the prostate what does that mean? I mean, we think of men having prostate cancer surgery over the years. I know there was the innovation of trying to have nerve-sparing prostate surgery so that a man would not have the risk of erectile dysfunction or incontinence, trying to limit that, but it was still a big surgery. Then we had laparoscopic surgery that some doctors did. Where are we now with this progression to robotic surgery? www.patientpower.info OHSU121511/AS/jf

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Dr. Amling: Yeah, it's a good question. I mean, radical prostatectomy for the treatment of prostate cancer has been around a long time. It's a very effective treatment for prostate cancer, particularly when the cancer is confined to the prostate. Like any surgical procedure for cancer if the cancer is confined and the organ is removed then it's a very effective way to cure it, remove it from the body. It really has evolved from being a pretty open surgery where we used a large incision with significant blood loss. We didn't know the anatomy of the prostate and the structures around it, so there were complications, especially with that surgery including large amounts of blood loss, erection problems as well as urinary incontinence. Well, the advances in prostate surgery or radical prostatectomy progressed from that open operation to more minimally invasive approaches. Minimally invasive simply means instead of making a large incision you operate through little tiny holes in the lower abdomen, and by doing that you limit the pain and discomfort associated with the recovery. You also allow men to return to full physical activity at a much earlier point in time. And in addition to that there's less blood loss associated with a procedure like that. So overall it hastens recovery, and it might also improve some of the outcomes we look for with radical prostatectomy. Robotic surgery is sort of the latest advance in the progression toward improvement in radical prostatectomy, and it works well because it allows technology to improve the way we see and improve the way we move the instruments that we control at the time of surgery. By using a camera that can magnify the field 10 times and make it three dimensional and by using instruments that instead of have three degrees of movement freedom have seven degrees of movement freedom, we can actually be very versatile in terms of how we perform the operation. So seeing well and being able to move the instruments through these tiny holes that we create allows for a much more precise operation, and because of that we think that it improves outcomes. And we know for sure that it lessens the recovery time. Who Should Consider Robotic Surgery? Andrew Schorr: So I want to understand who it's right for, so let's start there, Doctor. So can any man who has prostate cancer have surgery, to begin with, would that be the right choice? And what about whether robotic surgery is right, and would any previous surgeries maybe preclude him having robotic surgery? Dr. Amling: Robotic surgery or radical prostatectomy in general is best reserved for men who have what we call clinically localized prostate cancer. So prostate cancer that has spread beyond the prostate, for example to the lymph nodes or prostate cancer also likes to spread to the bone, so men who have prostate cancer that's gotten out of the prostate www.patientpower.info OHSU121511/AS/jf

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and spread elsewhere are not good candidates for radical prostatectomy. They are best treated with things like hormonal therapy or some of the newer drugs and other therapies that we have for more advanced disease. So when we do robotic prostatectomy or any kind of prostatectomy we do it with the intent of cure, so we select men for treatment based on the ability to cure that cancer. So if we think the cancer is confined to the prostate or in and around the prostate, then those are the best men to have robotic surgery. Now, men who have had previous radiation therapy, a lot of previous surgical procedures makes the robotic approach a bit more challenging, but often even in those cases we can perform robotic prostatectomy once you have the experience to deal with those more complex situations. So essentially any man who has an indication for radical prostatectomy in an effort to cure their cancer by surgical treatment are candidates for robotic prostatectomy. The Benefits of Robotic Surgery Andrew Schorr: Now, does the procedure take less time, more time? the expectation would be versus open.

Tell us about how it works, what

Dr. Amling: Yeah, the procedure itself takes about the same time as an open prostatectomy. Now, earlier on when you're learning to perform robotic surgery or haven't performed many of them it takes longer than it would with the standard open operation. By "open" I mean the operation where you make a bigger incision and do the surgery that way. So early on, it can take a longer period of time, but after you have experience and attain or ascend what we call the learning curve the amount of surgical time is identical to the time it would take to do an open prostatectomy. So it's about the same period of time. The trocars, little tubes or holes in the lower abdomen are then placed and then the instruments are placed through those holes, and then the robotic technology allows you to control those from a console that the surgeon sits at in the same room as the operating table. And then that robot is controlled from that console at the other side of the room, but because you can sit at that console and benefit from the improved visibility and control the instruments with the improved mobility, the thought is that we can perform again a more precise type of operation. Andrew Schorr: Let's talk about precision as it relates to prostate cancer. So I mentioned at the outset about the development years ago of nerve-sparing surgery trying to limit the complications that could come from having a radical prostatectomy. So this ability to www.patientpower.info OHSU121511/AS/jf

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see, from your experience, to see better and the precise movements, do you think it helps in that nerve-spearing approach? Dr. Amling: Yes, I do. And there are two advantages to the robotic approach in that regard. One, because of the visibility, and again you have a 10-times-magnified camera, and you have it in three dimensions. The camera that we use has two lenses, so it's like the movie theaters where you put the 3-D glasses on, you can actually see in a third dimension, which is unlike any other kind of laparoscopic surgery. So that three-dimensional, 10-times-magnified, high definition view now allows you to see things that you really can't see through an open lower abdominal incision. Secondly, because the robotic approach limits the blood loss associated with open prostatectomy sometimes can be significant, and because there's less blood loss there's less blood in the way when you're doing the operation, so the visibility is even better compared to the open approach. When we do nerve sparing it's very important to see planes, planes of tissue between the prostate and that nerve bundle we call it, and we can see that plane very precisely with the robotic technology. So I think it offers a lot in terms of the preciseness and consistency of nerve sparing compared to an open prostatectomy. Now, that's not to say that an experienced open prostatectomy surgeon couldn't do a good nerve-sparing operation as well, but I think what the robot offers is a very consistent, precise way to do that on a day-to-day basis. Weighing Your Treatment Options Andrew Schorr: You speak to men who are diagnosed with prostate cancer all the time, and so who how do present this? So you do both, and you're an urologist who does a broad range of treatments for prostate cancer, so this is really a dialogue. You're not selling the robotic procedure. Dr. Amling: No, and surgical treatment of prostate cancer is not for everybody. I think one of the things that we do well here at OHSU is we have a what we call a multidisciplinary sort of approach to this, and we think that men should be able to hear about all of the treatment options, and surgery is one of them. And again I do the surgery, but there's radiation therapy as well that can cure prostate cancer. In addition to that, we are now finding some cancers that are not very aggressive. As you mentioned earlier, some cancers that men die with but not of, and some of those cancers that we identify we now recommend against immediate treatment and more toward what we call active surveillance or following those cancers along. www.patientpower.info OHSU121511/AS/jf

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So when a man comes in to my office and we sit down and talk about their new diagnosis of prostate cancer we go over all of these approaches, and we try to find what the best fit for that man would be, and there's lots of pros and cons to either treatment. There are side effects to one that aren't associated with the other and vice versa, so we have a dialogue about all the treatments and then come to some kind of decision about what would be the best approach for that individual. So we really do try to individualize it and try not so sort of push one treatment over another. Andrew Schorr: Dr. Amling, when you think about the robotic approach for prostate cancer surgery though, you would call it an advance, though, wouldn't you? Dr. Amling: Absolutely. Yes, again I think that based on where we came from, and when I was doing my residency training and we were doing nothing but open prostatectomies and we evolved it to laparoscopic prostatectomies and now the robotic technology, just seeing the continued improvement in how the operation is performed and continued attention to the details of that operation and modifications of that operation which improve the outcomes that we're looking for. And there is really three options after prostatectomy that we're looking to achieve; one is obviously cancer cure and control. The other one is preserving urinary continence, and we can do that in a vast majority of men; and also preserving or allowing erections to recover after a nerve-sparing procedure. So those are the things that we are focusing on, and these sorts of refinements in techniques that we're seeing as the years go by and the technology and improvement in visibility I think allows us to sort of continue to improve those kinds of outcomes, and we do see that as the years go by. Terry's Diagnosis Andrew Schorr: Now I'd like to introduce you to one of Dr. Amling's patients. That's Terry Page. He's 60 years old and joins us from Tigard, Oregon, just outside Portland. He has a really cool job. He's a conductor on freight trains. For years he was an engineer, so for me, a grownup who is still a little kid, I think that's really cool. But going back to 2010, I guess it was Terry, you'd been watching your PSA over time with annual physicals and health fairs, and the numbers started changing, so you had two biopsies. What did the biopsies show? Terry: First it's nice to be on with you, and thank you for having me. The first biopsy showed that I had a cancer in the lower left quadrant, the part that was indicating to www.patientpower.info OHSU121511/AS/jf

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be firm, and the second biopsy showed that it was the whole left side, upper and middle quadrant, that I had cancer in all three sections. Andrew Schorr: Wow. Pretty scary for any man. Terry: Yes, it is.

It kind of takes the wind out of your sail.

Andrew Schorr: So there you are, anybody who has studied up on prostate cancer knows that there are different approaches. Certainly if the cancer has been contained as best you thought, the indications were in the prostate, do you have surgery, and which approach, and we're going to talk about the robotic approach as we continue, but you could have seeds or you could do, well, say watchful waiting or active surveillance where they're monitoring you and seeing whether at some later time or maybe not at all would you need let's say surgery or seeds. So you looked into surgery. I understand you had a first opinion, second opinion. You went to OHSU and the Knight Cancer Institute. You met with three doctors at once on that same day right after the other, an oncologist there. You met with a radiation oncologist I guess as well and also Dr. Amling as a urologist. You got all angles covered I guess, a lot of questions answered. Terry: Yes, I did. I was concerned about--I wanted to know as much as I could about what I could do for myself and the situation I was in and what all my options were and to make the right decision towards how to handle this, and so that's why I met with so many different people and found out as much information as I could to make a good solid decision for myself and my future. Andrew Schorr: Now, meeting a multidisciplinary team, as you did all in one day at OHSU, was that helpful? Terry: Very helpful. Like we discussed, it was like a one-stop shop. You know, you could go in there; you met with everybody that was going to be involved with you, your care, and your treatment. Whatever you decided to do, whatever procedure you were going to follow, they were there for you, and it was just really, really nice to have that all at one location. Terry’s Robotic Surgery Experience www.patientpower.info OHSU121511/AS/jf

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Andrew Schorr: So Terry, you had a constitution with Dr. Amling about surgery and there's the more traditional approach, the sort of retro pubic approach that's been done. It was radical prostatectomy for many years and helped a lot of men. And then there's the row robotic approach, and he tells you he's done 500 or more of those procedures. What attracted you to the robotic approach? Terry: Having gone and talked to a person individually that did just standard procedure, like you just mentioned, and another robotic specialist, the second opinion I had, talking to Dr. Amling and his stats and then finding and quizzing him more about what is better about robotics versus a standard procedure, and he informed me that first and foremost it's less intrusive on your body naturally. Second, you heal up faster, less blood loss. And the microscopic portion of it versus a set of glasses and a microscope versus it was like 10 times the magnification of what robotics can see, and then also the capability and the agility of these robotic fingers to be able to get in, around and underneath the prostate to be able to work better than a set of hands. Andrew Schorr: Made sense to you. So there you go, just on the eve of Thanksgiving 2010 you had the procedure. And I understand you were up and around and out of there pretty quickly. Terry: Yes, I was, to my surprise. You know, you have a little discomfort naturally, you come through this radical prostatectomy, and I only had six little holes in me, and that was phenomenal, so there is that portion of it that surprised me. But, yeah, I was up walking, I think my first walking was at three a.m. in the morning, and then the next day, I was out of there by that afternoon. Andrew Schorr: Wow. Now, of course you have a catheter for a couple of weeks, and you didn't go back to work as a conductor right away, but how has your recovery been? Terry: Yeah, I had the catheter in. That's standard procedure while your urinary tract tube there grows back together and gets sealed and stuff, and I had it for two weeks. And then, yeah, that's a little uncomfortable at first, but you get used to the thing, do you know what I mean? And after the catheter was removed I had zero problems with my continence. I was able to stop and start my flow, but that was also because I did my Kegel exercises before surgery and you do your Kegel exercises, your muscle exercises while you have the catheter in you to help you with your incontinence, so I had no problems with that at all. www.patientpower.info OHSU121511/AS/jf

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Andrew Schorr: Good for you. Now, some people wonder when you have robotic surgery and the doctor is at a console in the operating room but he's not like right there at the table, was that a big deal for you at all? Terry: Well, it was kind of figuring out, okay, the doctor is not going to really be there, but he had other people around me, the anesthesiologist and other people there at the table with me, but yeah, it was kind of strange that he was going to be at some joy stick or some robotic panel someplace across the room from where I'm sitting at, yeah it was. Andrew Schorr: But then again you realize the advantage of what he's able to do with that equipment. Terry: Absolutely. The technology is so phenomenal. I've been very fortunate that I've been able to actually go use and play with or practice with the actual robotic instruments that was used on me. Andrew Schorr: That's incredible. Well, you have to let somebody run one of your locomotives sometime. Terry: (Laughter.) Andrew Schorr: Okay. So the last is thing, then, what's your view of the future? So you had really state-of-the-art medicine with the robotic approach for your prostate cancer. I understand you've just had a medical exam with Dr. Amling, things look great. Low, micro low PSA. How do you feel about the future and having benefitted from really state-of-the-art medicine? Terry: Very blessed, very, very fortunate. And to have such a phenomenal, a phenomenal team, and a surgeon that I can't speak enough about. I consider him my friend even, not only my doctor because he did such a phenomenal job with me. And my future, it looks good. I plan on living another 40 years, I hope. And with technology the way it is and the advancements in it it's so important to keep the funding coming in for the research that's being done now by all the organizations, all the hospitals out there, especially OHSU that I'm familiar with and have been there. The research that's being done, it's getting better and better and I think there's a light at the end of the tunnel just that really they'll hopefully have a cure for www.patientpower.info OHSU121511/AS/jf

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this. Andrew Schorr: Dr. Amling, you hear Terry's comments, of course. Must make you feel good, first of all, that he's doing so well, but also I know you share what he says and that is the hope for a cure for prostate cancer. Dr. Amling: Yeah, I think ultimately, all of us who treat men with prostate cancer every day that's the Holy Grail. We want to at some time to be able to say that we have some way to prevent or cure. Now we obviously cure it with some of the therapies that we've been talking about, but ideally what we want to do is to prevent it. And the other challenge would be to identify those tumors that truly need treatment versus those that may not necessarily need treatment. So there's lots of room from new research, new advancement in finding ways to prevent prostate cancer and identifying which are the more aggressive cancers as well. Prostate Cancer Research and Clinical Trials Andrew Schorr: Let's talk about your work at the Knight Cancer Institute and OHSU. Trials going on there. Now, there are some men where the prostate cancer has spread outside the prostate itself. Is there hope for them and the medicines and the trials that are being investigated? Dr. Amling: Mm-hmm. Yeah, it's actually a really exciting time in prostate cancer research for men with advanced disease. And by "advanced disease" I mean, as you said, those cancers that have spread beyond the prostate, so simply removing the prostate wouldn't cure the cancer. We have to deal with the cancer cells that have progressed to the rest of the body. And in those men the first line of treatment is generally hormonal therapy. Hormonal therapy is a tried-and-true way to treat prostate cancer, and we've been doing for, well, since, the 1960s and 1970s. But hormonal therapy has its own set of side effects, and we're continually looking for newer treatments beyond that. There's been research looking at chemotherapy in advanced prostate cancer as well. And more recently there are some trials that have shown successfully that things like immunotherapy, so stimulating with sort of in the way you might get a vaccine, stimulating your own immune system to attack the prostate cancer cells. And there's currently a drug on the market, approved by the FDA recently that is used for that purpose. We also have some relatively new trials that have just been published in the last year which are what we refer to sort of secondary hormonal therapies, so www.patientpower.info OHSU121511/AS/jf

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more potent hormonal therapies once the primary or standard hormonal therapy might stop working. And these are exciting treatments because many men who have advanced prostate cancer, the men that we want to slow that disease down, if we can continue to slow that disease down over many years then we can get those men to not have to worry about prostate cancer being their problem and focus on other things. So there are lots of new drugs in that to be used for a subset of men with more advanced disease, and we're actively investigating some of those here at OHSU. Andrew Schorr: When you take all this together, the drugs, new drugs that have come out, drugs in development, and new surgical procedures, and I imagine even refined radiation procedures for men with early prostate cancer, and the work that's going on to try to prevent it or predict which men need treatment at all, as a urologist and as a chief of urology, are you encouraged? Dr. Amling: I'm very encouraged. I see a lot of advances just in the last five or 10 years in terms in terms of our impact on prostate cancer, and our philosophy in terms of how to treat early stage disease, that's evolved as well. So we have better treatments, more technologically advanced treatments. We know some men don't need treatment for early stage disease. And then for advanced disease we have newer drugs that are being investigated and coming on the market. Just as recently, within the last couple of years and more on the near horizon as well, so yes, we're very encouraged about the progress in prostate cancer treatment. I think there are only new and better things to come down the road in the relatively near future. Getting a Second Opinion Andrew Schorr: Very encouraging. One last thing. This is a complicated field I'm sure for urologists and it's super complicated for a man who confronts this all of a sudden. So are you in favor of men and you are okay with men even if they come to you, you're chief of urology, getting second opinions or even third opinions? Dr. Amling: Oh, I encourage second and third opinions, especially in prostate cancer where there's a lot of different options and a lot of different treatments. And I always encourage all men to get a second or even third or fourth opinion, and I see men all the time who come to me as their third or fourth opinion. So what I tell men is that when you are unfortunately sort of left with a diagnosis of, “I have prostate cancer,” what you want www.patientpower.info OHSU121511/AS/jf

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to do is get the most information you can about it and gather as much opinions and as much information as you can before you make a decision about how you're going to pursue with treatment and which treatment is right for you. And I think second and third and fourth opinions are often a good way to do that. Andrew Schorr: Dr. Christopher Amling, division chief of urology at OHSU and the Knight Cancer Institute there, thank you, for being with us. And I know Terry thanks you. I want to give the last word to Terry Page. Advice from Terry Terry, we've been hearing from you and your doctor. We've been learning about robotic surgery. There are men, maybe partners, spouses, listening too who are saying, gee, should we seriously consider this, and should we consider it with someone who has done a lot of it, someone like Dr. Amling. What would you say? Every man is different, have to make their own decision, but as far as it being something they consider, what would you say to them? Terry: You said it. It's every man's decision and every man's situation is different. I feel that you should, speaking from experience, get as much knowledge into your own self. Get as much knowledge about what you are going through. What is prostate cancer? What are your options? What is going to be the best treatment for you? You can't make that decision until you have a good source of information. Talk to more than one doctor, talk to two doctors, talk to three doctors, like I did. I chose robotics for my own self because of the stage that my cancer was in--the treatments that I was looking at, what damage or what it would do to my prostate. So that was my decision to take and go with the radical prostatectomy. And choosing the robotics was a no-brainer because of the short term of healing, loss of blood loss, and the intense magnification of during the surgery on how you can fine tune things. Those were my situations and my choices I made. Every individual should go through as much as they can, pick out the one thing that is best for you, for your longevity, for your health, what you're comfortable with, and also have a very good support in your family, friends and with your doctor. Andrew Schorr: Great, great advice. Terry Page, all the best to you now, going on with your life. Every time I see a freight train go by I usually wave, but now I'm going to think that I'm waving at you, okay? Terry: Well, I hope so, and if I can see you or recognize you I'll even toot the horn for you. www.patientpower.info OHSU121511/AS/jf

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Andrew Schorr: Okay. Terry Page, thank you so much for joining us. Thanks to Dr. Amling for being with us and explaining robotic surgery. This is what we do on Patient Power, connect you with experts and inspiring patients like Terry Page. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that’s how you’ll get care that’s most appropriate for you.

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