WEBVTT 1 00:00:00.063 --> 00:00:02.220 This podcast is created by Coelis. 2 00:00:02.720 --> 00:00:06.900 What I've learned about prostate biopsies is that there's no perfect solution. 3 00:00:07.040 --> 00:00:07.863 We've come a long way, 4 00:00:08.084 --> 00:00:09.429 but there's still further to go, 5 00:00:09.730 --> 00:00:12.220 and I'm sure the technology will change in time. 6 00:00:12.720 --> 00:00:13.040 Prostate. 7 00:00:13.061 --> 00:00:13.400 Prostate. 8 00:00:14.606 --> 00:00:15.040 Prostate. 9 00:00:15.140 --> 00:00:15.340 Prostate. 10 00:00:15.500 --> 00:00:15.900 Prostate. 11 00:00:20.281 --> 00:00:21.004 Dear listeners, 12 00:00:21.305 --> 00:00:23.813 welcome to a new episode of Prostatalk, 13 00:00:24.194 --> 00:00:27.228 the podcast where we boldly go where few have gone before, 14 00:00:27.490 --> 00:00:29.040 into the depths of urology. 15 00:00:29.400 --> 00:00:29.942 I'm your host, 16 00:00:30.003 --> 00:00:30.324 Thomas, 17 00:00:30.605 --> 00:00:32.955 and self-proclaimed urology enthusiast, 18 00:00:33.336 --> 00:00:36.640 here to guide you through the wild and wonderful world of prostates. 19 00:00:36.940 --> 00:00:37.221 Today, 20 00:00:37.462 --> 00:00:40.211 our guest is none other than the illustrious Dr. 21 00:00:40.272 --> 00:00:40.854 Simon Bott, 22 00:00:41.496 --> 00:00:47.700 hailing all the way from the UK with his charming British accent and an abundance of urological wisdom. 23 00:00:48.460 --> 00:00:50.648 We are diving deep in the world of urology, 24 00:00:50.949 --> 00:00:52.515 exploring elastic fusion, 25 00:00:52.796 --> 00:00:53.016 yes, 26 00:00:53.157 --> 00:00:53.679 that's right, 27 00:00:54.120 --> 00:00:56.347 merging MRI and ultrasound images, 28 00:00:56.689 --> 00:00:58.695 3D mapping technologies for the prostate, 29 00:00:59.277 --> 00:01:05.639 and ingenious techniques to counteract those pisky patient movements that throw off diagnosis exams. 30 00:01:06.100 --> 00:01:06.643 After all, 31 00:01:06.803 --> 00:01:07.827 when the patient moves, 32 00:01:07.827 --> 00:01:08.550 the process moves, 33 00:01:08.932 --> 00:01:12.233 and nobody wants a diagnosis based on a prostate in motion. 34 00:01:12.920 --> 00:01:13.041 So, 35 00:01:13.362 --> 00:01:13.885 sit back, 36 00:01:14.388 --> 00:01:14.769 relax, 37 00:01:15.091 --> 00:01:16.719 and prepare to have your minds blow. 38 00:01:17.116 --> 00:01:19.024 By the wonders of the prostate world, 39 00:01:19.345 --> 00:01:21.052 let's get ready to talk prostates! 40 00:01:23.225 --> 00:01:23.707 Hi Dr. 41 00:01:23.747 --> 00:01:24.008 Botts, 42 00:01:24.309 --> 00:01:25.694 we are really pleased to welcome you. 43 00:01:26.075 --> 00:01:28.484 We are live from the 2024 EU Congress, 44 00:01:29.025 --> 00:01:31.233 the place to be on this beginning of year. 45 00:01:31.715 --> 00:01:33.884 How are you today and how the Congress is going? 46 00:01:34.664 --> 00:01:35.066 I'm great, 47 00:01:35.106 --> 00:01:35.448 thank you. 48 00:01:35.549 --> 00:01:40.249 It's really good to be here at the conference with so many other urologists and urology colleagues. 49 00:01:40.389 --> 00:01:42.236 It's lovely to be in Paris particularly. 50 00:01:42.597 --> 00:01:44.504 I'm a really big fan of France, 51 00:01:45.205 --> 00:01:46.188 so I'm having a great time, 52 00:01:46.228 --> 00:01:46.529 thank you. 53 00:01:46.730 --> 00:01:47.493 We are glad too. 54 00:01:48.075 --> 00:01:48.877 Before to start, 55 00:01:49.279 --> 00:01:51.863 I heard that you spent time in French Halp. 56 00:01:52.353 --> 00:01:54.623 and try the French gastronomy. 57 00:01:55.105 --> 00:01:55.628 Am I wrong? 58 00:01:56.130 --> 00:01:57.013 I love French food. 59 00:01:57.315 --> 00:01:58.238 I love French wine. 60 00:01:58.258 --> 00:01:59.182 I love French cheese. 61 00:01:59.624 --> 00:02:00.527 I like French people. 62 00:02:00.748 --> 00:02:01.111 Yeah. 63 00:02:02.118 --> 00:02:02.742 French food. 64 00:02:04.090 --> 00:02:05.094 And more seriously, 65 00:02:05.234 --> 00:02:07.985 could you please tell us more about you and who is Dr. 66 00:02:08.045 --> 00:02:08.588 Simon Bott? 67 00:02:09.571 --> 00:02:11.576 So I'm a consultant urologist. 68 00:02:11.897 --> 00:02:13.462 I work at Frimley Park Hospital, 69 00:02:13.602 --> 00:02:15.467 which is just outside London in the UK. 70 00:02:16.495 --> 00:02:22.272 We are one of the busiest or largest hospitals in the country outside the teaching hospitals. 71 00:02:22.893 --> 00:02:27.024 And I have been a consultant since 2008. 72 00:02:27.485 --> 00:02:30.071 But I've been doing prostate biopsies since the late 1990s. 73 00:02:31.258 --> 00:02:31.680 Perfect. 74 00:02:31.680 --> 00:02:33.170 So an expert in prostate, 75 00:02:33.251 --> 00:02:33.412 right? 76 00:02:34.217 --> 00:02:34.801 I've done a lot. 77 00:02:35.063 --> 00:02:36.231 If that makes me an expert, 78 00:02:36.231 --> 00:02:36.412 possibly. 79 00:02:37.921 --> 00:02:38.725 Just to be curious, 80 00:02:39.147 --> 00:02:41.156 why did you choose urology during your studies? 81 00:02:41.478 --> 00:02:44.216 Do you have a speciality like biopsy or treatments? 82 00:02:44.758 --> 00:02:48.396 The first job I did when I qualified as a doctor was in urology, 83 00:02:49.300 --> 00:02:53.196 and I liked urology particularly because of the variety of conditions we treat. 84 00:02:54.018 --> 00:02:57.564 So whether it's prostate cancer or kidney cancer or bladder cancer, 85 00:02:57.624 --> 00:03:02.473 whether it's infections or stones or benign enlargement or infertility or andrology, 86 00:03:02.513 --> 00:03:04.316 there's a huge spectrum of things. 87 00:03:04.837 --> 00:03:07.223 And there's also a lot you can do with your hands. 88 00:03:07.484 --> 00:03:08.727 So it's very good operating, 89 00:03:09.168 --> 00:03:12.596 be that with a microscope or a robot or with a scalpel. 90 00:03:13.657 --> 00:03:17.548 And there's also a lot of intellectual interest because unlike some specialities, 91 00:03:17.608 --> 00:03:20.536 we don't have physicians who look after urology. 92 00:03:21.137 --> 00:03:25.918 With the heart you have cardiologists who look after the physician side and you have surgeons who do the surgical side. 93 00:03:26.219 --> 00:03:27.505 In urology it's just us, 94 00:03:27.545 --> 00:03:28.770 we can do as much or as little. 95 00:03:29.132 --> 00:03:32.407 For me it was a natural speciality to choose and I love it to this day. 96 00:03:32.769 --> 00:03:34.523 I still wake up on Monday morning and think, 97 00:03:34.583 --> 00:03:35.431 good I'm going to work. 98 00:03:35.793 --> 00:03:39.530 So a speciality where you can have the whole process from A to Z? 99 00:03:40.093 --> 00:03:40.474 Correct, 100 00:03:40.756 --> 00:03:40.896 yeah. 101 00:03:40.976 --> 00:03:42.644 From the start to finish we see the patient, 102 00:03:42.684 --> 00:03:43.106 yeah. 103 00:03:43.367 --> 00:03:44.050 And all ages, 104 00:03:44.070 --> 00:03:46.851 from children to the very eldest patients. 105 00:03:47.280 --> 00:03:48.986 In the previous episode of Prostatalk, 106 00:03:49.067 --> 00:03:51.924 we discussed the benefit of the Transparenil route. 107 00:03:52.516 --> 00:03:52.697 Dr. 108 00:03:52.777 --> 00:03:53.078 Proth, 109 00:03:53.138 --> 00:03:59.453 I've heard that you have been one of the first in UK to adopt the Transparenil approach under local anesthesia. 110 00:03:59.836 --> 00:04:00.423 Is that true? 111 00:04:01.600 --> 00:04:01.781 Yes, 112 00:04:01.781 --> 00:04:06.134 I was actually the first person to describe the template technique through the perineum. 113 00:04:06.876 --> 00:04:08.244 So my journey started, 114 00:04:08.244 --> 00:04:08.626 as I said, 115 00:04:08.626 --> 00:04:08.847 in the 116 00:04:09.712 --> 00:04:11.019 1990s. And at that stage, 117 00:04:11.059 --> 00:04:12.706 we were doing truss biopsies, 118 00:04:12.746 --> 00:04:14.594 so an ultrasound probe in the rectum, 119 00:04:14.654 --> 00:04:18.155 and then blindly firing needles through the rectum to the prostate. 120 00:04:18.877 --> 00:04:20.742 And I was struck at this point, 121 00:04:21.183 --> 00:04:23.008 even as a very junior urologist, 122 00:04:23.008 --> 00:04:26.336 at how poor this technique was really for diagnosing cancer. 123 00:04:26.916 --> 00:04:28.361 Because we couldn't see the cancer, 124 00:04:28.802 --> 00:04:33.536 we just blindly fired the needles in hoping we'd hit something and we didn't even know whether it was there or not. 125 00:04:33.656 --> 00:04:37.016 We just had the PSA that of course can be elevated due to other causes. 126 00:04:37.436 --> 00:04:43.476 So what I showed in my very early training was that we missed a lot of cancers using the transrectal approach. 127 00:04:43.918 --> 00:04:48.216 So we missed a lot of cancers in the front of the prostate because we simply didn't biopsy that part of the prostate. 128 00:04:48.714 --> 00:04:52.752 So then I worked at Guildford Hospital where they were doing a lot of brachytherapy. 129 00:04:52.852 --> 00:04:53.990 They're famous for brachytherapy. 130 00:04:54.552 --> 00:04:57.482 And using the brachytherapy technique with a grid, 131 00:04:57.883 --> 00:05:00.452 we decided then to adopt this to do a biopsy. 132 00:05:00.933 --> 00:05:03.825 So the brachytherapy grid is placed over the perineum, 133 00:05:03.925 --> 00:05:05.632 just like we see a template biopsy now. 134 00:05:06.012 --> 00:05:06.394 And we thought, 135 00:05:06.394 --> 00:05:06.514 well, 136 00:05:06.514 --> 00:05:10.892 why don't we use this grid to make sure we adequately sample the whole prostate, 137 00:05:11.152 --> 00:05:12.237 the anterior prostate, 138 00:05:12.719 --> 00:05:13.623 and posteriorly, 139 00:05:14.065 --> 00:05:15.552 you can take as many biopsies as you like. 140 00:05:16.056 --> 00:05:17.970 And so we adopted this in people who'd had... 141 00:05:18.480 --> 00:05:20.628 The trans-rectal biopsy previously, 142 00:05:21.050 --> 00:05:22.556 where the biopsies were negative, 143 00:05:22.877 --> 00:05:25.588 but we still had a concern they may have prostate cancer. 144 00:05:26.010 --> 00:05:36.688 And we showed that using that technique we'd pick up an extra 40% of patients with prostate cancer whom previously we told them they probably had not got cancer based on the trust biopsy. 145 00:05:37.612 --> 00:05:41.928 But this meant we had to give patients a general anaesthetic because we were taking a lot of biopsy cores, 146 00:05:42.470 --> 00:05:43.756 perhaps 60 to 80 cores, 147 00:05:43.776 --> 00:05:47.699 sometimes even in excess of 100 in patients who had very large prostates. 148 00:05:48.184 --> 00:05:49.369 So this was uncomfortable. 149 00:05:49.830 --> 00:05:51.296 It was general anaesthetic. 150 00:05:51.316 --> 00:05:52.360 It was a day case procedure. 151 00:05:52.480 --> 00:05:56.460 It took up operating theatre time and patients took a few days to recover. 152 00:05:56.900 --> 00:05:58.948 Quite a high risk of complications, 153 00:05:58.968 --> 00:06:00.675 particularly urinary retention, 154 00:06:01.297 --> 00:06:02.060 much less sepsis. 155 00:06:02.100 --> 00:06:05.940 We realised this very early on that the sepsis rates were considerably reduced. 156 00:06:06.420 --> 00:06:08.469 But clearly it was a lot of work for the urologist, 157 00:06:08.529 --> 00:06:09.653 for the pathologist, 158 00:06:10.155 --> 00:06:11.400 and it was worse for the patient. 159 00:06:11.680 --> 00:06:15.459 So when I was invited to be involved with the PROMIS study in the UK, 160 00:06:16.290 --> 00:06:19.064 where MRI was going to be shown to be effective, 161 00:06:19.647 --> 00:06:20.264 I was delighted. 162 00:06:20.444 --> 00:06:23.104 Now we all of a sudden had a target to aim at. 163 00:06:23.564 --> 00:06:26.664 And this meant that rather than taking 60 to 80 biopsy cores, 164 00:06:27.045 --> 00:06:30.444 we could reduce the number of cores right down to aim for a target, 165 00:06:30.945 --> 00:06:33.044 a target that we think is clinically significant, 166 00:06:33.765 --> 00:06:39.084 and we can also avoid biopsies in some patients and also miss insignificant cancers in others. 167 00:06:39.424 --> 00:06:40.877 So it seemed a natural progression, 168 00:06:41.180 --> 00:06:41.644 therefore. 169 00:06:42.076 --> 00:06:46.172 then to use the MR to target the lesion in the prostate, 170 00:06:46.793 --> 00:06:49.106 but of course we were using initially our brains, 171 00:06:49.106 --> 00:06:50.172 a cognitive biopsy. 172 00:06:50.964 --> 00:06:53.553 and once you've done a few thousand biopsies, 173 00:06:53.573 --> 00:06:55.400 then I think your brain is pretty good at it, 174 00:06:56.021 --> 00:06:57.387 but even for the small lesions, 175 00:06:57.407 --> 00:07:00.400 it's not as good as the technology we have now. 176 00:07:01.041 --> 00:07:09.240 So I was delighted when I went around the EAU in 2017 to look at all the different fusion software technologies out there, 177 00:07:09.722 --> 00:07:11.350 and I essentially had a blank canvas. 178 00:07:11.410 --> 00:07:13.460 I could choose whichever one I wanted to get, 179 00:07:13.940 --> 00:07:14.241 and 180 00:07:14.683 --> 00:07:19.100 I settled on the Coriolis Trinity system because I thought it made the most sense. 181 00:07:19.550 --> 00:07:28.328 It made the most sense to track the organ rather than to rely on some electromagnetic field or a satellite somewhere to tell me where I should be targeting. 182 00:07:28.888 --> 00:07:29.650 Very interesting. 183 00:07:30.092 --> 00:07:32.820 So you mentioned MRI and you mentioned fusion. 184 00:07:33.201 --> 00:07:34.224 So let's talk about, 185 00:07:34.244 --> 00:07:34.805 if you want, 186 00:07:34.986 --> 00:07:35.648 fusion biopsy. 187 00:07:36.049 --> 00:07:42.848 It can be interesting to speak about the learning curve when you adopted this new system and this new approach. 188 00:07:43.288 --> 00:07:47.668 Can you tell us about the learning curve about this new approach in your daily practice? 189 00:07:48.340 --> 00:07:48.721 I think 190 00:07:49.102 --> 00:07:56.858 I've learned the techniques as I've progressed during my career so I think it's quite difficult for me to say what the learning curve is because I haven't really 191 00:07:57.401 --> 00:08:02.815 I've gone to the learning curve in 15 years so I think it's important you can interpret an MRI scan 192 00:08:03.741 --> 00:08:05.627 But once you can interpret an MRI scan, 193 00:08:05.667 --> 00:08:07.092 you can contour the prostate, 194 00:08:07.554 --> 00:08:14.094 then taking the biopsies is relatively straightforward because you can always do a virtual biopsy before you take the biopsy. 195 00:08:14.437 --> 00:08:18.675 So you always know you're going to hit the target once you know where the target is, 196 00:08:18.897 --> 00:08:20.312 and that's all about the contouring. 197 00:08:20.716 --> 00:08:26.475 So I think the learning curve in many ways is about interpreting an MRI scan rather than learning the technique of the biopsy. 198 00:08:27.283 --> 00:08:29.730 Even if I think I already know the answer, 199 00:08:30.091 --> 00:08:32.699 do you prefer elastic fusion than rigid fusion? 200 00:08:33.421 --> 00:08:33.622 Yes, 201 00:08:33.944 --> 00:08:37.140 I have used both and I just think elastic fusion is more accurate. 202 00:08:38.112 --> 00:08:39.636 If you know you're hitting the target, 203 00:08:39.676 --> 00:08:40.981 you take fewer biopsies, 204 00:08:41.422 --> 00:08:43.348 that's better for the patient because it's less uncomfortable. 205 00:08:44.088 --> 00:08:46.279 It means you should reduce your complication rates, 206 00:08:46.459 --> 00:08:47.223 particularly of bleeding, 207 00:08:47.243 --> 00:08:48.348 but also probably infection. 208 00:08:49.030 --> 00:08:50.548 And it means less work for the pathologist. 209 00:08:50.808 --> 00:08:52.716 And we're very short of pathologists in the UK, 210 00:08:52.977 --> 00:08:55.808 so my pathologist isn't looking at lots of biopsies. 211 00:08:55.888 --> 00:08:59.708 He or she can look at more patients'biopsies and therefore get through more work. 212 00:09:00.048 --> 00:09:00.711 In another way, 213 00:09:01.072 --> 00:09:05.268 would you say that it allows you to do more personalised care to your patients? 214 00:09:05.888 --> 00:09:06.390 Absolutely, 215 00:09:06.490 --> 00:09:11.427 because you can target the number of biopsies you need to take based on the lesion size, 216 00:09:11.808 --> 00:09:13.353 based on the prostate size, 217 00:09:13.754 --> 00:09:15.580 based on the stage of the disease, 218 00:09:16.102 --> 00:09:18.500 and based on the patient and what you're likely to do with them. 219 00:09:19.024 --> 00:09:23.267 So in a 50-year-old man who's going to have a radical prostatectomy or radical therapy of some kind, 220 00:09:23.628 --> 00:09:27.022 then I'm going to take more biopsies around the neurovascular bundles. 221 00:09:27.604 --> 00:09:29.533 In a patient who might be suited for brachytherapy, 222 00:09:29.594 --> 00:09:31.623 I might take more biopsies around the urethra. 223 00:09:32.152 --> 00:09:35.082 But in an elderly gentleman who's got a T3A tumour, 224 00:09:35.102 --> 00:09:35.965 perhaps anteriorly, 225 00:09:36.386 --> 00:09:43.636 then I can just take two or three knowing I've hit the target without taking any other biopsies and that clearly reduces the discomfort for him, 226 00:09:44.038 --> 00:09:46.528 the operative time for me and the pathology time. 227 00:09:47.300 --> 00:09:47.481 Well, 228 00:09:47.542 --> 00:09:48.649 I assume you won't go back, 229 00:09:48.831 --> 00:09:49.032 right? 230 00:09:49.440 --> 00:09:49.652 Never. 231 00:09:50.777 --> 00:09:51.912 I think the only way is forward. 232 00:09:52.373 --> 00:09:54.712 We should work on trying to improve all the time. 233 00:09:55.601 --> 00:09:55.971 You're right. 234 00:09:56.312 --> 00:09:59.025 I have just one question about MRI images, 235 00:09:59.387 --> 00:10:00.392 because I understand it. 236 00:10:00.892 --> 00:10:05.932 MRI images are the key point for achieving a correct and precise elastic fusion, 237 00:10:06.112 --> 00:10:07.692 and it all matters about precision. 238 00:10:08.294 --> 00:10:09.351 How do you receive them? 239 00:10:09.653 --> 00:10:11.784 Is it you who read and annotate them, 240 00:10:11.884 --> 00:10:13.512 or do you work with radiologists? 241 00:10:13.692 --> 00:10:15.532 What is the process in your hospital? 242 00:10:16.253 --> 00:10:22.909 So all our MRI scans are reviewed by a radiologist and they will report any lesions that they see. 243 00:10:23.833 --> 00:10:29.570 I then review the images myself without reading the report and then I check that what I see is what they see. 244 00:10:30.190 --> 00:10:31.575 Sometimes I add them on. 245 00:10:31.796 --> 00:10:37.396 I will always biopsy a lesion that a radiologist has reported and they will then mark, 246 00:10:37.616 --> 00:10:48.869 they will either take a picture of the slice of the prostate on the MR that has a lesion on it or they'll write in the report which slice it is and which sequence it is and then I will then biopsy that lesion. 247 00:10:49.411 --> 00:10:49.961 Interesting. 248 00:10:50.327 --> 00:10:50.470 Well... 249 00:10:50.889 --> 00:10:54.016 When I did research for preparing this interview, 250 00:10:54.537 --> 00:10:58.486 there was an expression that came back a few times about you. 251 00:10:58.786 --> 00:11:00.820 It's the patient-friendly position. 252 00:11:01.122 --> 00:11:01.666 What do you mean? 253 00:11:02.326 --> 00:11:09.146 So I think a nicer way for a patient to undergo a prostate biopsy is in the left lateral position rather than the lithotomy position. 254 00:11:10.215 --> 00:11:12.023 And there are several reasons for this. 255 00:11:12.264 --> 00:11:16.820 I think that in the left lateral position the patient cannot see all the needles, 256 00:11:16.881 --> 00:11:21.098 the biopsy gun etc that tend to put people off having a biopsy. 257 00:11:21.561 --> 00:11:29.480 And there's actually been a study that has shown that if you patient sees the needles and things before the biopsy they suffer with more pain than if they don't see it. 258 00:11:29.903 --> 00:11:33.418 So I think if you have the patient facing away from you they can't see what you're doing. 259 00:11:34.282 --> 00:11:36.671 I also have a nurse talking to the patient, 260 00:11:36.771 --> 00:11:37.454 distracting them, 261 00:11:38.137 --> 00:11:42.940 and I have Spotify and a choice of music so that patients can listen to whatever music they like. 262 00:11:43.001 --> 00:11:47.362 And I think if the patient is comfortable and relaxed and not seeing what you're doing, 263 00:11:47.965 --> 00:11:50.638 then it makes the whole procedure much more comfortable. 264 00:11:51.202 --> 00:12:00.863 And that means I can get on quicker and get the biopsy over quicker and we've shown that patients by and large will tolerate the procedure very well without too much discomfort. 265 00:12:01.144 --> 00:12:06.881 Fascinating and is it the common way to perform transperineal biopsies under local anesthesia? 266 00:12:07.677 --> 00:12:11.288 I think in some ways the lithotomy position is perhaps easier to do, 267 00:12:12.010 --> 00:12:15.946 but I just think that the left lateral position is nicer for the patient. 268 00:12:16.509 --> 00:12:18.880 And I certainly think those people who do do the lithotomy position, 269 00:12:18.960 --> 00:12:22.416 once they've acquired the skill to do a biopsy in the lithotomy position, 270 00:12:22.798 --> 00:12:27.234 it's not very difficult just rotating the patient into the left lateral and doing it with the left lateral position. 271 00:12:27.794 --> 00:12:30.754 And do you train your team like that or peer like that? 272 00:12:31.531 --> 00:12:34.745 I train all my registrars to do it in the left lateral position, 273 00:12:34.765 --> 00:12:34.886 yeah. 274 00:12:35.529 --> 00:12:40.286 And do you know if other urologists are using this technique or it's just your particular thing? 275 00:12:40.949 --> 00:12:41.069 No, 276 00:12:41.270 --> 00:12:49.006 I've had several people come down from a number of hospitals to see how I do it and I know that a number of hospitals in London now do it in the left lateral position. 277 00:12:49.646 --> 00:12:50.008 as well. 278 00:12:50.409 --> 00:12:51.895 So I think it's gaining popularity. 279 00:12:52.316 --> 00:12:55.127 It's just a little bit harder because it's a little bit more freehand, 280 00:12:55.670 --> 00:12:57.297 but you can acquire the skill over time. 281 00:12:57.377 --> 00:12:59.809 So once you've done several biopsies in the thotomy position, 282 00:13:00.252 --> 00:13:04.551 then I think it's reasonable to turn the patient into the left lateral and try and do the left lateral position. 283 00:13:05.093 --> 00:13:08.527 What are the clinical advantages of this position? 284 00:13:08.527 --> 00:13:12.142 I think the advantage of this position are the patient finds it more comfortable. 285 00:13:12.911 --> 00:13:13.433 Therefore, 286 00:13:13.553 --> 00:13:15.521 you can take better quality biopsies, 287 00:13:15.883 --> 00:13:17.710 which means you can take fewer biopsies. 288 00:13:18.230 --> 00:13:23.770 And that means the whole procedure is over quicker with less complications and more time to do more patients. 289 00:13:24.431 --> 00:13:27.510 So I prefer the left lateral position and so do the patients. 290 00:13:27.770 --> 00:13:30.478 And I think the patients prefer it because they're more relaxed, 291 00:13:31.080 --> 00:13:32.585 because they're listening to music, 292 00:13:33.026 --> 00:13:34.290 because you're distracting them. 293 00:13:34.510 --> 00:13:35.990 We call it vocal anesthesia. 294 00:13:36.190 --> 00:13:40.150 I think it's really important to have a vocal anesthesia as well as local anesthesia. 295 00:13:40.533 --> 00:13:41.803 So have the patient talking, 296 00:13:42.307 --> 00:13:42.690 which is normal. 297 00:13:42.690 --> 00:13:52.930 It's very easy to do and then the patient have their mind taken off what's going on behind them and then I can then do the biopsies without them being too anxious and this stops them moving. 298 00:13:53.615 --> 00:13:54.095 Of course, 299 00:13:54.176 --> 00:13:55.938 with the coalesce system as well, 300 00:13:55.998 --> 00:13:58.401 if the patient does move because you're tracking the organ, 301 00:13:58.902 --> 00:14:01.665 not the needle or the ultrasound probe, 302 00:14:02.026 --> 00:14:03.548 then even if the patient does move, 303 00:14:03.688 --> 00:14:08.514 it's not a problem because you just do another sweep to the prostate gland and you realize that the patient's moved. 304 00:14:09.114 --> 00:14:18.714 So do you have any tips and tricks for urologists who are listening us right now and who wants to set up more patients from the approach and vocal anesthesia? 305 00:14:19.317 --> 00:14:22.634 I think it's about the whole atmosphere in the biopsy room when you're doing it. 306 00:14:23.098 --> 00:14:24.022 And this is about, 307 00:14:24.203 --> 00:14:24.645 as I say, 308 00:14:24.725 --> 00:14:26.994 putting music on which they want to listen to, 309 00:14:27.717 --> 00:14:29.123 nothing too hardcore perhaps. 310 00:14:29.585 --> 00:14:32.117 Sometimes if patients say I don't mind I put on Pink Floyd, 311 00:14:32.177 --> 00:14:32.901 Comfortably Numb, 312 00:14:33.262 --> 00:14:34.388 because I think that's appropriate. 313 00:14:34.930 --> 00:14:43.067 And then it's about distracting the patient and ensuring all your team know what they're doing so there's a sort of air of calm in the room. 314 00:14:43.569 --> 00:14:46.321 I tell patients every time I do anything that might be uncomfortable, 315 00:14:46.824 --> 00:14:50.877 I tell patients before they actually have the biopsy exactly what's involved. 316 00:14:51.538 --> 00:14:56.174 and I constantly reassure them as I'm going through the process that I'm hitting the target, 317 00:14:56.815 --> 00:14:58.973 that I've only got one or two more biopsies to do, 318 00:14:59.534 --> 00:15:04.454 and then most patients find the whole experience not something they necessarily want to repeat every week, 319 00:15:04.756 --> 00:15:06.214 but they certainly find it tolerable. 320 00:15:06.755 --> 00:15:10.254 So what I understand is you are very patient-centric, 321 00:15:10.475 --> 00:15:15.294 and it's very reassuring for the patient because we are all patient one day. 322 00:15:15.494 --> 00:15:16.406 So thank you for that, 323 00:15:16.588 --> 00:15:16.791 Dr. 324 00:15:16.811 --> 00:15:17.014 Simon. 325 00:15:18.146 --> 00:15:19.431 Before to finish this interview, 326 00:15:19.753 --> 00:15:22.002 could you tell us more about your next plan? 327 00:15:22.737 --> 00:15:30.582 So I think what I've learned about prostate biopsies over the last many years is that there's no perfect answer, 328 00:15:30.602 --> 00:15:31.726 there's no perfect solution. 329 00:15:31.766 --> 00:15:34.738 We've come a long way from blind trust biopsies, 330 00:15:35.039 --> 00:15:39.636 but there's still further to go and I'm sure the technology will change in time. 331 00:15:39.958 --> 00:15:43.896 In five to ten years we may be doing things differently like we did five to ten years ago. 332 00:15:44.779 --> 00:15:46.687 So I think there's lots of areas to improve on. 333 00:15:46.968 --> 00:15:48.454 We can improve on the anaesthetic. 334 00:15:49.190 --> 00:15:50.455 Whilst it is tolerable, 335 00:15:50.956 --> 00:15:53.164 it is a bit uncomfortable having a prostate biopsy. 336 00:15:53.746 --> 00:16:06.544 I have looked at a number of ways of trying to anaesthetise the prostate better and I've acquired the help of a number of anaesthetists who specialise in regional anaesthetic blocks and we've tried a number of different blocks but I'm afraid none of them work very well. 337 00:16:07.006 --> 00:16:09.002 But I think that we can improve on that. 338 00:16:09.606 --> 00:16:15.426 I think that using the coaxial needle rather than just purely going through the grid helps. 339 00:16:15.772 --> 00:16:18.970 because if you put a carotid needle and you've got a small to medium-sized prostate, 340 00:16:19.090 --> 00:16:21.070 you can just put one carotid needle in the left, 341 00:16:21.470 --> 00:16:22.680 and then when you do the right-hand side, 342 00:16:22.680 --> 00:16:25.379 you take the carotid needle out and put it on the other side, 343 00:16:25.620 --> 00:16:30.150 so you're only puncturing the skin twice in a sort of small to medium-sized prostate. 344 00:16:30.270 --> 00:16:30.949 I think that helps. 345 00:16:31.530 --> 00:16:34.610 And I think that the MRI quality is improving, 346 00:16:35.332 --> 00:16:38.970 so I think we're going to be picking up more lesions as time goes by. 347 00:16:39.831 --> 00:16:40.795 Currently at my hospital, 348 00:16:40.815 --> 00:16:42.764 we have quite an old 1.5 349 00:16:43.186 --> 00:16:43.990 Tesla MRI, 350 00:16:44.660 --> 00:16:45.167 and I think... 351 00:16:45.525 --> 00:16:54.514 When we get our new MRI scanner we'll get a 3T but I think even the new style 1.5 Tesla MRIs are better than the old-fashioned 352 00:16:55.236 --> 00:16:58.749 3T MRI scan so even that will be a major step forward so I think 353 00:16:59.191 --> 00:17:10.744 MRI technology is improving and the other thing I'm looking at now in the future is AI both in terms of interpreting MRI but also potentially contouring the prostate and contouring the lesion. 354 00:17:11.307 --> 00:17:14.352 It takes five to ten minutes to contour a prostate it's not a big deal 355 00:17:14.748 --> 00:17:16.236 But if I can get AI to do that, 356 00:17:16.457 --> 00:17:17.865 that's going to save us all time. 357 00:17:18.366 --> 00:17:21.026 And if AI is interpreting the MRI in the first place, 358 00:17:21.426 --> 00:17:24.066 the AI can contour everything it sees as being abnormal. 359 00:17:24.186 --> 00:17:26.146 But maybe that's a little bit further away, 360 00:17:26.266 --> 00:17:29.120 but we are using AI now in trials, 361 00:17:29.140 --> 00:17:30.346 and I think that is the future. 362 00:17:30.946 --> 00:17:33.446 Thanks a lot for your time and this precious information. 363 00:17:34.107 --> 00:17:36.506 Before to leave and go back downstairs to the Congress, 364 00:17:37.468 --> 00:17:40.366 I'd like to ask my guest a last-minute question. 365 00:17:41.146 --> 00:17:41.267 So, 366 00:17:42.354 --> 00:17:44.206 we spoke a lot about music. 367 00:17:44.673 --> 00:17:47.180 And the importance of music for vocal anesthesia. 368 00:17:47.702 --> 00:17:49.286 What is your song of the moment, 369 00:17:49.487 --> 00:17:49.728 Dr. 370 00:17:49.768 --> 00:17:49.989 Bud? 371 00:17:52.776 --> 00:17:53.438 I like 372 00:17:55.003 --> 00:17:56.668 Tom O'Dell's Black Friday. 373 00:17:56.728 --> 00:17:57.490 That's my song of the moment. 374 00:17:58.312 --> 00:17:59.235 But I will listen to, 375 00:17:59.937 --> 00:18:00.739 my default is 376 00:18:01.481 --> 00:18:04.510 1980s because that's my era and that's happy music on the whole. 377 00:18:06.263 --> 00:18:07.828 But if you listen to that every day, 378 00:18:08.409 --> 00:18:08.911 every week, 379 00:18:09.452 --> 00:18:10.756 every year for 30 years, 380 00:18:10.776 --> 00:18:11.971 it gets a bit monotonous. 381 00:18:12.378 --> 00:18:15.657 So I'm listening to modern music as well. 382 00:18:16.441 --> 00:18:19.056 Thanks a lot and see you in the next episode, 383 00:18:19.056 --> 00:18:19.338 I hope. 384 00:18:19.621 --> 00:18:20.613 Thank you very much for having me. 385 00:18:21.038 --> 00:18:21.630 Merci beaucoup. 386 00:18:22.239 --> 00:18:24.735 Huge thanks to our dedicated listeners. 387 00:18:25.278 --> 00:18:26.744 If you enjoyed the podcast, 388 00:18:26.945 --> 00:18:29.575 make sure to subscribe for more captivating content. 389 00:18:30.238 --> 00:18:31.977 Your support means the world. 390 00:18:33.766 --> 00:18:35.432 If you found this informative, 391 00:18:35.673 --> 00:18:36.536 quick favor please, 392 00:18:36.897 --> 00:18:38.182 drop a 5 star review. 393 00:18:38.642 --> 00:18:42.062 Your feedback helps us grow and deliver credit insights. 394 00:18:43.043 --> 00:18:44.582 Have topics you'd love us to cover? 395 00:18:45.042 --> 00:18:48.402 Share your ideas in the comments or connect with us on social media. 396 00:18:49.042 --> 00:18:51.802 Your input guides future of Pros to Toss. 397 00:18:52.383 --> 00:18:55.102 Thanks for being a crucial part of our community. 398 00:18:56.042 --> 00:18:57.692 For more urology insights, 399 00:18:58.014 --> 00:18:59.141 visit collies.com. 400 00:18:59.605 --> 00:19:01.642 Stay tuned and see you next time. 401 00:19:04.843 --> 00:19:05.506 Thank you.