This podcast is created by Coelis.
What I've learned about prostate biopsies is that there's no perfect solution.
We've come a long way,
but there's still further to go,
and I'm sure the technology will change in time.
Prostate.
Dear listeners,
welcome to a new episode of Prostatalk,
the podcast where we boldly go where few have gone before,
into the depths of urology.
I'm your host,
Thomas,
and self-proclaimed urology enthusiast,
here to guide you through the wild and wonderful world of prostates.
Today,
our guest is none other than the illustrious Dr.
Simon Bott,
hailing all the way from the UK with his charming British accent and an abundance of urological wisdom.
We are diving deep in the world of urology,
exploring elastic fusion,
yes,
that's right,
merging MRI and ultrasound images,
3D mapping technologies for the prostate,
and ingenious techniques to counteract those pisky patient movements that throw off diagnosis exams.
After all,
when the patient moves,
the process moves,
and nobody wants a diagnosis based on a prostate in motion.
So,
sit back,
relax,
and prepare to have your minds blow.
By the wonders of the prostate world,
let's get ready to talk prostates!
Hi Dr.
Botts,
we are really pleased to welcome you.
We are live from the 2024 EU Congress,
the place to be on this beginning of year.
How are you today and how the Congress is going?
I'm great,
thank you.
It's really good to be here at the conference with so many other urologists and urology colleagues.
It's lovely to be in Paris particularly.
I'm a really big fan of France,
so I'm having a great time,
thank you.
We are glad too.
Before to start,
I heard that you spent time in French Halp.
and try the French gastronomy.
Am I wrong?
I love French food.
I love French wine.
I love French cheese.
I like French people.
Yeah.
French food.
And more seriously,
could you please tell us more about you and who is Dr.
Simon Bott?
So I'm a consultant urologist.
I work at Frimley Park Hospital,
which is just outside London in the UK.
We are one of the busiest or largest hospitals in the country outside the teaching hospitals.
And I have been a consultant since 2008.
But I've been doing prostate biopsies since the late 1990s.
Perfect.
So an expert in prostate,
right?
I've done a lot.
If that makes me an expert,
possibly.
Just to be curious,
why did you choose urology during your studies?
Do you have a speciality like biopsy or treatments?
The first job I did when I qualified as a doctor was in urology,
and I liked urology particularly because of the variety of conditions we treat.
So whether it's prostate cancer or kidney cancer or bladder cancer,
whether it's infections or stones or benign enlargement or infertility or andrology,
there's a huge spectrum of things.
And there's also a lot you can do with your hands.
So it's very good operating,
be that with a microscope or a robot or with a scalpel.
And there's also a lot of intellectual interest because unlike some specialities,
we don't have physicians who look after urology.
With the heart you have cardiologists who look after the physician side and you have surgeons who do the surgical side.
In urology it's just us,
we can do as much or as little.
For me it was a natural speciality to choose and I love it to this day.
I still wake up on Monday morning and think,
good I'm going to work.
So a speciality where you can have the whole process from A to Z?
Correct,
yeah.
From the start to finish we see the patient,
yeah.
And all ages,
from children to the very eldest patients.
In the previous episode of Prostatalk,
we discussed the benefit of the Transparenil route.
Dr.
Proth,
I've heard that you have been one of the first in UK to adopt the Transparenil approach under local anesthesia.
Is that true?
Yes,
I was actually the first person to describe the template technique through the perineum.
So my journey started,
as I said,
in the
1990s. And at that stage,
we were doing truss biopsies,
so an ultrasound probe in the rectum,
and then blindly firing needles through the rectum to the prostate.
And I was struck at this point,
even as a very junior urologist,
at how poor this technique was really for diagnosing cancer.
Because we couldn't see the cancer,
we just blindly fired the needles in hoping we'd hit something and we didn't even know whether it was there or not.
We just had the PSA that of course can be elevated due to other causes.
So what I showed in my very early training was that we missed a lot of cancers using the transrectal approach.
So we missed a lot of cancers in the front of the prostate because we simply didn't biopsy that part of the prostate.
So then I worked at Guildford Hospital where they were doing a lot of brachytherapy.
They're famous for brachytherapy.
And using the brachytherapy technique with a grid,
we decided then to adopt this to do a biopsy.
So the brachytherapy grid is placed over the perineum,
just like we see a template biopsy now.
And we thought,
well,
why don't we use this grid to make sure we adequately sample the whole prostate,
the anterior prostate,
and posteriorly,
you can take as many biopsies as you like.
And so we adopted this in people who'd had...
The trans-rectal biopsy previously,
where the biopsies were negative,
but we still had a concern they may have prostate cancer.
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.
But this meant we had to give patients a general anaesthetic because we were taking a lot of biopsy cores,
perhaps 60 to 80 cores,
sometimes even in excess of 100 in patients who had very large prostates.
So this was uncomfortable.
It was general anaesthetic.
It was a day case procedure.
It took up operating theatre time and patients took a few days to recover.
Quite a high risk of complications,
particularly urinary retention,
much less sepsis.
We realised this very early on that the sepsis rates were considerably reduced.
But clearly it was a lot of work for the urologist,
for the pathologist,
and it was worse for the patient.
So when I was invited to be involved with the PROMIS study in the UK,
where MRI was going to be shown to be effective,
I was delighted.
Now we all of a sudden had a target to aim at.
And this meant that rather than taking 60 to 80 biopsy cores,
we could reduce the number of cores right down to aim for a target,
a target that we think is clinically significant,
and we can also avoid biopsies in some patients and also miss insignificant cancers in others.
So it seemed a natural progression,
therefore.
then to use the MR to target the lesion in the prostate,
but of course we were using initially our brains,
a cognitive biopsy.
and once you've done a few thousand biopsies,
then I think your brain is pretty good at it,
but even for the small lesions,
it's not as good as the technology we have now.
So I was delighted when I went around the EAU in 2017 to look at all the different fusion software technologies out there,
and I essentially had a blank canvas.
I could choose whichever one I wanted to get,
and
I settled on the Coriolis Trinity system because I thought it made the most sense.
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.
Very interesting.
So you mentioned MRI and you mentioned fusion.
So let's talk about,
if you want,
fusion biopsy.
It can be interesting to speak about the learning curve when you adopted this new system and this new approach.
Can you tell us about the learning curve about this new approach in your daily practice?
I think
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
I've gone to the learning curve in 15 years so I think it's important you can interpret an MRI scan
But once you can interpret an MRI scan,
you can contour the prostate,
then taking the biopsies is relatively straightforward because you can always do a virtual biopsy before you take the biopsy.
So you always know you're going to hit the target once you know where the target is,
and that's all about the contouring.
So I think the learning curve in many ways is about interpreting an MRI scan rather than learning the technique of the biopsy.
Even if I think I already know the answer,
do you prefer elastic fusion than rigid fusion?
Yes,
I have used both and I just think elastic fusion is more accurate.
If you know you're hitting the target,
you take fewer biopsies,
that's better for the patient because it's less uncomfortable.
It means you should reduce your complication rates,
particularly of bleeding,
but also probably infection.
And it means less work for the pathologist.
And we're very short of pathologists in the UK,
so my pathologist isn't looking at lots of biopsies.
He or she can look at more patients'biopsies and therefore get through more work.
In another way,
would you say that it allows you to do more personalised care to your patients?
Absolutely,
because you can target the number of biopsies you need to take based on the lesion size,
based on the prostate size,
based on the stage of the disease,
and based on the patient and what you're likely to do with them.
So in a 50-year-old man who's going to have a radical prostatectomy or radical therapy of some kind,
then I'm going to take more biopsies around the neurovascular bundles.
In a patient who might be suited for brachytherapy,
I might take more biopsies around the urethra.
But in an elderly gentleman who's got a T3A tumour,
perhaps anteriorly,
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,
the operative time for me and the pathology time.
Well,
I assume you won't go back,
right?
Never.
I think the only way is forward.
We should work on trying to improve all the time.
You're right.
I have just one question about MRI images,
because I understand it.
MRI images are the key point for achieving a correct and precise elastic fusion,
and it all matters about precision.
How do you receive them?
Is it you who read and annotate them,
or do you work with radiologists?
What is the process in your hospital?
So all our MRI scans are reviewed by a radiologist and they will report any lesions that they see.
I then review the images myself without reading the report and then I check that what I see is what they see.
Sometimes I add them on.
I will always biopsy a lesion that a radiologist has reported and they will then mark,
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.
Interesting.
Well...
When I did research for preparing this interview,
there was an expression that came back a few times about you.
It's the patient-friendly position.
What do you mean?
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.
And there are several reasons for this.
I think that in the left lateral position the patient cannot see all the needles,
the biopsy gun etc that tend to put people off having a biopsy.
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.
So I think if you have the patient facing away from you they can't see what you're doing.
I also have a nurse talking to the patient,
distracting them,
and I have Spotify and a choice of music so that patients can listen to whatever music they like.
And I think if the patient is comfortable and relaxed and not seeing what you're doing,
then it makes the whole procedure much more comfortable.
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.
Fascinating and is it the common way to perform transperineal biopsies under local anesthesia?
I think in some ways the lithotomy position is perhaps easier to do,
but I just think that the left lateral position is nicer for the patient.
And I certainly think those people who do do the lithotomy position,
once they've acquired the skill to do a biopsy in the lithotomy position,
it's not very difficult just rotating the patient into the left lateral and doing it with the left lateral position.
And do you train your team like that or peer like that?
I train all my registrars to do it in the left lateral position,
yeah.
And do you know if other urologists are using this technique or it's just your particular thing?
No,
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.
as well.
So I think it's gaining popularity.
It's just a little bit harder because it's a little bit more freehand,
but you can acquire the skill over time.
So once you've done several biopsies in the thotomy position,
then I think it's reasonable to turn the patient into the left lateral and try and do the left lateral position.
What are the clinical advantages of this position?
I think the advantage of this position are the patient finds it more comfortable.
Therefore,
you can take better quality biopsies,
which means you can take fewer biopsies.
And that means the whole procedure is over quicker with less complications and more time to do more patients.
So I prefer the left lateral position and so do the patients.
And I think the patients prefer it because they're more relaxed,
because they're listening to music,
because you're distracting them.
We call it vocal anesthesia.
I think it's really important to have a vocal anesthesia as well as local anesthesia.
So have the patient talking,
which is normal.
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.
Of course,
with the coalesce system as well,
if the patient does move because you're tracking the organ,
not the needle or the ultrasound probe,
then even if the patient does move,
it's not a problem because you just do another sweep to the prostate gland and you realize that the patient's moved.
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?
I think it's about the whole atmosphere in the biopsy room when you're doing it.
And this is about,
as I say,
putting music on which they want to listen to,
nothing too hardcore perhaps.
Sometimes if patients say I don't mind I put on Pink Floyd,
Comfortably Numb,
because I think that's appropriate.
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.
I tell patients every time I do anything that might be uncomfortable,
I tell patients before they actually have the biopsy exactly what's involved.
and I constantly reassure them as I'm going through the process that I'm hitting the target,
that I've only got one or two more biopsies to do,
and then most patients find the whole experience not something they necessarily want to repeat every week,
but they certainly find it tolerable.
So what I understand is you are very patient-centric,
and it's very reassuring for the patient because we are all patient one day.
So thank you for that,
Dr.
Simon.
Before to finish this interview,
could you tell us more about your next plan?
So I think what I've learned about prostate biopsies over the last many years is that there's no perfect answer,
there's no perfect solution.
We've come a long way from blind trust biopsies,
but there's still further to go and I'm sure the technology will change in time.
In five to ten years we may be doing things differently like we did five to ten years ago.
So I think there's lots of areas to improve on.
We can improve on the anaesthetic.
Whilst it is tolerable,
it is a bit uncomfortable having a prostate biopsy.
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.
But I think that we can improve on that.
I think that using the coaxial needle rather than just purely going through the grid helps.
because if you put a carotid needle and you've got a small to medium-sized prostate,
you can just put one carotid needle in the left,
and then when you do the right-hand side,
you take the carotid needle out and put it on the other side,
so you're only puncturing the skin twice in a sort of small to medium-sized prostate.
I think that helps.
And I think that the MRI quality is improving,
so I think we're going to be picking up more lesions as time goes by.
Currently at my hospital,
we have quite an old 1.5
Tesla MRI,
and I think...
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
3T MRI scan so even that will be a major step forward so I think
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.
It takes five to ten minutes to contour a prostate it's not a big deal
But if I can get AI to do that,
that's going to save us all time.
And if AI is interpreting the MRI in the first place,
the AI can contour everything it sees as being abnormal.
But maybe that's a little bit further away,
but we are using AI now in trials,
and I think that is the future.
Thanks a lot for your time and this precious information.
Before to leave and go back downstairs to the Congress,
I'd like to ask my guest a last-minute question.
So,
we spoke a lot about music.
And the importance of music for vocal anesthesia.
What is your song of the moment,
Dr.
Bud?
I like
Tom O'Dell's Black Friday.
That's my song of the moment.
But I will listen to,
my default is
1980s because that's my era and that's happy music on the whole.
But if you listen to that every day,
every week,
every year for 30 years,
it gets a bit monotonous.
So I'm listening to modern music as well.
Thanks a lot and see you in the next episode,
I hope.
Thank you very much for having me.
Merci beaucoup.
Huge thanks to our dedicated listeners.
If you enjoyed the podcast,
make sure to subscribe for more captivating content.
Your support means the world.
If you found this informative,
quick favor please,
drop a 5 star review.
Your feedback helps us grow and deliver credit insights.
Have topics you'd love us to cover?
Share your ideas in the comments or connect with us on social media.
Your input guides future of Pros to Toss.
Thanks for being a crucial part of our community.
For more urology insights,
visit collies.com.
Stay tuned and see you next time.
Thank you.