This podcast is created by Coelis.
So we are not just offering one option for all patients.
We are trying to tailor-make a treatment option that is best for the patient.
So I think focal therapy exactly falls into place in this concept because we know,
of course,
some patients have more advanced disease,
need more radical treatment.
So robotic radical prostatectomy still has its place.
But focal therapy is exciting because it can cure the disease.
at the same time give you a very good functional outcome.
Dear Prostat enthusiasts,
welcome to another frosty episode of Prostat Talk,
where today we are chinged out quite literally to talk about a cutting-edge treatment for prostate cancer,
focal therapy and most specifically,
cryotherapy.
Now,
if you ever reach you could just freeze cancer in these tracks,
well,
turn out,
you actually can.
It's a technique that's making waves,
or rather ice crystals,
in prostate cancer management.
And who better to guide us through this sub-zero adventure than an expert who travels all the way from the warm climate of Hong Kong to talk about making things very,
very cold.
Joining me today is Dr.
Yi,
who knows exactly how to put...
cancer cells on ice without giving patients the cold shoulder.
So butter up but stay comfortable down there because we are about to dive into how cryotherapy is giving prostate cancer the cold treatment and why that's very good news for patients and their prostates.
Hello Dr.
Yi,
we are very happy to welcome you to our podcast Prostate Talk.
How are you today?
Thank you Thomas.
I'm very happy to be here.
And in this beautiful city of Madrid,
I'm very happy to talk about prostate cryotherapy.
That's true.
We have to say to our listeners that we are actually live from the first
EAU Congress in Madrid.
So that's why we are in Madrid today with you,
Dr.
Yi.
Before to talk about prostate,
could you please tell us a bit more about yourself?
Who is Dr.
Yi and who is the man behind the scrub?
So my name is Samuel Yi.
I'm from Hong Kong.
born and raised there.
I have some experience in Europe as well because I did my fellowship in robotic and laparoscopic surgery in Paris in
IMM, Montsouris.
And also that's the place where I was first exposed to focal therapy,
namely HIFU and chiral therapy and brachytherapy more than 10 years ago.
So it's a good experience.
So may I ask you if you have some French word for us?
Bonjour.
Great,
thank you for this information.
Let's now talk about prostate and specially prostate cancer treatments.
First,
could you please tell me what kind of treatment do you offer to your patients?
We have a spectrum of available options right now,
probably not just in Hong Kong,
but in a lot of places in the world.
For radical treatment,
we can have robotic radical prostatectomy or radiotherapy.
But of course,
right now we have new progress in prostate cancer treatment because we want to minimize the side effect.
So that's why we have a few options for focal therapy.
In my center,
we have three to four options right now.
We have high full focal therapy.
We have cryotherapy.
We have microwave.
And also we have trials going on for equilibration and also for
IRE. So it's a very exciting field to be in right now.
So a large panel of focal therapy for the patients.
So we know that focal therapy,
as you mentioned,
is a hot topic now.
A lot of studies on TRIOL are published.
2024 EU guidelines are talking about it.
It could become a recommendation in the next years.
What is your opinion about it?
And how do you see the future of this technique?
Well,
I think right now we are in the era of precision medicine.
So we are not just offering one option for all patients.
We are trying to tailor-make a treatment option that is best for the patient.
So I think focus therapy exactly falls into place in this concept.
Because we know,
of course,
some patients have more advanced disease,
need more radical treatments.
So robotic radical prostatectomy still has its place.
But focal therapy is exciting because it can cure the disease at the same time give you a very good functional outcome.
So I think right now we're in the stage where we know how it works.
We're trying to define which patients would be best for this type of therapy and also what are the additional strategies we can expand the indication for this therapy.
So,
in another way,
you mean that the choice of the focal therapy depends on the patient,
right?
Yes,
we want to find the right patient for the right treatment.
Kurt,
during my research,
I have learned that you are performing MRI fusion guided focal cryotherapy.
Am I right?
Yes,
correct.
So in the past,
I think most of the phototherapists have been using kind of a cognitive fusion.
We know where the lesion is at,
and we try to use our imagination to map the ablation zone.
But right now,
when we are doing the diagnosis of prostate cancer,
in fact,
we are using MRI fusion,
which means
We know where the lesion is on MRI,
and when we do the biopsy,
we know where we should puncture the needle.
The same concept can be applied to a treatment,
to a therapeutic option.
So we know where the lesion is.
We try to map the lesion into our ultrasound image so that we know where to ablate,
where we put our energy to.
I think it's a more precise way to deliver the energy,
and also it gives the surgeons some peace of mind.
We're actually doing the right region with the right intensity.
So you can guide precisely the needle for biopsies due to the fusion.
And so at the end,
you can guide the needle for the treatment.
That's true.
Very exact.
Are you performing cryotherapies for all lesions?
I mean,
I know that most of the lesions are posterior and they are difficult to target with needle-guided treatment,
right?
Yeah.
So in the beginning of our full therapy experience,
we are using the a la carte model.
So for a la carte model,
meaning we try to tailor make
each location of the prostate with each specific treatment.
The anterior lesion,
which is far from the rectum,
may be better for needle-based ablation like cryotherapy.
The posterior lesion,
which is closer to the rectum,
we would use energy more precisely like HIFU.
But of course,
in some centers,
they don't have the luxury of having more than one energy modality because full therapy is not cheap for most of the places.
So we try to see whether we can expand the use of a single energy and cover lesions around the prostate.
And that's why we try to see whether we can move the rectum away from the prostate during the procedure so that the cryotherapy ice ball would have less chance to hit the rectum,
even if it is a posterior lesion.
With the rectum,
do you use like the rectal spacers?
I think it's an important topic and we never mention in our podcast.
So could you...
please explain to us why and how do you place it correctly?
So for the rectal spacer is initially used for radiotherapy for the prostate.
The concept is that during radiotherapy because of the proximity of the rectum to the prostate it can get hurt so patient may have bleeding from the rectum etc.
So the rectal spacer is using some gel trying to separate the prostate from the rectum so that that the radiotherapy would not hit the rectum.
So we use the same concept.
except we are not using it in radiotherapy.
We try to use it during the ablation.
So in the procedure,
we look at the prostate with rectal ultrasound,
seeing the position of the prostate relative to the rectum,
and then we put the rectal spacer in between the rectum and the prostate.
Specifically in this procedure,
we knew where the lesion is,
so we may not need to cover the whole rectum or the whole prostate we try to focus the location of the lesion and then try to space it out
with the hydrogel.
I think you already answered my next question but what are the risks if we don't use it if you don't use a rectal spacer?
So I think if we're redoing a posterior lesion ablation without the spacer the rectum would be quite close so either we try to reserve the ablation zone and then the cancer may still be there after treatment or we are becoming very aggressive hitting all the cancer with the risk of hurting your rectum as well.
So.
And the erectile spacer,
the hydrogel,
in fact,
helps us mitigate this problem.
And I have heard that another option is also available,
setting water injection.
What is your opinion about it?
Is it better?
Well,
I think this is the classical way to create space between two organs.
It works in a way it still can create some space and also it can carry away the energy.
So no matter it's heat energy or cryotherapy,
the cold energy,
continuous flow of water can help.
However,
it is being absorbed by the tissue very quickly.
So sometimes during the procedure,
you need to inject quite a lot of water in this area.
And also it can create some inconvenience.
So I think spacer is a relatively more convenient way where we can do this kind of protected ablation.
Regarding cryotherapy,
can we use any ultrasound system to perform it?
How do your system is helpful for that?
And what are the main requirements to start with a focal therapy and especially for focal therapy?
Well for chiro-therapy we're doing an ultrasound guidance so not only we try to guide it with the ultrasound seeing where we should put the needle also during the process the eye spore formation can be seen on ultrasound so we know the zone of ablation.
Right now we are not just using ultrasound in fact we are using a fusion platform in our center we're using the coalesce fusion platform where we can in fact have some simulation before the ablation so that we can
know where the prostate is,
where supposedly the ice ball would be created around the lesion.
So it creates a 3D image in the computer where we can visualize the ablation before we start.
So I think it's a very good way for us to estimate where the ablation zone is and in order to cover it adequately for the lesion.
To be sure that I fully understand,
so you mean you can see in real time where is the prostate,
where is the needle and in a three dimension,
right?
Yes,
so
before we start we have simulation so this is a visualization and during the procedure we have real-time monitoring so i think it is quite a good way to assist cryotherapy very interesting and how do you plan your treatment is a planification tool is useful for your practice and
what are the benefits of such a tool well if we want to be very precise about the ice ball formation i think pre-operative planning is very essential
So the first step,
of course,
is to have MRI fusion.
And then we can plan where the ablation zone is by simulating the needle injection or the needle puncture position.
Right now,
I'm kind of spoiled.
So I would really like to have this system all the time.
But I know for some experienced phototherapists,
they are more comfortable without the system.
So I think either way would work.
But with the comfort from MRI fusion biopsy,
more and more...
urologists are getting used to navigation
3D planning beforehand.
So I think it's a good way to carry the treatment forward like this.
And would you say that
MRI is the first step for the diagnosis before making a biopsy and it's still an important way to diagnose cancer?
Yeah,
I think from guideline also from increasing evidence,
MRI first is probably the approach for most of the cases,
except you have a suspicion of
a heavy cancer load,
suspicion of metastatic disease,
then maybe the MRI can be at a later stage if not before the treatment or biopsy.
But right now,
most of the cases diagnose of its early prostate cancer.
And in that sense,
the MRI would give us a better accuracy and precision in doing biopsy.
How do you follow the treatment procedure?
Right now,
we have a lot of discussion about it concerning a post-focal therapy follow-up.
I think the consensus is PSA is important.
but we haven't concluded what is the optimal drop in PSA.
MR is important,
but we haven't quite the experience to make certain which are the suspicious lesions,
which are the post-operative changes.
And also a biopsy is important.
However,
the timing of biopsy is still under discussion.
So I think it's an exciting and evolving field because we know what we still need to define when and which type of assessment that we need to do.
And another question about that,
because you mentioned MRI and etc.
What do you think about the use of PET-CT scan for focal therapy?
And could you please remind us,
what is this technology and the difference between to the traditional MRI?
So right now,
the PET scan or so-called the PSMA scan is very popular.
And the sensitivity is very good.
So it's replacing conventional metastatic staging,
light bone scan or even CT scan.
I think for prostate focal therapy,
we want to know where the lesion is.
So if we just have the MRI,
it's good.
We know where we should do the biopsy.
But with the reference to a PSMA scan,
maybe we can increase our accuracy of biopsy as well.
So I think
MRI and PSMA can complement each other in the diagnostic process.
In terms of staging,
PSMA scans are excellent.
But usually for phototherapy,
we are looking at earlier disease.
So we have less worry for metastatic staging in that sense.
Perfect.
That is clear for me.
Thank you.
Let's take a step up.
We have talked about cryotherapy,
but are you performing other treatments?
Yes.
So besides cryotherapy,
I'm also a kin phototherapist for Haifu.
And now,
Santa,
we have microwave.
I still think each energy has its own merit.
If we are talking about posterior lesion near the apex,
HIFU does give me some sense of precision because it is essentially having a 3mm block of ablation zone.
So when it's near the apex...
I would feel more comfortable using HIFU.
And of course,
posteriorly,
besides using the hydrogel technique,
HIFU is also a very good alternative.
So I think when you have the luxury to have more than one end-to-end modality,
try to have more than one.
May I ask you,
Dr.
Yi,
what advice would you give to a doctor who would like to perform focal therapy?
What are for you the critical elements to choose a good focal energy,
in addition,
of course,
to their carcinological efficacy?
So I think when we are starting phototherapy,
a lot of questions are directed to the type of energy source.
But I would advise,
in fact,
patient selection is the key to success.
It's all based on the patient.
Yes.
So when you have the right patient,
I think most of the time you can succeed with any energy source.
So my advice is find the right patient.
And with the right patient,
they can let you know what is the best energy source.
Perfect.
Thank you.
I'm sure it is very useful for our listeners.
Before ending this interview,
I'd like to ask my guests their plans for the future.
So what is yours?
So right now,
phototherapy is changing a lot.
And I think for us,
we'd like to answer three questions.
First of all,
can we use phototherapy in an extended indication?
Because right now we try to look at intermediate risk,
low risk.
But right now we have some low volume,
high risk disease.
Can we use them in extended indication?
And second of all,
the question is,
can we follow up the patient more wisely or efficiently?
Because right now we still want to use biopsy,
but most patients want to avoid biopsy.
So can we do something less traumatic in order to have better follow-up?
And lastly,
I think we want to see whether we have some energy source we can have better real-time monitoring.
Because right now,
even for cryotherapy,
we know the ice ball,
but it's not the
boundary of the eye spot that matters is the core of the eye spot that matters.
For HIFU,
we know some tissue ablation changes,
but we don't know exactly where the boundary is.
But for surgeons,
we would like to see what's happening in real time.
And I think in the future,
if we have some ultrasound with say contrast ultrasound to look at the ablation in real time or MRI looking at ablation in real time,
we can have a better assessment of ablation zone.
It can give us some comfort.
That's exciting.
Thank you again for your time and your valuable insight.
I'd like to ask my guest before leaving a special question.
Dr.
Yi,
what is your favorite song or your song of the moment?
Well,
this is a surprise question.
So,
in fact,
well,
I'm going to go to a Coldplay concert soon.
Wow,
you're so lucky.
I'm jealous.
So,
on my flight here,
I've been listening to their song.
And of course...
Yellow,
I mean,
this is a classic from Coldplay and it has been ringing in my mind all the time.
So
Yellow is the song of the moment.
Thank you.
I hope you love this exercise and maybe we will have the opportunity to have you again for explaining your new research works and the future.
Thank you.
Thank you,
Dr.
Yi.
Thank you very much.
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,
a quick favor,
please.
Drop up a five-star review.
Your feedback helps us grow and deliver quality insight.
Have topics you'd love us to cover?
Share your ideas in the comments or connect with us on social media.
Your input guides the future of...
prostate talk.
Thanks for being a crucial part of our community.
For more urology insights,
visit Kallis.com.
Stay tuned and see you next time.