WEBVTT

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This podcast is created by Coelis.

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So we are not just offering one option for all patients.

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We are trying to tailor-make a treatment option that is best for the patient.

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So I think focal therapy exactly falls into place in this concept because we know,

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of course,

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some patients have more advanced disease,

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need more radical treatment.

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So robotic radical prostatectomy still has its place.

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But focal therapy is exciting because it can cure the disease.

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at the same time give you a very good functional outcome.

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Dear Prostat enthusiasts,

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welcome to another frosty episode of Prostat Talk,

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where today we are chinged out quite literally to talk about a cutting-edge treatment for prostate cancer,

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focal therapy and most specifically,

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cryotherapy.

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Now,

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if you ever reach you could just freeze cancer in these tracks,

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well,

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turn out,

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you actually can.

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It's a technique that's making waves,

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or rather ice crystals,

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in prostate cancer management.

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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,

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very cold.

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Joining me today is Dr.

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Yi,

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who knows exactly how to put...

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cancer cells on ice without giving patients the cold shoulder.

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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.

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Hello Dr.

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Yi,

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we are very happy to welcome you to our podcast Prostate Talk.

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How are you today?

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Thank you Thomas.

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I'm very happy to be here.

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And in this beautiful city of Madrid,

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I'm very happy to talk about prostate cryotherapy.

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That's true.

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We have to say to our listeners that we are actually live from the first

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EAU Congress in Madrid.

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So that's why we are in Madrid today with you,

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Dr.

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Yi.

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Before to talk about prostate,

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could you please tell us a bit more about yourself?

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Who is Dr.

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Yi and who is the man behind the scrub?

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So my name is Samuel Yi.

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I'm from Hong Kong.

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born and raised there.

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I have some experience in Europe as well because I did my fellowship in robotic and laparoscopic surgery in Paris in

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IMM, Montsouris.

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And also that's the place where I was first exposed to focal therapy,

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namely HIFU and chiral therapy and brachytherapy more than 10 years ago.

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So it's a good experience.

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So may I ask you if you have some French word for us?

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Bonjour.

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Great,

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thank you for this information.

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Let's now talk about prostate and specially prostate cancer treatments.

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First,

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could you please tell me what kind of treatment do you offer to your patients?

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We have a spectrum of available options right now,

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probably not just in Hong Kong,

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but in a lot of places in the world.

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For radical treatment,

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we can have robotic radical prostatectomy or radiotherapy.

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But of course,

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right now we have new progress in prostate cancer treatment because we want to minimize the side effect.

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So that's why we have a few options for focal therapy.

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In my center,

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we have three to four options right now.

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We have high full focal therapy.

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We have cryotherapy.

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We have microwave.

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And also we have trials going on for equilibration and also for

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IRE. So it's a very exciting field to be in right now.

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So a large panel of focal therapy for the patients.

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So we know that focal therapy,

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as you mentioned,

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is a hot topic now.

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A lot of studies on TRIOL are published.

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2024 EU guidelines are talking about it.

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It could become a recommendation in the next years.

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What is your opinion about it?

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And how do you see the future of this technique?

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Well,

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I think right now we are in the era of precision medicine.

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So we are not just offering one option for all patients.

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We are trying to tailor-make a treatment option that is best for the patient.

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So I think focus therapy exactly falls into place in this concept.

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Because we know,

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of course,

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some patients have more advanced disease,

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need more radical treatments.

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So robotic radical prostatectomy still has its place.

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But focal therapy is exciting because it can cure the disease at the same time give you a very good functional outcome.

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So I think right now we're in the stage where we know how it works.

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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.

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So,

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in another way,

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you mean that the choice of the focal therapy depends on the patient,

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right?

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Yes,

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we want to find the right patient for the right treatment.

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Kurt,

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during my research,

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I have learned that you are performing MRI fusion guided focal cryotherapy.

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Am I right?

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Yes,

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correct.

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So in the past,

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I think most of the phototherapists have been using kind of a cognitive fusion.

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We know where the lesion is at,

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and we try to use our imagination to map the ablation zone.

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But right now,

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when we are doing the diagnosis of prostate cancer,

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in fact,

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we are using MRI fusion,

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which means

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We know where the lesion is on MRI,

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and when we do the biopsy,

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we know where we should puncture the needle.

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The same concept can be applied to a treatment,

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to a therapeutic option.

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So we know where the lesion is.

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We try to map the lesion into our ultrasound image so that we know where to ablate,

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where we put our energy to.

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I think it's a more precise way to deliver the energy,

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and also it gives the surgeons some peace of mind.

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We're actually doing the right region with the right intensity.

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So you can guide precisely the needle for biopsies due to the fusion.

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And so at the end,

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you can guide the needle for the treatment.

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That's true.

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Very exact.

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Are you performing cryotherapies for all lesions?

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I mean,

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I know that most of the lesions are posterior and they are difficult to target with needle-guided treatment,

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right?

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Yeah.

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So in the beginning of our full therapy experience,

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we are using the a la carte model.

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So for a la carte model,

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meaning we try to tailor make

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each location of the prostate with each specific treatment.

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The anterior lesion,

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which is far from the rectum,

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may be better for needle-based ablation like cryotherapy.

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The posterior lesion,

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which is closer to the rectum,

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we would use energy more precisely like HIFU.

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But of course,

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in some centers,

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they don't have the luxury of having more than one energy modality because full therapy is not cheap for most of the places.

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So we try to see whether we can expand the use of a single energy and cover lesions around the prostate.

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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,

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even if it is a posterior lesion.

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With the rectum,

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do you use like the rectal spacers?

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I think it's an important topic and we never mention in our podcast.

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So could you...

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please explain to us why and how do you place it correctly?

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So for the rectal spacer is initially used for radiotherapy for the prostate.

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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.

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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.

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So we use the same concept.

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except we are not using it in radiotherapy.

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We try to use it during the ablation.

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So in the procedure,

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we look at the prostate with rectal ultrasound,

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seeing the position of the prostate relative to the rectum,

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and then we put the rectal spacer in between the rectum and the prostate.

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Specifically in this procedure,

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we knew where the lesion is,

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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

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with the hydrogel.

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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?

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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.

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So.

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And the erectile spacer,

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the hydrogel,

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in fact,

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helps us mitigate this problem.

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And I have heard that another option is also available,

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setting water injection.

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What is your opinion about it?

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Is it better?

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Well,

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I think this is the classical way to create space between two organs.

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It works in a way it still can create some space and also it can carry away the energy.

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So no matter it's heat energy or cryotherapy,

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the cold energy,

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continuous flow of water can help.

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However,

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it is being absorbed by the tissue very quickly.

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So sometimes during the procedure,

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you need to inject quite a lot of water in this area.

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And also it can create some inconvenience.

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So I think spacer is a relatively more convenient way where we can do this kind of protected ablation.

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Regarding cryotherapy,

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can we use any ultrasound system to perform it?

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How do your system is helpful for that?

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And what are the main requirements to start with a focal therapy and especially for focal therapy?

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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.

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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

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know where the prostate is,

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where supposedly the ice ball would be created around the lesion.

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So it creates a 3D image in the computer where we can visualize the ablation before we start.

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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.

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To be sure that I fully understand,

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so you mean you can see in real time where is the prostate,

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where is the needle and in a three dimension,

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right?

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Yes,

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so

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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

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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

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So the first step,

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of course,

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is to have MRI fusion.

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And then we can plan where the ablation zone is by simulating the needle injection or the needle puncture position.

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Right now,

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I'm kind of spoiled.

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So I would really like to have this system all the time.

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But I know for some experienced phototherapists,

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they are more comfortable without the system.

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So I think either way would work.

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But with the comfort from MRI fusion biopsy,

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more and more...

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urologists are getting used to navigation

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3D planning beforehand.

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So I think it's a good way to carry the treatment forward like this.

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And would you say that

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MRI is the first step for the diagnosis before making a biopsy and it's still an important way to diagnose cancer?

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Yeah,

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I think from guideline also from increasing evidence,

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MRI first is probably the approach for most of the cases,

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except you have a suspicion of

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a heavy cancer load,

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suspicion of metastatic disease,

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then maybe the MRI can be at a later stage if not before the treatment or biopsy.

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But right now,

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most of the cases diagnose of its early prostate cancer.

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And in that sense,

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the MRI would give us a better accuracy and precision in doing biopsy.

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How do you follow the treatment procedure?

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Right now,

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we have a lot of discussion about it concerning a post-focal therapy follow-up.

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I think the consensus is PSA is important.

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but we haven't concluded what is the optimal drop in PSA.

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00:12:42.797 --> 00:12:43.738
MR is important,

254
00:12:44.158 --> 00:12:49.121
but we haven't quite the experience to make certain which are the suspicious lesions,

255
00:12:49.161 --> 00:12:50.922
which are the post-operative changes.

256
00:12:51.462 --> 00:12:53.763
And also a biopsy is important.

257
00:12:54.164 --> 00:12:54.484
However,

258
00:12:54.485 --> 00:12:57.005
the timing of biopsy is still under discussion.

259
00:12:57.286 --> 00:13:06.571
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.

260
00:13:07.491 --> 00:13:09.032
And another question about that,

261
00:13:09.072 --> 00:13:10.593
because you mentioned MRI and etc.

262
00:13:11.313 --> 00:13:15.115
What do you think about the use of PET-CT scan for focal therapy?

263
00:13:15.615 --> 00:13:16.976
And could you please remind us,

264
00:13:17.396 --> 00:13:21.719
what is this technology and the difference between to the traditional MRI?

265
00:13:22.919 --> 00:13:23.700
So right now,

266
00:13:23.900 --> 00:13:27.262
the PET scan or so-called the PSMA scan is very popular.

267
00:13:27.722 --> 00:13:30.263
And the sensitivity is very good.

268
00:13:30.524 --> 00:13:34.386
So it's replacing conventional metastatic staging,

269
00:13:34.526 --> 00:13:36.647
light bone scan or even CT scan.

270
00:13:37.247 --> 00:13:39.108
I think for prostate focal therapy,

271
00:13:39.568 --> 00:13:41.209
we want to know where the lesion is.

272
00:13:41.369 --> 00:13:43.130
So if we just have the MRI,

273
00:13:43.270 --> 00:13:43.690
it's good.

274
00:13:43.770 --> 00:13:45.431
We know where we should do the biopsy.

275
00:13:45.951 --> 00:13:49.092
But with the reference to a PSMA scan,

276
00:13:49.593 --> 00:13:53.654
maybe we can increase our accuracy of biopsy as well.

277
00:13:54.135 --> 00:13:54.755
So I think

278
00:13:55.535 --> 00:13:59.337
MRI and PSMA can complement each other in the diagnostic process.

279
00:14:00.077 --> 00:14:01.238
In terms of staging,

280
00:14:01.878 --> 00:14:03.539
PSMA scans are excellent.

281
00:14:03.799 --> 00:14:04.880
But usually for phototherapy,

282
00:14:04.920 --> 00:14:06.341
we are looking at earlier disease.

283
00:14:06.501 --> 00:14:09.943
So we have less worry for metastatic staging in that sense.

284
00:14:10.764 --> 00:14:11.164
Perfect.

285
00:14:11.204 --> 00:14:12.165
That is clear for me.

286
00:14:12.805 --> 00:14:13.166
Thank you.

287
00:14:13.426 --> 00:14:14.567
Let's take a step up.

288
00:14:15.187 --> 00:14:17.088
We have talked about cryotherapy,

289
00:14:17.168 --> 00:14:19.090
but are you performing other treatments?

290
00:14:20.270 --> 00:14:20.451
Yes.

291
00:14:20.651 --> 00:14:22.192
So besides cryotherapy,

292
00:14:22.632 --> 00:14:25.214
I'm also a kin phototherapist for Haifu.

293
00:14:25.774 --> 00:14:26.175
And now,

294
00:14:26.255 --> 00:14:26.515
Santa,

295
00:14:26.555 --> 00:14:27.556
we have microwave.

296
00:14:28.336 --> 00:14:31.378
I still think each energy has its own merit.

297
00:14:32.687 --> 00:14:36.450
If we are talking about posterior lesion near the apex,

298
00:14:36.891 --> 00:14:45.017
HIFU does give me some sense of precision because it is essentially having a 3mm block of ablation zone.

299
00:14:45.377 --> 00:14:47.159
So when it's near the apex...

300
00:14:47.791 --> 00:14:49.612
I would feel more comfortable using HIFU.

301
00:14:50.052 --> 00:14:50.512
And of course,

302
00:14:50.592 --> 00:14:51.212
posteriorly,

303
00:14:51.692 --> 00:14:53.353
besides using the hydrogel technique,

304
00:14:53.413 --> 00:14:55.353
HIFU is also a very good alternative.

305
00:14:55.513 --> 00:14:59.014
So I think when you have the luxury to have more than one end-to-end modality,

306
00:14:59.734 --> 00:15:00.735
try to have more than one.

307
00:15:01.615 --> 00:15:02.335
May I ask you,

308
00:15:02.355 --> 00:15:02.695
Dr.

309
00:15:02.755 --> 00:15:02.875
Yi,

310
00:15:03.436 --> 00:15:07.377
what advice would you give to a doctor who would like to perform focal therapy?

311
00:15:08.197 --> 00:15:12.038
What are for you the critical elements to choose a good focal energy,

312
00:15:12.398 --> 00:15:12.978
in addition,

313
00:15:12.979 --> 00:15:13.418
of course,

314
00:15:13.419 --> 00:15:15.499
to their carcinological efficacy?

315
00:15:16.339 --> 00:15:18.620
So I think when we are starting phototherapy,

316
00:15:19.080 --> 00:15:23.542
a lot of questions are directed to the type of energy source.

317
00:15:24.122 --> 00:15:25.363
But I would advise,

318
00:15:25.443 --> 00:15:25.883
in fact,

319
00:15:26.103 --> 00:15:28.384
patient selection is the key to success.

320
00:15:28.564 --> 00:15:29.744
It's all based on the patient.

321
00:15:29.905 --> 00:15:30.145
Yes.

322
00:15:30.425 --> 00:15:32.305
So when you have the right patient,

323
00:15:33.266 --> 00:15:36.527
I think most of the time you can succeed with any energy source.

324
00:15:37.087 --> 00:15:40.609
So my advice is find the right patient.

325
00:15:40.969 --> 00:15:41.929
And with the right patient,

326
00:15:42.189 --> 00:15:44.230
they can let you know what is the best energy source.

327
00:15:44.891 --> 00:15:45.311
Perfect.

328
00:15:45.351 --> 00:15:45.711
Thank you.

329
00:15:46.171 --> 00:15:48.153
I'm sure it is very useful for our listeners.

330
00:15:48.893 --> 00:15:50.134
Before ending this interview,

331
00:15:50.515 --> 00:15:53.197
I'd like to ask my guests their plans for the future.

332
00:15:53.397 --> 00:15:54.578
So what is yours?

333
00:15:55.359 --> 00:15:55.959
So right now,

334
00:15:56.179 --> 00:15:57.721
phototherapy is changing a lot.

335
00:15:58.181 --> 00:15:59.742
And I think for us,

336
00:16:00.343 --> 00:16:02.545
we'd like to answer three questions.

337
00:16:02.985 --> 00:16:03.525
First of all,

338
00:16:04.066 --> 00:16:08.109
can we use phototherapy in an extended indication?

339
00:16:08.429 --> 00:16:10.851
Because right now we try to look at intermediate risk,

340
00:16:10.972 --> 00:16:11.372
low risk.

341
00:16:11.992 --> 00:16:14.254
But right now we have some low volume,

342
00:16:14.334 --> 00:16:15.115
high risk disease.

343
00:16:15.255 --> 00:16:17.176
Can we use them in extended indication?

344
00:16:17.696 --> 00:16:18.316
And second of all,

345
00:16:18.456 --> 00:16:19.257
the question is,

346
00:16:19.697 --> 00:16:22.818
can we follow up the patient more wisely or efficiently?

347
00:16:23.198 --> 00:16:25.239
Because right now we still want to use biopsy,

348
00:16:25.499 --> 00:16:27.220
but most patients want to avoid biopsy.

349
00:16:27.700 --> 00:16:31.282
So can we do something less traumatic in order to have better follow-up?

350
00:16:31.822 --> 00:16:32.682
And lastly,

351
00:16:33.082 --> 00:16:40.005
I think we want to see whether we have some energy source we can have better real-time monitoring.

352
00:16:40.125 --> 00:16:40.926
Because right now,

353
00:16:40.966 --> 00:16:41.946
even for cryotherapy,

354
00:16:42.046 --> 00:16:42.886
we know the ice ball,

355
00:16:42.926 --> 00:16:44.167
but it's not the

356
00:16:44.407 --> 00:16:47.129
boundary of the eye spot that matters is the core of the eye spot that matters.

357
00:16:47.229 --> 00:16:47.729
For HIFU,

358
00:16:47.749 --> 00:16:49.770
we know some tissue ablation changes,

359
00:16:49.870 --> 00:16:52.592
but we don't know exactly where the boundary is.

360
00:16:52.872 --> 00:16:53.492
But for surgeons,

361
00:16:53.493 --> 00:16:56.294
we would like to see what's happening in real time.

362
00:16:56.694 --> 00:16:57.835
And I think in the future,

363
00:16:57.855 --> 00:17:05.760
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,

364
00:17:05.900 --> 00:17:07.941
we can have a better assessment of ablation zone.

365
00:17:08.001 --> 00:17:09.202
It can give us some comfort.

366
00:17:09.462 --> 00:17:10.543
That's exciting.

367
00:17:11.643 --> 00:17:14.005
Thank you again for your time and your valuable insight.

368
00:17:14.545 --> 00:17:17.527
I'd like to ask my guest before leaving a special question.

369
00:17:17.867 --> 00:17:18.127
Dr.

370
00:17:18.167 --> 00:17:18.287
Yi,

371
00:17:18.748 --> 00:17:21.950
what is your favorite song or your song of the moment?

372
00:17:22.630 --> 00:17:22.850
Well,

373
00:17:23.210 --> 00:17:24.451
this is a surprise question.

374
00:17:25.052 --> 00:17:25.172
So,

375
00:17:25.952 --> 00:17:26.513
in fact,

376
00:17:26.653 --> 00:17:26.853
well,

377
00:17:26.993 --> 00:17:29.374
I'm going to go to a Coldplay concert soon.

378
00:17:29.454 --> 00:17:29.615
Wow,

379
00:17:29.655 --> 00:17:30.555
you're so lucky.

380
00:17:30.795 --> 00:17:31.716
I'm jealous.

381
00:17:32.096 --> 00:17:32.216
So,

382
00:17:32.637 --> 00:17:33.677
on my flight here,

383
00:17:33.777 --> 00:17:35.538
I've been listening to their song.

384
00:17:35.719 --> 00:17:36.219
And of course...

385
00:17:36.619 --> 00:17:36.939
Yellow,

386
00:17:37.099 --> 00:17:37.379
I mean,

387
00:17:37.479 --> 00:17:41.261
this is a classic from Coldplay and it has been ringing in my mind all the time.

388
00:17:41.421 --> 00:17:41.541
So

389
00:17:42.281 --> 00:17:43.982
Yellow is the song of the moment.

390
00:17:45.142 --> 00:17:45.522
Thank you.

391
00:17:46.003 --> 00:17:55.306
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.

392
00:17:55.366 --> 00:17:55.706
Thank you.

393
00:17:56.146 --> 00:17:56.506
Thank you,

394
00:17:56.526 --> 00:17:56.807
Dr.

395
00:17:56.808 --> 00:17:56.927
Yi.

396
00:17:57.167 --> 00:17:57.867
Thank you very much.

397
00:18:04.435 --> 00:18:06.936
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398
00:18:07.396 --> 00:18:08.957
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399
00:18:09.137 --> 00:18:11.778
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400
00:18:12.358 --> 00:18:14.259
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401
00:18:15.960 --> 00:18:17.601
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402
00:18:17.681 --> 00:18:18.401
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403
00:18:18.461 --> 00:18:18.781
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404
00:18:19.101 --> 00:18:20.402
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405
00:18:20.862 --> 00:18:25.224
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406
00:18:25.225 --> 00:18:26.844
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407
00:18:27.244 --> 00:18:30.646
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408
00:18:31.246 --> 00:18:33.227
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409
00:18:33.347 --> 00:18:34.088
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410
00:18:34.569 --> 00:18:37.353
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411
00:18:38.274 --> 00:18:39.897
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412
00:18:40.237 --> 00:18:41.379
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413
00:18:41.780 --> 00:18:43.883
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