Phillip Koo: Hi, I'm Phillip Koo. And welcome back to our exclusive coverage of the 13th International Uroncology Congress here in São Paul Brazil. We're very fortunate to have with us today, Dr. Arie Carneiro, who is a urologic oncologist at Albert Einstein here in São Paulo. He's giving two lectures at this conference, one on robotics and one on HIFU. So wanted to start on the topic of robotics. Can you give us sort of an update on robotics here in Brazil and the perspective on who the ideal candidate, especially in Brazil and Latin America?

Arie Carneiro: Yes. Nice. Very happy to be here with you. It's a big pleasure to be here. So about the robotic here in Latin America. It's growing up few years ago. So we don't have so many machinists like US like Europe. But now, the last two years, we have a lot of robots in different parts of the country. The big challenge here for Latin America population, Brazilian population, the erectile dysfunction is the most, not problem for us. The patients are so many concern about that. So we have robots just in private practice, so they have to pay for that. So when they come to us, the first question is, "How will be my erectile dysfunction?" So we have to talk a lot of these patients, the risks of that. So most of the case have to focus in a good neurovascular bundle preservation, sometimes more than US surgeons and European surgeons used to do, because this profile of our patients, there's much more concern about erectile dysfunction than their concern.

Phillip Koo: So it seems like erectile dysfunction is driving the patient choices to seek out something like robotic surgery.

Arie Carneiro: Yes. Yes.

Phillip Koo: And then in general, in terms of urologists who are performing this, are we seeing a greater number of urologists being trained in this and comfortable doing this procedure?

Arie Carneiro: Yes, the past three years we have some centers in Brazil, two or three, that they are training new surgeons. We had a gap for that 10 years that our Brazilians surgeons had to go to Europe or US like I did to train. But now the last three years, we can training Brazilian surgeons here in our hospital and other two hospitals in Brazil.

Phillip Koo: I think, when I hear stories like that, it's always so inspiring. And it's really a model of how we need to tackle some of these problems. And this idea of training and bringing that training home and then training more people underneath you is such a rewarding experience. So thank you for being a leader in that space.

Arie Carneiro: Yeah, it's nice.

Phillip Koo: So the second topic you're talking about is HIFU, and HIFU... A very interesting topic, and look forward to hearing Dr. Klotz speak about HIFU. What has your experience been with HIFU in Brazil, and how would you describe the best candidate for HIFU in Latin America?

Arie Carneiro: Yes. The HIFU, or focal therapy for prostate cancer, is very controversial topic still here in Brazil. Countries like our country, like undeveloped countries, technology is more... Comes late. The concept come late. The urologists delay to accept these new concepts. So we bring HIFU for our hospital in 2018, the focal one. And we started the program. I believe in this technology. I believe in the focal treatment, because we know that a lot of patients do not have improve of the cancer specific survival with the surgery, with the hydration therapy. Some patients with small disease, mainly patients with ISUP 2 unilateral, for me, spot case. I think that's the best case for them, because it's a very small disease. I'm not comfortable for active surveillance. And the prostatectomy or hydration therapy maybe is too much aggressive for these kind of patients.

I used to tell for the patients in this scenario, "So we can do a focal therapy with two objectives. One to avoid radical treatment, or delay radical treatments." Sounds good. The patients like that. If I have sixty-five years old, I'm working, I have a new wife, something like that. We can perform the HIFU to delay 10 years a radical treatment like hydration therapy or something like that. The results are good. Our [inaudible 00:05:00], we have 150 cases. We have 90% of recurrence. Half of this recurrency is ISUP 1 that you are adjusting acute survival in this moment. And another, we can play with another HIFU or radical prostatectomy.

So the patients like... Because at the clinic treatment, they come to the hospital 7:00 AM, and at the lunch time he's at his house. And the next week he can work, he can play, he can play tennis and do whatever he want. So the experience is nice, but there is some limitations. We cannot treat a huge lesions like dilateral disease. I don't believe in [inaudible 00:05:47] HIFU. If I feel that I have to treat the whole prostate, I perform prostatectomy. But if my patient has unilateral disease, ISUP 2, I believe that a focal therapy can be a good option for these patients.

In Brazil, another particularity that active surveillance is very difficult for us. Our culture, most of the patients don't want to stay with cancer. The word cancer is to have, for most of the patients, families say no I have to treat brother. You have to treat friends, you have to treat... Most of these patients come to us to do the surgery. When you suggest active surveillance, you have to spend one hour more to try to convince this patient to do active surveillance. And most of that, no. I'd like a treatment. Most of the case, they go through radical prostatectomy. But for me, I offer HIFU earlier, before I offer prostatectomy for these patients. Some studies show that we can delay the progression and avoid radical treatment in this population also.

Phillip Koo: So there clearly seems to be a niche where, especially here in Brazil, patients might be seeking this out. And I think with erectile dysfunction being such a concern, maybe that has helped driving some patients in that direction. So for MRI, how often are you following these patients with MR post-HIFU?

Arie Carneiro: Yeah. These patients... Before HIFU everyone has MRI and fusion biopsy, because you have to see what you want to treat. If you don't have a good exam, like a good MRI, good biopsy. You cannot do a focal treatment because you don't know if on the other side you have disease also. Every patient that I perform HIFU, after six months I repeat the MRI, and then try to repeat the biopsy to confirm the success of the treatment with control biopsy. But 40% of my patients has PSA less than one and MRI very good. They don't want to do the biopsy. So, "Oh, why I have to do, doctor. My PSA is less than one. My MRI is good." I need a research protocol, please. But most of them are not... Don't want to do that.

Phillip Koo: Maybe that's a protocol you could lead here in Brazil. That would be wonderful.

Arie Carneiro: Yeah.

Phillip Koo: Good. Well, thank you very much for your perspective. I think this is very enlightening, and I think there's a lot of opportunity here to explore these different areas. So thank you.

Arie Carneiro: Thank you so much. Good to see, good to be with you. Thank you so much.