Transcript LUTS :GP investigation of Lower Urinary Tract Symptoms

Connect Meeting Men's Health
November 20th 2008
Urology Update
Mr Jim Adshead MA MD FRCS (Urol)
Consultant Urological Surgeon
Lister Hospital, Stevenage
Spire Hospital Harpenden
E mail: [email protected]
Update to include
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MTOPS study
Times study
Erectile dysfunction update
2 cases to discuss
Da Vinci Robotic
Prostatectomy
MTOPS worth a look
•MTOPS Medical treatment of prostate symptoms 4 arms
•3000 men randomised to doxazosin finasteride placebo or both
•But needed to treat 52 men to prevent 1 AUR
•27 men to prevent 1 TURP
•Very expensive
•Back to the risk of progression again 2 options
•1 Dual therapy for >40 ml prostates or PSA above 4 and severe symptoms
17/35
•2 Maybe we could stop the alpha blocker after 9 months
5-alpha reductase inhibitors
• Finasteride 5mg daily -type 1 activity
• Dutasteride 0.5mg daily -type 1 and 2
• Warnings
– Avoid blood donation(teratogenic)
– Females of child-bearing age shouldn’t touch
the tablet (teratogenic)
• MTOPS study –dual therapy
• Combat study -2 yr data
Sexual function and LUTS
from MTOPS
• Worse IPSS worse IIEF irrespective of age
– Unknown why
• More RX along the MTOPs pathway
– Worse ED
• All 3 PDEi improve IPSS as much as a
blockers
– Lots of papers coming out of daily PDEis
– Watch out for alpha blockers and PDEis
– Flomax ok
How do we differentiate the
Symptoms?
Erectile dysfunction
Case study 1
• 58 man presents with LUTS or a
headache
• What is the likelihood of finding prostate
cancer in these men?
• PSA is 9.8 - what to do
• Biopsy result
• 6 months later PSA 10.9
The Discovery of PCA3
• The PCA3 gene was discovered by Dr. Marion Bussemakers while
working with Dr. Jack Schalken at the University of Nijmegen in the
Netherlands and in the laboratory of Dr. William Isaacs at Johns
Hopkins University in Baltimore
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PCA3 test
58% positive
predictive value
90% negative
predictive value
Case study 2
• 82 man with AF presents with obstructed
LUTS
• DRE hard craggy prostate
• PSA 27
• What to do
Antiandrogens to all?
• Newly diagnosed prostate cancer patients
who received ADT for at least 1 year were
found to have a 20% higher risk of serious
cardiovascular morbidity compared with
similar men who did not receive ADT.
Subjects began incurring this higher risk
within 12 months of treatment.
The Da Vinci Robotically
Assisted Laparoscopic
Radical Prostatectomy
Mr James M Adshead
MA MD FRCS (urol)
Consultant Urological
Surgeon
Lister Hospital
Prostate cancer
• 2nd commonest Male cancer now
–neglected ct breast
• Explosion of incidence of early cancer
• 18% US
• 9% in UK
• Gold standard for early cancer is surgery
• Biggest Longest studies
• Best cure rates
• Back up plan
The search for minimally invasive
treatments
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Radiotherapy
HIFU
Cryotherapy
Why has surgery been unpopular
– More bleeding
– higher incontinence
– Likely erectile dysfunction
– May not die anyway
High Quality Care for all- NHS
Next Stage Review
•July 2008, p29…. “For the same illness, open surgery
leaves patients in hospital for several weeks where
keyhole surgery enables them to go home in just a few
days. With advances in robotics, patients can look
forward to scar-free surgery”…
•Earlier return to work is generally achievable with
robotic assisted surgery which benefits the economy as
a whole. As Lord Darzi, Health Minister, said this week
(quoted in The Sunday Times 6th July 2008) “ We need
robot technology. The cost may appear high but let us
not forget that currently patients are in recovery for 6
weeks – which is a huge cost for them personally”.
da Vinci Prostatectomy access
80% 5 yrs ago in US
Open Surgical Incision
80% last year in US
da Vinci® Prostatectomy Incision
The surgeon directs the
instruments
Surgeon directs the instrument
movements using Console
controls
Goals of prostatectomy
X
Remove the cancer
X
Preserve urinary function
X
Preserve erectile function
Why are patients demanding
robotic surgery
Fewer complications
Less blood loss, transfusions
Less postoperative pain
Quicker return to normal activities
Faster recovery
Shorter length of hospital stay
Shorter catheterization
Less scarring
Potential benefits of da
Prostatectomy
Improved cancer control
Faster return to continence
Faster return potency
®
Vinci
Wrist and finger movement
Connect Meeting Men's Health
November 20th 2008
Urology Update
Thank you