Transcript Managing the side effects of a radical prostatectomy

MANAGING THE SIDE EFFECTS OF A
RADICAL PROSTATECTOMY
Mr Rohan Hall
Goldfields Urology
STAGES OF DIAGNOSIS
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Receiving a result of an elevated PSA
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Referral to urologist
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Prostatic biopsy (TRUS or transperineal)
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Receiving the diagnosis
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Staging
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Receiving results
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Discussing management of localised prostate cancer
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Discussing the side effects of each treatment option
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Anxiety
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Depression
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Loss of autonomy
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Futility
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Anger
MANAGING THE “TRIFECTA”
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Oncology
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Pre-op
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Post-op
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Review appointments
Continence
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Pre-op lower urinary tract symptoms
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Pre-op preparation
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Post-op expectations
Erectile Function
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Pre-op erectile function
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Social circumstances
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Medical comorbidities
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Intra-operative variation
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Post-op expectations
POST-OP
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Wound
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IDC
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Pain
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Scrotal oedema
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Driving
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Cycling
URINARY CONTINENCE
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Male continence mechanism
URINARY CONTINENCE
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Pre-op pelvic floor education benefits post-op return to continence
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Post-op pelvic floor exercises – when to start
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What level of continence is normal in the post-operative period
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3/12 – 1 pad/day
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12/12 – 1 pad/day
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2% of patients will be wet, wet, wet
Other factors affecting ability to be continent:
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Chronic cough
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Obesity
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Diuretics
What if continent, then new incontinence?
BEHAVIOURAL MODIFICATIONS
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Decrease fluid intake
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Void frequently
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Avoid caffeine, alcohol
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Avoid activity that increases intraabdominal pressure
URINARY CONTINENCE
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What next – formal urodynamics to rule out over active bladder, also can
assess ALPP.
• Bulking agents
• Considered successful 17% of the time for post radical
prostatectomy SUI
• Pro’s - minor procedure
• Con’s – may need to be repeated
• Can set up local chronic inflammatory response making
further treatment difficult
URINARY INCONTINENCE
ADVANCE™ MALE SLING
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Sling restores urethra to its proper anatomical position for optimal
sphincter function, restoring urinary control
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Procedure:
– Spinal or general anesthesia
can be used
– Three small incisions: 1 under the
scrotum, 2 over groin creases
– Specially designed surgical tools
are used to position the sling
– Sling is gently tensioned
– Incision closed
ARTIFICIAL URINARY SPHINCTER (AUS)
• The Gold Standard for treatment
of moderate to severe
incontinence
• 60± minute outpatient procedure
• 92% of patients would have the
device placed again
• 96% of patients would
recommend it to a friend
• Device is placed completely in
the body, providing simple,
discreet control
- Requires dexterity for use of pump
ERECTILE DYSFUNCTION
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“The inability to attain and/or maintain penile erection sufficient for
satisfactory sexual performance”
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Prevalence of ED: 52% men older than 40 have some degree of erectile
dysfunction
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“Mandropause”
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Age 60 – 20% ED
• Age 70 – 70% ED
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Set expectations
• “The best erection they will achieve post-op is 70% of there pre-op
erection, and this may be with the aid of a PDE5-I”
ERECTILE DYSFUNCTION
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Aetiology
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Vasculogenic: arteriogenic vs veno-occlusive dysfunction
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Neurogenic
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Psychogenic – depression, stress, anxiety, psychiatric disorder
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Endocrinologic – hyperprolactinemia, thyroid disorder, hypogonadism
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Medications (b-blockers,antidepressants,spironolactone,sedatives,
phenytoin
ERECTILE DYSFUNCTION
• PDE5-I
• Penile Pump
• Intra-urethral suppository
• Intracavernosal injection
ERECTILE DYSFUNCTION
PDE5-inhibitors
Contraindications
How to use these tablets?
ERECTILE DYSFUNCTION
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Penile Rehabilitation
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- Daily cialis
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Aim to achieve 3 erections per week
• High dose PDE5-I
• Intracavernosal injections
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Alprostadil (caverject)
• Trimix
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Theoretically makes sense
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Lack of evidence
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Expensive
ERECTILE DYSFUNCTION – PENILE IMPLANTS
Ideal for men who have tried other treatments without success
• On the market for over 30 years
• 25,000 penile implants per year
• Over 300,000 implants to date
• High patient and partner satisfaction
TYPES OF PENILE IMPLANTS
One-piece non-inflatable
Two-piece inflatable
Three-piece inflatable
ONE - PIECE NON-INFLATABLE PENILE
IMPLANT
Advantages
• Easy for you or your
partner to activate
• Good option for men with
limited dexterity
• Totally concealed in body
• The simplest surgical
procedure
• Least expensive prosthesis
Disadvantages
• Stays firm when not in erect
position
• May “show” through
clothing
THREE – PIECE INFLATABLE PENILE
IMPLANT
Advantages
• Simple to use
• Fast and simple one-step
deflation
• Totally concealed in body
• Acts and feels more like a
natural erection
• Expands the girth of the penis
• More firm and full than other
implants
• Feels softer and more flaccid
when deflated
Disadvantages
• Requires some manual dexterity
• Possibility of leakage or
malfunction
• Possibility of unintentional
erections
QUESTIONS?