GP Masterclass in Urology Problems with the Prostate Mr Alvan Pope - Urological Surgeon, Hillingdon Hospital Functions of the prostate • The role of the prostate gland in ejaculation and continence is uncertain • The prostate gland secretes nutrients and fluid • The prostatic epithelium secretes prostatespecific antigen (PSA), which is responsible for liquefying semen BPH Benign Prostatic Hyperplasia • Increasingly common over 50 y • Symptoms have major QOL impact • Potential serious complications • Both medical and surgical treatments Men with BPH The Patient - who seeks advice? - who to investigate? - who to treat? - who to refer? Who seeks advice? • The worried well (esp. about cancer) • Incidental findings on health screening (poor stream, nocturia, urgency) • symptomatic lower urinary tract symptoms (LUTS) • other causes - eg: prostatitis, urethral stricture, bladder dysfunction Who to investigate? • LUTS with IPSS > 8 • Prostate cancer concern • Examination - enlarged bladder, genital pathology (eg. phimosis,meatal stenosis) - DRE (enlarged or not?, benign or not?) • Invests. - urinalysis (sugar and blood), MSU - PSA, creatinine - imaging, residual urine and flow rate Who to treat? • Reassurance often sufficient (c.f. cancer) • Watchful waiting is legitimate management • Treat those with moderate symptoms who are bothered (IPSS > 8-10) Medical therapy for BPH • Consider the dynamic (urethral pressure) and static (prostate bulk) components • Most of the enlarged prostate is stroma which has lots of smooth muscle. Bigger = more glandular tissue • Alpha blockers (Tamsulosin, Alfuzosin, Doxazosin) • 5 alpha reductase inhibitors (Finasteride, Dutasteride) 5-AR inhibitors Block conversion of testosterone to DHT in prostate The ONLY randomised double blind placebo controlled trial of Finasteride versus Dutasteride demonstrated NO differences in any of the outcome measures at any of the time points sp on ne so v e red r p tr ub i al li s - A he R d I4 00 01 The EPICS trial • Enlarged Prostate International Comparator Study (EPICS) • Multicentre trial, Intention to treat analysis • Number randomised: 1630 • IPSS >12 G S K • Prostate volume >30ml • Qmax <15ml/s • Data collection: 3, 6 and 12 months Drugs for bladder dysfunction • Overactive bladder - anticholinergics • Oxybutynin (Ditropan, Lyrinel XL, Kentera patch) • Tolterodine & Fesoterodine (Detrusitol XL, Toviaz) • Solifenacin (Vesicare) poorly tolerated esp. dry throat, constipation contraindicated in closed-angle glaucoma • Nocturnal polyuria (Diuretics, DDAVP) Symptomatic BPH Monotherapy or combination therapy ? Alpha blocker and 5aRI Evidence for: • increased symptom benefit • reduction in complications or need for intervention • possible reduction in prostate cancer risk MTOPS Study • Combination therapy with doxazosin and finasteride led to a greater decrease in the risk of clinical progression of BPH than either drug alone, in patients with a baseline prostate volume above 25ml • With smaller prostates the benefit was towards the dozasosin only arm, except for the need for surgery CombAT Study • 4 yr study of nearly 5000 men with moderate to severe BPH symptoms • Randomised to either Dutasteride or Tamsulosin alone or to the combination • The combination group were best for: symptom improvement (IPSS down 6) reduction of risk of AUR (66% over T) Who to refer? • Abnormal DRE examination • PSA raised (>6ng/ml below 70 or >10 in older men) • Failed medical treatment • Haematuria, recurrent UTI, retention • Severe symptoms (IPSS>19) • (Anxious patients) Hospital assessment • Integrated prostate clinics (CNS run one-stop shop) • flow rates, residuals • urodynamic assessment (esp. if predominately irritative symptoms) • TRUS and biopsy • flexible cystoscopy Surgical Treatment • TURP is still the ‘gold standard’ - some new angles • Laser techniques (safer in frail, anticoagulated etc.) • Green-light laser • Holmium laser • Prostate stents (good temporary measure in unfit men - unless large residual) Does a 5-ARI drug reduce the risk of prostate cancer? Probably YES • Several studies (PCPT, REDUCE, combAT) have shown reduction in incidence of prostate cancer in men on 5-aRI • PCPT trial - 25% reduction in risk with finasteride Gleason grade 8-10 in 6.4% of treated group, 5.1% of control group • 40% reduction in CaP diagnosis over 4 yr with Dutasteride vs. Tamsulosin • Study where routine biopsies - 23% reduction. Caes History - 76 yr man • Longstanding lower urinary tract symptoms • Drugs - alpha blocker (Doxasosin) and 5-ARI (Finasteride) • O/E - large BPH on DRE • Tests - MSU >105 coliform • Flow rate prolonged and <10ml/s • 350ml post-void residual • PSA 12.8 ng/ml • Management • Antibiotics (quinolones) for 10 days • Prostate surgery (TURP) Types of retention • • Acute Chronic (high or low pressure) Acute Retention Surgical emergency Assessment History Examination (abdomen & prostate) Catheterise and admit Consider trial of voiding (a blocker) Some catheters are tricky Precipitating causes • • • • • • Post-operative Constipation Infection Haematuria Pelvic pathology Neuropathy Management of retention • • • • Urethral catheter (consider size & type) Suprapubic catheter RECORD RESIDUAL VOLUME Watch for post-obstructive diuresis esp. in chronic retention with obstructive nephropathy Chronic retention Chronic retention Obstructive Nephropathy Post Obstructive Diuresis • Diuresis with high sodium excretion represents tubular damage rather than solute load • Most at risk - heart failure, confusion • Replace majority of loss with saline • Prognosis for chronically obstructed kidney difficult to predict (u/s, renography) Prostatitis • Acute bacterial prostatitis - serious systemic infection • High dose systemic antibiotics eg. Gentamicin • Complications of retention and prostatic abscess • Chronic bacterial prostatitis (CBP) • Significant inflammation • Isolation of organism from urine or semen • Chronic pelvic pain syndrome (CPPS) • Inflammatory - leucocytes in semen/urine/prostate fluid • Non-inflammatory - no leucocytes • Symptoms • Perigenital or perineal pain • Voiding symptoms (frequency, straining, dysuria, UTI’s) Prostate Cancer Prostate Cancer Facts • 10,000 deaths a year in UK , 30,000 new cases • Commonest male cancer death in non-smokers • Can only reliably cure localised disease • No agreed screening programme • A lot of low-risk disease • Risk of over-treatment is substantial Tools to aid managment Epidemiology z Prostate cancer is the most common form of cancer in men in the UK. In 2002 there were 31,923 new cases diagnosed in the UK. z It is the second commonest cause of cancer death in men. In 2004 there were 10,209 deaths in the UK z The lifetime risk of being diagnosed is 1 in 13 Epidemiology Diagnosis and screening • DRE - digital rectal examination • PSA - prostate-specific antigen • TRUS-guided needle biopsy • Bone scan and/or CT • Diffusion weighted MRI PSA and Prostate Cancer • Prostate cancer more common as PSA rises • Age specific range • Under 3 ng/ml age 50 - 59 • Under 4 ng/ml age 60 - 69 • Under 5 ng/ml age > 70 • PSA increases with prostate size & inflammation Signs and symptoms of Prostate Cancer • Often asymptomatic • LUTS - perhaps rapid onset • Raised PSA level - on suspicion or screening • Look for change in PSA (eg 2ng/ml/yr, 50% in 2yr) • Urinary tract infection • Haematuria, haematospermia • Urinary retention (may cause anuria, uraemia) • Bone pain - most common symptom of metastases Histological grading The Gleason grading system Gleason score Histological characteristics 10-year likelihood of local progression <4 Well differentiated 25% 5-7 Moderately differentiated 50% >7 Poorly differentiated 75% Staging of prostate cancer Clinical presentation Three stages of prostate cancer • Localised disease • Locally advanced disease • Advanced (metastatic disease) Treatment options: localised prostate cancer • Watchful waiting/active surveillance • Surgery - Radical Prostatectomy • Radiotherapy • External Beam (with or without LHRH analogue) • Brachytherapy (low/high dose) • Combination (EBRT with HDR boost) • Cyber Knife (possible future role) • Cryotherapy and HIFU (experimental as first line) • TURP if symptomatic Treatment options: localised prostate cancer • Young men (<60) - AM or surgery • Middle age (60 - 70) • Low risk - AM or brachytherapy (LDR) • High risk - surgery or radiotherapy (HDR) • Older men (70 - 80) - WW or Ext beam RT • Very old men (>80) - watchful waiting Radical Prostatectomy Da Vinci Robotic Prostatectomy Problems after surgery - 1 Incontinence - sphincter weakness • Pelvic floor exercises • Yentreve early on • Male urethral sling (cf: TVT) • Rarely need for artificial urinary sphincter Problems after surgery - 2 Erectile Dysfunction • Still 40% even with nerve sparing • Worse with increased age and wide excision • New technologies not proven better • Oral drugs often ineffective - Caverject • Rationale for penile rehabilitation - Vacuum device and regular low-dose Tadalafil Treatment options: locally advanced disease • Watchful waiting • Radiotherapy with hormonal therapy • Hormonal therapy – LHRH analogue or antiandrogen monotherapy, surgical castration • TURP for symptom relief • Radical prostatectomy in selected cases Treatment options: advanced prostate cancer • Androgen ablation therapy - medical castration (LHRH analogue) or surgical castration (orchidectomy) • Maximal androgen blockade (MAB) LHRH analogue/surgical castration with anti-androgen therapy • Chemotherapy (Taxotere based, Abiaterone) Usually only when established hormonal resistance • TURP for relief of symptoms • Radiotherapy Treatment options: Advanced disease (distant metastases - esp. bone) • • • • Palliation of bone pain and urinary symptoms Hormonal therapy - androgen ablation Radiotherapy can relieve pain Radiopharmaceuticals can provide targeted pain relief • Chemotherapy should be considered if tumour is resistant to hormonal therapies Prostate cancer: Hormonal treatment options Aim to block production or action of testosterone • LHRH agonists Goserelin (Zoladex), Leuprorelin (Prostap) Triptorelin (Decapeptyl) Histrelin - 1 year implant • LHRH antagonists Degarelix (Firmagon) - no flare, rapid effect • Oestogens - either oral (Stilboestrol) or transcutaneous (Fem7 patches) Side effects of Androgen Deprivation Therapy • • • • • • • Lethargy, sweats, hot flushes (CPA) Lack of libido, loss of erections Loss of muscle mass/gain fat Loss of physical capacity, fatigue Changes in mental capacity Gynaecomastia and breast pain (Tamoxifen) Osteoporosis/fractures Salvage Prostate Cryotherapy For failed primary radiotherapy - NICE approved QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. 2 freeze/thaw cycles down to 40oC with rectal warming Prostate Cancer Follow-up Largely PSA surveillance • Hospital Based? clinic visits or telephone • Patient triggered • GP for stable patients (SCP, SLA) CASE HISTORY Prostate Disease • A fit 64 year old man volunteered a history of mild voiding symptoms at routine medical • IPSS 7 • DRE mild enlargement of prostate, sulcus intact but a firm nodule in the right lobe, prostate not tender • Urinalysis clear • PSA 9 ng/ml CASE HISTORY Prostate Disease Questions • What is a possible cause of a prostatic nodule? • What is the significance of the PSA result? • How should this patient be further investigated? • If the PSA had been normal how would your management have differed? Screening for PC Only way to pick up early disease whilst curable Still cannot separate tigers from pussycats • Happening by default increased public awareness more media exposure • March 2010 - PC awareness month • Charities, fundraising, support groups That’s all Folks! Questions to the panel after all the talks please
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