Mr Jim Adshead MA MD FRCS (Urol)Consultant Urological SurgeonLister Hospital, StevenageSpire Hospital HarpendenE mail: j.adshead@nhs.net

Connect Meeting Men's Health November 20th 2008

Urology Update

Update to include

• 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 LUTSfrom 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

•

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

• Radiotherapy

• HIFU

• Cryotherapy

• Why has surgery been unpopular– More bleeding– higher incontinence– Likely erectile dysfunction– May not die anyway

•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”.

High Quality Care for all- NHS Next Stage Review

da Vinci Prostatectomy access

Open Surgical Incision

da Vinci® Prostatectomy Incision

80% 5 yrs ago in US 80% last year in US

The surgeon directs the instruments

Surgeon directs the instrument movements using Console controls

Goals of prostatectomy

Remove the cancer

Preserve urinary function

Preserve erectile function

X

X

X

Why are patients demanding robotic surgery

Fewer complicationsLess blood loss, transfusionsLess postoperative painQuicker return to normal activitiesFaster recoveryShorter length of hospital stayShorter catheterizationLess scarring

Potential benefits of da Vinci® Prostatectomy

Improved cancer controlFaster return to continenceFaster return potency

Wrist and finger movement

Thank you

Connect Meeting Men's Health November 20th 2008

Urology Update