Urology Update Sanofi- Aventis

1
Urology Update Sanofi- Aventis

• Kenneth Lim, D.O.
• Urology Residency Director
• POH/ Detroit Medical Center

2
(No Transcript)
3
BPH and Aging
4
Diseases of the Prostate

• BPH / LUTS / OAB / Retention
• Signs and Symptoms
• Medical Management
• Prostate Cancer Detection

5
Anatomy of BPH
Normal
BPH
Bladder
Hypertrophied detrusor muscle
Prostate
Urethra
Obstructed urinary flow
Kirby RS et al. Benign prostatic hyperplasia.
Health Press, 1995.
6
Symptoms Suggestive of BPH

• Obstructive (Voiding)
• Weak stream
• Prolonged micturition
• Straining
• Hesitancy
• Intermittent stream
• Feeling of incomplete bladder emptying

• Irritative (Storage)
• Frequency
• Nocturia
• Urgency
• Incontinence

7
American Urological Association Symptom Index
(AUA-SI)

• Incomplete bladder emptying
• Frequency
• Intermittency
• Urgency
• Weak stream
• Straining
• Nocturia

AUA Practice Guidelines Committee. J Urol.
2003170(2 Pt 1)530?537. Barry MJ et al. J
Urol. 19921481549?1557.
8
AUA Symptom Index (AUA-SI)

• Classification
• Mild
• Moderate
• Severe

• AUA-SI
• 0 7
• 8 19
• 20 35

9
Criteria to Determine Treatment

• AUA Symptom Score (Quality of Life)
• Elevated Post-Void Residual
• UTI
• Hematuria
• Bladder calculus
• Retention

10
Medical Management for Symptomatic BPH

• Alpha blockers
• 5 Alpha reductase inhibitors
• Combination
• OAB drugs
• Observation

11
Pharmacotherapy of BPH
Alpha Blockers
5ARIs

• Reduce the prostate volume
• Improve symptoms
• Arrest the disease process

• Relax smooth muscle
• Improve symptoms

McConnell JD et al. N Engl J Med.
20033492387?2398.
12
Alpha-Blockers (Uroxatral, Flomax)

• Offers symptomatic relief within days/weeks
• Does not change size of prostate
• Side effects
• Nasal stuffiness, orthostatic hypotension
• Flomax retrograde ejaculation
• Uroxatral no retrograde ejaculatio

13
5 Alpha Reductase Inhibitor (Proscar, Avodart)

• Slower effect on urinary symptoms than alpha
  blockers
• Prostate size reduction
• Urinary retention risk reduction

14
Selection Criteria

• If Signs Symptoms Moderate to Severe
  (prostate size lt 30-40 gms)
• Alpha blocker - 2 weeks
• Cystoscopy /- Prostate Ultrasound
• If Signs Symptoms - Moderate to Severe
  (prostate size gt 50 gms
• Alpha blocker 5 alpha reductase inhibitor

15
OAB Drugs

• Direct action on bladder
• Storage
• Urgency, frequency

16
American Cancer Society Screening Guidelines

• DRE and PSA - Annually
• Age 50 no risk factors
• Age 40 - Family history of Ca Breast or
  Prostate - baseline prostate ultrasound

17
NEJM 5/04 PSA Inaccurate as Screening Test for
Prostate Cancer

• 15 of Patients with normal PSA diagnosed with
  Prostate Cancer
• PSA single best test for prostate cancer
  screening
• DRE and Prostate Ultrasound to compliment PSA
• TRUS Biopsy when any abnormality

18
Age related norms for PSA

• 40-49 lt 2.5 ng/ml
• 50-59 lt 3.5 ng/ml
• 60-69 lt 4.5 ng/ml
• 70-79 lt 6.5 ng/ml

19
PSA

• PSA velocity - .75 ng/ ml / year PSA
  velocity(2-4) - .4 ng / ml / year
• PSA 4-10
• Free PSA gt 20 low risk
• 10 20 intermediate
  risk
• lt 10 high risk

20
What to do with an abnormal PSA?

• 1. Look for a previous PSA, DRE
• If DRE abnormal, proceed to Biopsy
• 2. Cipro 500mg BID x 2 weeks
• 3. Free and Total PSA
• 4. Assess Cancer Risks for Biopsy
• 5. Biopsy when in Doubt

21
Prostate Ultrasound Biopsies

• Sextant format, local anesthesia, 10-12 biopsies
• Saturation biopsies 1 biopsy / gm
• Indications for biopsies
• Abnormal PSA high risk free PSA, PSA density
• Abnormal DRE
• Abnormal prostate ultrasound

22
The Buzz Robot Prostatectomy

• Better Cancer Cure
• Less Impotence, Blood loss
• Higher Incontinence
• Shorter Hospitalization

23
NEJM 4 / 08 Robot vs. Open Prostatectomy

• Conclusion No Difference
• Selection determined by patient bias