prostate cancer detection, urolifts, haematuria
TRANSCRIPT
Urological Cancer Indicators & Innovations in Prostate Disease Management
Marc Laniado MD FEBU FRCS(Urol) Consultant Urological Surgeon
Specialising in prostate cancer and BPH
Nuada Medical
Three main areas of interest
Visible haematuria: suspected cancer referrals
• >45 years
• unexplained visible haematuria without UTI or
• visible haematuria that recurs after UTI treatment
Non-visible haematuria (NVH) is + or more blood on urinalysis
Non-visible Haematuria (3 urine dipstick over 2 to 3 weeks)
Symptomatic “s-NVH”
Significant if ≥1 of 3 samples dipstick +, ++, +++
Asymptomatic “a-NVH”
Significant if ≥ 2 of 3 urine samples dipstick +, ++, +++
> 60 years old
• non-visible haematuria AND
• dysuria
OR
• WBC elevated [NEW CG27, 2015]
Bladder cancer: suspected cancer referral
Non-urgent referral for NVH if < 60 years old
<40 years 40-60 years >60 years
Asymptomatic: risk factors for significant disease ! refer to haematuria clinic, otherwise monitor
Routine referral to haematuria clinic
Urgent Referral under 2 week wait
Symptomatic: Routine referral to haematuria clinic
Non-urgent referral for haematuria/bladder cancer clinic
Recurrent UTI & > 60 y old
Prostate cancer testing?Symptomatic men Asymptomatic men
• Consider PSA & do prostate examination for
[1.6.2]
Symptoms of concern - urological evaluation
• unexplained weight loss [1.13.2]
• Carry out evaluation symptoms/signs/findings to clarify which cancer
• Suspected cancer referral [new 2015] • PSA > age specific reference range PSA [1.6.3] • Abnormal DRE [1.6.1]
PSA thresholds vary…
Age Range
Public Health England & PCRMP*
BAUS Prostate Cancer UK
45 to 49 2.7 2.5 + risk factors
50 to 59 3 3.960 to 69 3 5.070 to 79 7.2≧ 80
❋Prostate Cancer Risk Management Programme 2016, Consensus Statement
Prostate cancer testing?Symptomatic men Asymptomatic men
PCRMP guidance states that "The PSA test is available free to any man aged 50 or over who requests it, after careful consideration of the
implications".
Don’t test PSA if recent UTI, ejaculation, cycling, prostate stimulation
Always repeat the PSA 2 to 4 weeks later
PSA
Freq
uenc
y
50% of abnormal PSA values ARE NORMAL on retest
PSA testing in asymptomatic men
Prostate Cancer Risk Management Programme, Public Health England 2016
If risk factors for PCa, refer with PSA below threshold in some situations
Pan
Pr
Pr PanBr
Br
PrPr
O
C
Family History
Black men
Obesity
Old pathway for investigation
Cancer
Many flaws….
Treatment Options are Broad & Unclear
?
10 y Prostate Ca mortality same when compared by original treatment allocation
NEJM 2016
Ave age 62, (life expectancy 17 y)
20% progressed if randomised to active monitoring
NEJM 2016
Surgery/RTActive
monitoring
Over 50% of monitoring group eventually needed treatment as misclassified
NEJM 2016
Prebiopsy MRI & MRI-targeted transperineal biopsies correctly stratify patients (& no infections)
Cancer
Monitor PSA & no biopsy if normal MRI
Radical prostatectomy
Conventional whole prostate treatments cannot assure good functional outcomes
Radical radiotherapyActive monitoring
Solution is to treat only that part of the prostate with significant cancer - Focal Therapy
Prostate cancer on right side Half the prostate
scheduled for treatment ∴ fewer side-effects
MRI-targeted HIFU @ PMH
Post HIFU MRI shows ablation
Ablated area
Unaffected Prostate
Prostatic Urethral Lifts - symptom relief & normal
ejaculation
Marc Laniado MD FEBU FRCS(Urol) Consultant Urologist
BPH affects all older men
30 40 50 60 70 80
100%
50%
0%
Age
Perc
enta
ge o
f men
affe
cted
Here today to learn about for BPH - your patients have read it in the Daily Mail!
Current treatments for BPH cause sexual dysfunction
Surgery: HOLEP
Drugs: 𝝰 blocker
….men don’t want sexual side-effects
Functional anatomy of the male genitourinary tract
Normal ejaculation requires an intact bladder neck
UroLift implant designed to compress prostate lobes
Implant
Delivery Device
UroLift retract prostate lobes without affecting bladder neck
Urinary symptoms score drops by 11 points after UroLift
UroLift
TURP
Sonksen 2015 Eur Urol
UroLifts relieve symptoms by 4 weeks, last at least 4 years
IPSS
Poi
nts
4 years
Storage symptoms
Voiding symptoms
14
1210
864
2
0
Roehrborn 2015 Can J Urol
Faster quality of life recovery after UroLift compared to TURP
TURP
UroLift
Sonksen 2015 Eur Urol
Antegrade wet ejaculation & better sex after UroLift compared to TURP
UroLift
TURP
Ejac
ulat
ory
& Se
xual
Fun
ctio
n
Sonksen 2015 Eur Urol
Side effects are transient (2 weeks) & well tolerated
UroLift Controls
Dysuria 34% 17%
Hematuria 26% 5%
Pelvic pain 18% 5%
Urge Incontinence 4% 2%
UTI 3% 2%
UroLift fits well into the existing pathway
Man with persistent LUTS due
to BPH
Ejaculation important
?
Tamsulosin
Alfuzosin
≦80 g No Median lobe PVR < 150 ml
N
Y
still bothered
still bothered
Y
N
UroLift
HoLEP