Advances in Urology Practice , a historical perspective • 1995 TRUS biopsies and open radical prostatectomy • 1996 Urodynamics • 1997 Uro-Gynecology service • 1997 Laser Prostatectomy (Neodymium Yag) • 1998 Smiley Incision open radical prostatectomy • 1999 TVT colposuspension • 2000 PCNL service for kidney stones • 2002 Model for Evaluation of Dynamics of Prostate Cancer • 2003 Specialist MDT • 2004 Laparoscopic Nephrectomy • 2004 Laparoscopic Radical Prostatectomy • 2005Laparoscopic Pyeloplasty • 2006 Robotic Arm LRP • 2007 Laparoscopic Partial Nephrectomy • 2008 PCA3 Urine Test for early diagnosis of Prostate Cancer • 2009 Holmium Laser for stones • 2010 Single 1 cm technique of LRP • 2011 Template prostatic biopsies • 2011 Zero ischaemia partial nephrectomy • 2011 HOLEP for BPH • 2013 Hand Assisted Laparoscopic Radical Prostatectomy( under evaluation)
Transcript
Advances in Urology Practice , a historical perspective
• 1995 TRUS biopsies and open radical prostatectomy• 1996 Urodynamics• 1997 Uro-Gynecology service• 1997 Laser Prostatectomy (Neodymium Yag)• 1998 Smiley Incision open radical prostatectomy• 1999 TVT colposuspension• 2000 PCNL service for kidney stones• 2002 Model for Evaluation of Dynamics of Prostate Cancer• 2003 Specialist MDT• 2004 Laparoscopic Nephrectomy• 2004 Laparoscopic Radical Prostatectomy• 2005Laparoscopic Pyeloplasty• 2006 Robotic Arm LRP• 2007 Laparoscopic Partial Nephrectomy• 2008 PCA3 Urine Test for early diagnosis of Prostate Cancer• 2009 Holmium Laser for stones• 2010 Single 1 cm technique of LRP• 2011 Template prostatic biopsies• 2011 Zero ischaemia partial nephrectomy• 2011 HOLEP for BPH • 2013 Hand Assisted Laparoscopic Radical Prostatectomy( under evaluation)
Why Urology in primary care
• Ageing population
• Dignity, aesthetics and quality of life
• Urological cancers
• Cost of pads and appliances
• Cost of falls and orthopaedics operationsShiv Bhanot
Urology Service at BHRT
• Comprehensive Service• Based at KGH, Cancer centre• Clinics at Queens and in the community• 6 Consultants• 8 middle grade urologists• 3 CNSs• Acute Receiving Unit
What will be covered ?
• What is LUTS• Assessment and treatment of LUTS• When to refer for LUTS• When to do a PSA• When to refer for raised PSA• Early Prostate Cancer Treatment• Kidney Stones• Urinary Incontinence
Shiv Bhanot
LUTS
• Lower urinary tract symptoms• Frequency, urgency and nocturia• Hesitancy • Weak or interrupted flow of urine• Incomplete bladder emptying• Post micturition dribbling
* Dysuria and pain are not LUTS
Shiv Bhanot
The urological basis of LUTS Two special muscles of urinary tract
Detrusor
(always resting except)
Sphincter
(always active except)
Bladder
Prostate
UrethraShiv Bhanot
What can you do for LUTS• General medical history• Physical examination, DRE• Urine test• Frequency volume chart• Reassurance, life style advice• Offer serum creatinine• Offer IPSS• Offer PSA• Offer drug treatment• Offer specialist referal
Shiv Bhanot
Shiv Bhanot
Drug TreatmentIndication Treatment Review
LUTS Alpha bocker at 4-6 weeks then 6-12 m
OAB Anticholinergic at 4-6 weeks then 6-12 m
>30gm, PSA>1.4 5 alpha reductase inhibitor at 3-6 m then 6-12 m
High IPSS, >30gm, PSA>1.4 5 ARI + alpha blocker at 4-6 weeks then 6-12 m
The vast majority can tolerate TURP, selection is the key to success for surgery
Shiv Bhanot
An alternative to surgery for Retention
Done under local anaesthetic, can be easily reversedShiv Bhanot
PSA Test
• Very good tumour marker• No positive or negatives for diagnosis• Marker of prostatic size in BPH• Truly speaking not a test but a measure• Measure of probability and not diagnostic of Ca• Allows diagnosis of early prostate cancer• 20% of all prostate cancers have normal PSA
Shiv Bhanot
When to offer a PSA Testoffer information, advice and time to decide
• Active surveillance• Surgery• Radiotherapy• HIFU• Brachytherapy• Cryotherapy• Hormonal treatment
Shiv Bhanot
EPC Treatment, Patient Choice
• Age and Life Expectancy
• Risks vs Certainty
• Possibilty of second and third treatment
• Intensity of follow up
Shiv Bhanot
Surgery for Early Prostate Cancer
• Open Radical Prostatectomy
• Laparoscopic Radical Prostatectomy (Pure or Robotically assisted)
Shiv Bhanot
Single 1 cm port opBritish Journal of Urology International March 2011
Shiv Bhanot
Laparoscopic Partial Nephrectomy
• Why ?• High Prevalence of DM and HT• Ageing population• 5 and 10 yr survival becoming rather
irrelevant( 20 to 50 yr life expectancy !)• Nephron sparing cancer surgery• Laparoscopy and combination of minimal or
zero ischaemia surgery
Shiv Bhanot
Kidney Stones
• Majority expel spontaneously• Tamsulosin helps in expulsion• ESWL and ureteroscopic Laser/mechanical
treatment for the reminder• Very few PCNLs• Open Surgery very rare
Shiv Bhanot
Prevention of Kidney Stones
• If overweight lose weight• Decouple fluid intake and out put• Aim for at least 2 litre out put every day• Reduce meat and alcohol intake• Reduce salt intake• Do not reduce calcium intake• Treat metabolic abnormality
Shiv Bhanot
Female Urinary Incontinence
• Prolapse does not cause urinary incontinence• Stress or urge incontinence ?• Oxybutynin or solfenicin• Trickling down the thighs or flooding of floor• Urethral mobility• Pelvic floor tone and PFEs• TVT is the standard surgical treatment for SUI
Shiv Bhanot
Surgical Experience, 20 years
• > 1200 major cases of kidney, bladder and prostate cancer
• Other interests, Female Urology, TVT, Stones
• Since 2004 all kidney and prostate cancer operations done laparoscopically
