Urology and male health

Eamonn RogersEamonn RogersMercy University HospitalMercy University Hospital

CorkCork

Role of Urologist

CancerCancer ProstateProstate TestisTestis

Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia Erectile DysfunctionErectile Dysfunction Urinary IncontinenceUrinary Incontinence

The Prostate – Why does it become diseased so often? Only male organ to enlarge with ageOnly male organ to enlarge with age Enlargement impedes urine emptying from Enlargement impedes urine emptying from

bladderbladder May inhibit ejaculationMay inhibit ejaculation Commonest cause of cancer in malesCommonest cause of cancer in males

Aging and the Prostate

Only 2 known risk factors for developing Only 2 known risk factors for developing Prostate Hyperplasia / NeoplasiaProstate Hyperplasia / Neoplasia

AgingAging Functional testicular tissue (Testosterone)Functional testicular tissue (Testosterone)

Ageing Male

TThe he IIrish rish LLongtituongtituDDinal inal AAgeing Studygeing Study 1999 = 11% > 65 YEARS1999 = 11% > 65 YEARS 2011 = 15% > 65 YEARS2011 = 15% > 65 YEARS 2031 = 19% > 65 YEARS2031 = 19% > 65 YEARS

2035 = 66% > 80 YEARS2035 = 66% > 80 YEARS

Benign Prostatic Hyperplasia (BPH) develops Benign Prostatic Hyperplasia (BPH) develops deep within the prostate and is more likely to deep within the prostate and is more likely to “squeeze” the water passage and cause symptoms“squeeze” the water passage and cause symptoms It is much more common than cancer (90%)It is much more common than cancer (90%) It starts in men from the age of 40 and progressively It starts in men from the age of 40 and progressively

growsgrows

Cancer develops in the outside of the gland and Cancer develops in the outside of the gland and rarely causes symptoms in its early stages until the rarely causes symptoms in its early stages until the tumour becomes advancedtumour becomes advanced

Structure of the Bladder

Prostate cancer

Slow growing but eventually lethalSlow growing but eventually lethal Most prevalent male cancerMost prevalent male cancer 2nd commonest cause of male cancer deaths2nd commonest cause of male cancer deaths 85% PSA detetcted cancers will eventually 85% PSA detetcted cancers will eventually

progress (7-10 years)progress (7-10 years)

Therefore the only way one can detect early Therefore the only way one can detect early prostate cancer is with prostate cancer is with

A) a blood test (PSA)A) a blood test (PSA) B) feeling the surface of the prostate by means B) feeling the surface of the prostate by means

of an internal examinationof an internal examination

Histological Differentiation – Gleason Grade /Score In multivariate analysis the most important In multivariate analysis the most important

clinical parameter predicting the clinical parameter predicting the NATURAL HISTORY OF PROSTATE NATURAL HISTORY OF PROSTATE CANCER i.e.CANCER i.e.

Rate of progressionRate of progression PrognosisPrognosis

Histology – Gleason Grade 3

Histology – Gleason Grade 5

Histological Differentiation – Gleason Grade /Score 5 Gleason grades (1-5) based on 5 Gleason grades (1-5) based on

histological aggression of tissuehistological aggression of tissue ArchitectureArchitecture CytologyCytology

Gleason score estimates the 2 most Gleason score estimates the 2 most prevalent patterns (e.g. 3+4 = 7; 2+2 = 4)prevalent patterns (e.g. 3+4 = 7; 2+2 = 4)

Histological Differentiation – Gleason Grade /Score

Histological Differentiation – Gleason Grade /Score

Well differentiated = Gleason score(2,3,4)Well differentiated = Gleason score(2,3,4)

Mod. differentiated = Gleason score(5,6,7)Mod. differentiated = Gleason score(5,6,7)

Poor differentiation = Gleason score(8,9,10)Poor differentiation = Gleason score(8,9,10)

Natural History - Histology

Well differentiated / Gleason score(2,3,4)Well differentiated / Gleason score(2,3,4) 10% metastases at 10 years10% metastases at 10 years

Mod. differentiated = Gleason score(5,6,7)Mod. differentiated = Gleason score(5,6,7) 42% metastases at 10 years42% metastases at 10 years

Poor differentiation = Gleason score(8,9,10)Poor differentiation = Gleason score(8,9,10) 74% metastases at 10 years74% metastases at 10 years

Radical Retropubic Prostatectomy 1

Radical Retropubic Prostatectomy 2

Radical Retropubic Prostatectomy 3

Radical Retropubic Prostatectomy 4

Complications - Longterm

Bladder neck contractureBladder neck contracture ImpotenceImpotence Urinary IncontinenceUrinary Incontinence

Sphincter =StressSphincter =Stress BladderBladder

Robotic Prostatectomy 1

Robotic Prostatectomy 2

Robotic Prostatectomy 3

Robotic Prostatectomy 4

Robotic Prostatectomy 5

Laparoscopic or Open

Very user dependentVery user dependent Robotic promising but extremely expensiveRobotic promising but extremely expensive No prospective trial comparing modalities with No prospective trial comparing modalities with

longterm cancer specific survivallongterm cancer specific survival Potency better ?Potency better ? Positive margin ratesPositive margin rates

Open = 9%Open = 9% Lap = 14%Lap = 14%