Urology Update Sanofi- Aventis

Kenneth Lim, D.O.

Urology Residency Director

POH/ Detroit Medical Center

BPH and Aging

Diseases of the Prostate

BPH / LUTS / OAB / RetentionSigns and SymptomsMedical Management

Prostate Cancer Detection

Anatomy of BPH

Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

NormalNormal BPHBPH

Hypertrophied detrusor muscle

Obstructed urinary flow

Prostate

Bladder

Urethra

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

American Urological Association Symptom Index (AUA-SI)

AUA Practice Guidelines Committee. J Urol. 2003;170(2 Pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.

Incomplete bladder emptying

Frequency Intermittency Urgency Weak stream Straining Nocturia

AUA Symptom Index (AUA-SI)AUA Symptom Index (AUA-SI)

ClassificationClassification

MildMild

ModerateModerate

SevereSevere

ClassificationClassification

MildMild

ModerateModerate

SevereSevere

AUA-SIAUA-SI

0 – 70 – 7

8 – 198 – 19

20 – 3520 – 35

AUA-SIAUA-SI

0 – 70 – 7

8 – 198 – 19

20 – 3520 – 35

Criteria to Determine Treatment

AUA Symptom Score (Quality of Life)Elevated Post-Void Residual

UTIHematuriaBladder calculusRetention

Medical Management for Symptomatic BPH

Alpha blockers5 Alpha reductase inhibitorsCombinationOAB drugsObservation

Pharmacotherapy of BPH

Alpha Blockers 5ARIs

Relax smooth muscleRelax smooth muscle• Improve symptomsImprove symptoms

Reduce the prostate volumeReduce the prostate volume• Improve symptomsImprove symptoms• Arrest the disease processArrest the disease process

McConnell JD et al. N Engl J Med. 2003;349:23872398.

Alpha-Blockers (Uroxatral, Flomax)

Offers symptomatic relief within days/weeks

Does not change size of prostateSide effects

Nasal stuffiness, orthostatic hypotensionFlomax – retrograde ejaculation Uroxatral – no retrograde ejaculatio

5 Alpha Reductase Inhibitor (Proscar, Avodart)

Slower effect on urinary symptoms than alpha blockers

Prostate size reductionUrinary retention risk reduction

Selection Criteria

If Signs & Symptoms – Moderate to Severe (prostate size < 30-40 gms)Alpha blocker - 2 weeksCystoscopy +/- Prostate Ultrasound

If Signs & Symptoms - Moderate to Severe (prostate size > 50 gmsAlpha blocker + 5 alpha reductase inhibitor

OAB Drugs

Direct action on bladderStorageUrgency, frequency

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

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

Age related norms for PSA

40-49 < 2.5 ng/ml50-59 < 3.5 ng/ml60-69 < 4.5 ng/ml70-79 < 6.5 ng/ml

PSA

PSA velocity - .75 ng/ ml / year PSA velocity(2-4) - .4 ng / ml / year

PSA 4-10 % Free PSA > 20 low risk 10 – 20 intermediate risk < 10 high risk

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 weeks3. Free and Total PSA4. Assess Cancer Risks for Biopsy5. Biopsy when in Doubt

Prostate Ultrasound Biopsies

Sextant format, local anesthesia, 10-12 biopsies

Saturation biopsies – 1 biopsy / gmIndications for biopsies

Abnormal PSA – high risk free PSA, PSA density

Abnormal DREAbnormal prostate ultrasound

The Buzz: Robot Prostatectomy

Better Cancer CureLess Impotence, Blood lossHigher IncontinenceShorter Hospitalization

NEJM 4 / 08: Robot vs. Open Prostatectomy

Conclusion: No DifferenceSelection determined by patient bias