urology update sanofi- aventis

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Urology Update Sanofi- Aventis Kenneth Lim, D.O. Urology Residency Director POH/ Detroit Medical Center

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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 / Retention Signs and Symptoms Medical Management Prostate Cancer Detection. Anatomy of BPH. Normal. BPH. - PowerPoint PPT Presentation

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Page 1: Urology Update               Sanofi- Aventis

Urology Update Sanofi- Aventis

Kenneth Lim, D.O.

Urology Residency Director

POH/ Detroit Medical Center

Page 2: Urology Update               Sanofi- Aventis
Page 3: Urology Update               Sanofi- Aventis

BPH and Aging

Page 4: Urology Update               Sanofi- Aventis

Diseases of the Prostate

BPH / LUTS / OAB / RetentionSigns and SymptomsMedical Management

Prostate Cancer Detection

Page 5: Urology Update               Sanofi- Aventis

Anatomy of BPH

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

NormalNormal BPHBPH

Hypertrophied detrusor muscle

Obstructed urinary flow

Prostate

Bladder

Urethra

Page 6: Urology Update               Sanofi- Aventis

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

Page 7: Urology Update               Sanofi- Aventis

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

Page 8: Urology Update               Sanofi- Aventis

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

Page 9: Urology Update               Sanofi- Aventis

Criteria to Determine Treatment

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

UTIHematuriaBladder calculusRetention

Page 10: Urology Update               Sanofi- Aventis

Medical Management for Symptomatic BPH

Alpha blockers5 Alpha reductase inhibitorsCombinationOAB drugsObservation

Page 11: Urology Update               Sanofi- Aventis

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.

Page 12: Urology Update               Sanofi- Aventis

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

Page 13: Urology Update               Sanofi- Aventis

5 Alpha Reductase Inhibitor (Proscar, Avodart)

Slower effect on urinary symptoms than alpha blockers

Prostate size reductionUrinary retention risk reduction

Page 14: Urology Update               Sanofi- Aventis

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

Page 15: Urology Update               Sanofi- Aventis

OAB Drugs

Direct action on bladderStorageUrgency, frequency

Page 16: Urology Update               Sanofi- Aventis

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

Page 17: Urology Update               Sanofi- Aventis

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

Page 18: Urology Update               Sanofi- Aventis

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

Page 19: Urology Update               Sanofi- Aventis

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

Page 20: Urology Update               Sanofi- Aventis

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

Page 21: Urology Update               Sanofi- Aventis

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

Page 22: Urology Update               Sanofi- Aventis

The Buzz: Robot Prostatectomy

Better Cancer CureLess Impotence, Blood lossHigher IncontinenceShorter Hospitalization

Page 23: Urology Update               Sanofi- Aventis

NEJM 4 / 08: Robot vs. Open Prostatectomy

Conclusion: No DifferenceSelection determined by patient bias