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Urology Update Sanofi- Aventis

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.

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Urology Update Sanofi- Aventis

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

  2. BPH and Aging

  3. Diseases of the Prostate • BPH / LUTS / OAB / Retention • Signs and Symptoms • Medical Management • Prostate Cancer Detection

  4. Anatomy of BPH Normal BPH Bladder Hypertrophied detrusor muscle Prostate Urethra Obstructed urinary flow Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

  5. Obstructive (Voiding) Weak stream Prolonged micturition Straining Hesitancy Intermittent stream Feeling of incomplete bladder emptying Irritative (Storage) Frequency Nocturia Urgency Incontinence Symptoms Suggestive of BPH

  6. American Urological Association Symptom Index (AUA-SI) • Incomplete bladder emptying • Frequency • Intermittency • Urgency • Weak stream • Straining • Nocturia AUA Practice Guidelines Committee. J Urol. 2003;170(2 Pt 1):530537. Barry MJ et al. J Urol. 1992;148:15491557.

  7. Classification Mild Moderate Severe AUA-SI 0 – 7 8 – 19 20 – 35 AUA Symptom Index (AUA-SI)

  8. Criteria to Determine Treatment • AUA Symptom Score (Quality of Life) • Elevated Post-Void Residual • UTI • Hematuria • Bladder calculus • Retention

  9. Medical Management for Symptomatic BPH • Alpha blockers • 5 Alpha reductase inhibitors • Combination • OAB drugs • Observation

  10. Pharmacotherapy of BPH Alpha Blockers 5ARIs • Reduce the prostate volume • Improve symptoms • Arrest the disease process • Relax smooth muscle • Improve symptoms McConnell JD et al. N Engl J Med. 2003;349:23872398.

  11. Alpha-Blockers (Uroxatral, Flomax) • Offers symptomatic relief within days/weeks • Does not change size of prostate • Side effects • Nasal stuffiness, orthostatic hypotension • Flomax – retrograde ejaculation • Uroxatral – no retrograde ejaculatio

  12. 5 Alpha Reductase Inhibitor (Proscar, Avodart) • Slower effect on urinary symptoms than alpha blockers • Prostate size reduction • Urinary retention risk reduction

  13. Selection Criteria • If Signs & Symptoms – Moderate to Severe (prostate size < 30-40 gms) • Alpha blocker - 2 weeks • Cystoscopy +/- Prostate Ultrasound • If Signs & Symptoms - Moderate to Severe (prostate size > 50 gms • Alpha blocker + 5 alpha reductase inhibitor

  14. OAB Drugs • Direct action on bladder • Storage • Urgency, frequency

  15. 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

  16. 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

  17. Age related norms for PSA • 40-49 < 2.5 ng/ml • 50-59 < 3.5 ng/ml • 60-69 < 4.5 ng/ml • 70-79 < 6.5 ng/ml

  18. 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

  19. 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 weeks • 3. Free and Total PSA • 4. Assess Cancer Risks for Biopsy • 5. Biopsy when in Doubt

  20. Prostate Ultrasound Biopsies • Sextant format, local anesthesia, 10-12 biopsies • Saturation biopsies – 1 biopsy / gm • Indications for biopsies • Abnormal PSA – high risk free PSA, PSA density • Abnormal DRE • Abnormal prostate ultrasound

  21. The Buzz: Robot Prostatectomy • Better Cancer Cure • Less Impotence, Blood loss • Higher Incontinence • Shorter Hospitalization

  22. NEJM 4 / 08: Robot vs. Open Prostatectomy • Conclusion: No Difference • Selection determined by patient bias

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