Advances in Urology Practice , a historical perspective

1. 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)

2. 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 operations ShivBhanot

3. 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

4. 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 ShivBhanot

5. 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 ShivBhanot

6. The urological basis of LUTS Two special muscles of urinary tract Bladder Detrusor (always resting except) • Prostate Sphincter ShivBhanot (always active except) Urethra

7. 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 ShivBhanot

8. Shiv Bhanot

9. Drug Treatment ShivBhanot

10. LUTSIndications for referal to hospital • Bothersome symptoms • UTIs • Retention • Renal impairment • Suspected urological cancerhaematuria, sterile pyuria and raised PSA • Stress urinary incontinence ShivBhanot

11. Who is fit for surgery (TURP) for LUTS • Good head • Good legs The vast majority can tolerate TURP, selection is the key to success for surgery ShivBhanot

12. An alternative to surgery for Retention Done under local anaesthetic, can be easily reversed ShivBhanot

13. 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 ShivBhanot

14. When to offer a PSA Testoffer information, advice and time to decide( Pre Test PSA info sheet ) • Suspect benign prostatic enlargement or BPH • Prostate feels abnormal • Patient concern regarding prostate cancer ShivBhanot

15. Pre PSA Test Information Shiv Bhanot

16. PSA Video ShivBhanot

17. Diagnosis of Prostate Cancer • PSA • Rectal Examination • Free PSA* • pCA3 gene test* • MRI, MRI Spectroscopy and diffusion weighted imaging* • Transrectal ultrasound guided biopsies • Transperineal biopsies* * Not routinely available yet ShivBhanot

18. Early Prostate CancerPSA <20, T1 and T2 • Active surveillance • Surgery • Radiotherapy • HIFU • Brachytherapy • Cryotherapy • Hormonal treatment ShivBhanot

19. EPC Treatment, Patient Choice • Age and Life Expectancy • Risks vs Certainty • Possibilty of second and third treatment • Intensity of follow up ShivBhanot

20. Surgery for Early Prostate Cancer • Open Radical Prostatectomy • Laparoscopic Radical Prostatectomy (Pure or Robotically assisted) ShivBhanot

21. Single 1 cm port op British Journal of Urology International March 2011 ShivBhanot

22. 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 ShivBhanot

23. 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 ShivBhanot

24. 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 ShivBhanot

25. 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 ShivBhanot

26. 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 ShivBhanot

27. Shiv Bhanot

28. Urology, when to refer ? Follow the guidelines When in doubt please call or email NHS 0208 970 8138 Private 07711335083 shiv.bhanot@nhs.net ShivBhanot