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George Yardy Consultant Urological Surgeon the Ipswich Hospital, ESNEFT Topics Covered

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George Yardy Consultant Urological Surgeon the Ipswich Hospital, ESNEFT Topics Covered Urology and Men’s Health 17th June 2021 George Yardy Consultant Urological Surgeon The Ipswich Hospital, ESNEFT Topics covered • Male LUTS – Case study – Medication – surgery • Covid and urology • Female incontinence and UTI – Case study – Catheters – Botox • General paediatric urology – Foreskin – Groin • Bladder pain syndrome / chronic prostatitis / chronic pelvic pain syndrome • Vasectomy reversal Male LUTS: case study Mr C.W., 72 y.o. 20/06/2017 Male LUTS / prostate assessment clinic I yr urgency, frequency, nocturia x6, occ urge urinary incontinence No better with tamsulosin Satis. erectile fn. PMH: hypertension, hernia repair DH: atorvastatin, losartan RE: moderate (60g?) benign prostate PSA 5.3, Creatinine 104, urine dip NAD Male LUTS: case study • IPSS 20/35, QoL 5/6 • Frequency / volume chart: – Total 14 – 18 voids / 24h – Intake 4000ml / day Male LUTS: case study • 19/07/2017 Urodynamics Male LUTS: case study • 19/07/2017 Urodynamics Impression: Equivocal bladder outlet obstruction, no detrusor overactivity, empties fully. Ie. “sensory urge” Male LUTS: case study • 07/08/2018 flexible cystoscopy – large occlusive prostate, bladder normal • 12/02/2019 brought in for TURP but cancelled – c/o esp. urgency, some urge inco, not had med for this LUTS termiology Lower urinary tract symptoms (LUTS) are storage, voiding and postmicturition symptoms affecting the lower urinary tract. Bothersome LUTS may occur in up to 30% of men older than 65 years. Storage Post Voiding (previously ‘irritative’) (previously ‘obstructive’) Micturition weak or intermittent urgency urinary stream dribbling frequency straining incontinence hesitancy Nocturia terminal dribbling incomplete emptying BPH and Progression Anatomy of BPH NormalBPH Bladder Hypertrophied Prostate detrusor muscle Urethra Obstructed Adapted from Kirby RS et al. Benign Prostatic urinary flow Hyperplasia.Health Press 1999 Medication for LUTS • α blockers – Tamsulison, Alfuzosin – “uroselective” – Work quickly – days – s/e.s – dizzy (first doses?), ejaculatory dysfunction • 5 α-reductase inhibitors – Finasteride, Dutasteride – Works only for larger prostates – Effect takes 3-6 months – s/e.s - libido, erections • Combination α blocker / 5ARI – Decreases risk of progression (worsening IPSS, retention sugery) – If at risk (large prostate, PSA >1.4, IPSS >10 • PDE5 inhibitors – Some evidence of common pathophysiology of ED and LUTS – More relevant now generic Tadalafil available? Medication for LUTS • Antimuscarinics – Low risk of retention if residual >200ml – Side effects – Generic Tolterodine, Solifenacin • Β3 agonist – Mirabegron seems as effective as antimuscarinic, without side effects Male LUTS: case study • Some improvement with tolterodine and physio • Repeat UDS 11/09/20 Definite bladder outlet obstruction, Minor detrusor overactivity Listed for TURP Start finasteride to decrease intra-operative bleeding Surgical options • “Cavitating procedures” – TURP – Laser operations • “MIST” – minimally invasive surgical therapy – Urolift – prostatic urethral lift – Rezum – steam – PAE – prostate artery embolisation – iTIND – others on the way Conventional TURP • Established “gold standard” – National Prostatectomy Audit BJUi 1995 • Monopolar diathermy – Affects pacemaker? • Glycine irrigation – Resection time limited to 1 hour – Or else “TUR syndrome” – fluid overload, hyponatraemia, neurotoxic metabolites Bipolar TURP • Mechanistically similar to TURP • Bipolar diathermy energy • Saline irrigation • Allows longer resection • Better haemostasis / less blood loss • No TUR syndrome “TURis” – transurethral resection in saline = Olympus PLASMA System Introducing The UroLift® System Treatment 1. The UroLift delivery 2. UroLift implants are placed through a needle that 3. The UroLift delivery device is placed through comes out of the delivery device to lift the device is removed, the urethra to access enlarged prostate tissue out of the way. leaving a more open the enlarged prostate. urethra. The UroLift ® System directly opens the urethra without prostate tissue removal or ablation. 20 The UroLift® System • Single-use device • CE marked, TGA approved and now with a positive, finalized NICE guidance: – Indicated for the treatment of symptoms due to urinary outflow obstruction secondary to BPH in men over the age of 50. Delivery device UroLift System Implant U.S. Patents: 7,645,286; 7,758,594; 7,766,923; 7,905,889; 8,007,503 21 UroLift® System Is A Whole New Approach PRE POST • Immediately opens the prostatic urethra • Can treat LUTS without compromising normal prostate function • Provides rapid relief without complications from prostate injury • Opens up a new option for urologists and patients *Data on file at NeoTract, Inc. 22 •Day case •No catheter •Small / medium prostate •No ejaculatory dysfunction Prostate Aretry Embolisation • Embolisation already established eg for refractory pelvic bleeding, fibroids • Local anaesthesia, X-ray guidance • Groin approach -> femoral artery -> Super- selective catheterisation of small prostatic arteries • Embolisation with microparticles via fine microcatheters • Necrosis and shrinking of prostate PAE • Where does it fit in our BPH pathway? • Complex but safe procedure • Men who wish to avoid or at least delay surgery but accept inferior symptom improvement and effect may be temporary • Nigel Hacking, Interventional Radiologist, Southampton Rezum • Steam / radiofrequency energy to ablate tissue • Prostate up to 80g • Transurethral • GA or sedation • Up to 20 minute procedure, day case • Catheter 4-7 days • No ED, little retrograde ejac Summary of surgical options • Cavitating procedures – Treat large prostates, severe symptoms – Significant improvement in sx, for long duration – low reoperation rate – Longer hospital stay and recovery • MIST – Now accumulating experience nationally and locally – Short procedures, quicker recovery, lower sexual side effects – Do not improve sx as much, may require further procedure later Male LUTS: case study •28/04/21 uneventful TURP 21g resected, histology benign •clinic 09/06/21 Pleased Flow better Nocturia x3 (was x6) OAB symptoms likely to settle further over months Covid • effects of Covid on urinary tract • effects of Covid on urological services • prioritisation categories Effects of Covid on urinary tract Bladder and kidney at risk of invasion ▪ SARS-CoV-2 spike protein binds to ACE2 receptors – detected on cells of kidney and bladder ▪ contribute to AKI in Covid +/- septic shock, cytokine storm, immune mech.s Viral RNA • 6.9% Covid patients, remains positive after throat swab returns neg • but 0% in another study No report of transmission to hospital staff via urine / bladder irrigation fluid Effect of Covid on urological services Adapt, prioritise, delay, recover Virtual clinics – great for some follow-ups, impossible for many new patients Referral delays England 2WW suspected urological cancer referral Feb 2020: 18,534 Apr 2020: 7,859 (58% reduction) 3/12 delay to diagnosis 10% 10 yr survival for bladder cancer little change for prostate / testis cancer Risk prioritisation Theatre delays Nosocomial infection Operative prioritisation • Priority 1a: <24h – Obstructed infected kidney – Uncontrolled haematuria – Fourniere gangrene • Priority 1b: <72h – Upper urinary tract obstruction – Acute stones with pain / renal impairment – Penile # Operative prioritisation • Priority 2: < 1/12 – Some MDT-directed bladder / renal cancer – Ureteroscopy for stones with stents – Visible haematuria investigation • Priority 3: <3/12 – High / intermediate risk prostate cancer – Bladder outlet surgery in catheterised males – Non-visible haematuria investigation – Stent change – Orchidopexy for undescended testis Operative prioritisation • Priority 4: >3/12 – Benign female incontinence – Uncomplicated stone surgery – ED, infertility – Low risk prostate cancer, superficial TCC – Bladder outlet surgery – TURP – Benign penoscrotal surgery Case study: female with MS and urinary symptoms • Mrs MM. 55 yrs old • MS diagnosed 1989 – optic neuritis, right arm weakness • 2007 weak left side of body, back pain, tingling & spasms both legs • 2008 short period in wheelchair • Fluctuating, slowly progressive, unsteady walking • Received treatments inc Avonex, Copaxone, Tecfidera, pregabalin, baclofen • Bladder overactivity initially controlled with oxybutinin Case study: female with MS and urinary symptoms: UTI • 2015 also recurrent UTI – Rx 6/12 continuous trimethoprim – Then “self-start” ABx • 2016 Rx methenamine • 2018 Cystistat Some general comments about recurrent UTI • USS worthwhile but cystoscopy rarely contributory in neurologically normal pre-menopausal female • Men need flow rate +/- cystoscopy +/- Rx for chronic prostatitis • Lifestyle advice: leaflet from RCGP / BAUS / patient.info • Topical (intravaginal) oestrogen • D-mannose (vs cranberry, lactobacillus) Some general comments about recurrent UTI • Antibiotics – Standby / self start – Trigger (eg. post-coital) – Continuous prophylactic • Resistance • Review at least 6 months • Not at all keen on “rotational” ABx • Methenamine – “Hiprex” – Large tablet b.d., tastes of vinegar – Metabolised to formaldehyde in acidic urine – Surprisingly well-tolerated! • Other (secondary care) – Instillations – Cystistat, Hyacyst Case study: female with MS and urinary symptoms: catheters • 2011 started intermittent self-catheterisation (ISC) – ISC frequently reqd in incomplete bladder emptying in MS – Rarely required after Botox in neurologically normal females • 2016 constant bladder
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