Transcript What’s new in Urology?

WHAT’S NEW IN
UROLOGY?
GP UPDATE
16th October, 2014
Miss Janelle Brennan
Mr. Rohan Hall
Learning Objectives
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Describe the various treatments for overactive
bladder
To be able to safely prescribe new therapeutic
agents for overactive bladder
To understand new treatment modalities for BPH
To be familiar with new treatments for metastatic
prostate cancer
To be aware of current controversies in prolapse
surgery
Overactive bladder (OAB)
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First line treatment
 Anticholinergics
 Oxybutynin
(regular or prn, therapeutic dose limited by dry
mouth)
 Oxytrol patches (PBS, can use 1.5 patches, skin irritation)
 Vesicare (solifenacin) - ~$50, 5 or 10mg, main S/E is
constipation
 Enablex (darifenacin) - ~$50, 7.5 or 15mg, ?<cognitive S/Es
 Second
line treatment
 Mirabegron
(Betmiga)
Mirabegron (betmiga)
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Became available in Australia in April 2014, ~ $57/month
Beta 3 adrenergic agonist
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Starting dose 25mg
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Renal or liver impairment, uncontrolled hypertension
Side effects
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BUT 50mg dose more effective & same price
Use low dose if:
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B3 receptors in bladder induce detrusor relaxation (esp around trigone) increasing
bladder storage capacity
Hypertension
Urinary retention
Drug interactions/contra-indications
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Mild prolongation of QT interval – care with sotalol, amiodarone, haloperidol,
erythromycin, clarithromycin
CYP2D6 inhibitors e.g. fleicanide, metoprolol
Digoxin
Pregnancy/breast feeding/paediatrics
Botox
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PBS approval for neurogenic bladder 2013 – 200IU
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Strict criteria:
MS, Spinal cord injury, cerebral palsy
 Urodynamic confirmed DO
 > 14 incontinence episodes/week, 50% improvement with
treatment, day case
 Willing to perform CISC
 Registered urologist with MBS/ S100 scheme
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Botox for idiopathic detrusor overactivity (DO)
Likely available on 1/11/14
 100IU, usually lasts 6/12
 Wide availability to urologists
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If non approved ~ $475 for 100 IU
Side effects – 6% urinary retention, 10% failure
Sacral Nerve Stimulation
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Medtronic
Electrode in S3 nerve root
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Urinary frequency/urgency/incontinence
Urinary retention
Faecal urgency/incontinence
2 stages – lead then implantable generator
Unable to have spinal MRI
70% chance of 50% improvement for OAB and 50%
chance of 50% improvement for urinary retention (Even
better success with faecal incontinence)
Unable to have MRI spine (although can have MRI head,
1.5T magnet)
Follow up clinic available in Bendigo (need GP referral)
Sacral nerve stimulation
Female urology
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Prolapse
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FDA mesh warning – July 2011
Class action(Aust) vs J&J (prosima) – October 2012
Very litiginous so need informed consent/appropriate training
Indications – recurrent prolapse esp vault, multiple co-morbidities
Move to sacrocolpopexy (open/lap/robot) – this mesh is OK!
Stress urinary incontinence (SUI)
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Bulkamid (98% water, hydrogel) most common agent
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Macroplastique is less popular, contigen not available
No issues with mesh slings
Recurrent UTIs
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Cranberry, Hiprex, Keflex 250mg nocte (Streamline code 4243)
Ellura – high dose cranberry supplement
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~$50 month
Equivalent to 70g of fresh cranberries, standardised to provide the
recommended dose of 36mg bioactive proanthocyanidins (PACs) in each
capsule
BPH/bladder outlet obstruction –
Medical Therapy
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Alpha blockers
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Prazosin – up to 2mg bd
Tamsulosin (generic now available for ~ $30, flowmaxtra
supposedly more selective to alpha1a receptor so less postural
hypotension)
Duodart
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Must have baseline PSA due to risk of high grade prostate cancer –
expect 50% PSA reduction at 6 months
Risk of low libido/erectile dysfunction (not always reversible)
PDE5 inhibitors
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Cialis 5mg daily
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PDE5 enzymes in prostate and bladder & known to cause smooth
muscle relaxation - ?mechanism of action
~$160/month
BPH – surgical therapy
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Gold standard
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TURP
Green light laser
Available in Melbourne
 Day case or overnight stay
 Can stay on anticoagulants
 BUT 20% risk of repeat surgery at 5 years, post op dysuria
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Urolift
Lateral lobe enlargement
 Only rebatable in private
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Urolift
Day case
No significant
median lobe
Can have
TURP if
unsuccessful
No sexual
side effects
Early prostate cancer - phi
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Phi = Prostate Health Index
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through Melbourne Pathology
$90
Mathematical formula that combines total PSA, free
PSA and [-2] proPSA
 Outperforms
individual components for prediction of
overall and high grade prostate cancer on biopsy
 ~10% improved accuracy with greater specificity
 AUC – PSA 0.53, %fPSA 0.65, PHI 0.70
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Performs best in PSA 2-10 range
Early prostate cancer - MRI
mp-MRI
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Available at Bendigo
Health, ~ $250
 Indications
 Persistently
elevated
PSA despite negative
biopsies
 Active surveillance
 Pre-operatively to plan
nerve sparing
Early prostate cancer – TP biopsy
Transperineal prostate biopsy
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Almost zero risk of sepsis
Increased risk urinary
retention (~2%, up to 10%)
Up to 30% improved cancer
detection (apex)
Available at SJOG (hopefully
soon available at
Castlemaine/Rochester for
uninsured patients)
General anaesthetic
MRI fusion
Advanced prostate cancer - metastatic
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Firmagon (degarelix)
 LHRH
antagonist (as opposed to agonist)
 Avoids tumour flare so no need for anti-androgen
treatment
 Rapid decrease in testosterone
 Monthly injection – 240mg loading dose then 80mg
monthly
 Improved
cardiovascular side effect profile
 BUT injection site reaction
Advanced Prostate Cancer – Castrate
Resistant
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Abiraterone (Zytiga)
Castrate resistant prostate cancer & Post docetaxol
chemotherapy (for PBS)
 Inhibits 17 a-hydroxylase/C17,20 lysase in testicular,
adrenal & prostate tumour tissues
 Decreases circulating levels of testosterone by blocking
androgen synthesis
 Given with daily prednisolone
 Side effects – HT, low K, peripheral edema
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Carbazitaxel (Jevtana)
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2nd line chemotherapy
Enzalutamide – targets androgen receptor (?coming
soon)
Other urological cancers
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Kidney cancer
Active surveillance/renal biopsy
 Partial nephrectomy
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Laparoscopic assisted
 ?improved long term cardiovascular morbidity with nephron
sparing
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TKIs for metastatic disease
?role of cytoreductive nephrectomy
 Sunitinib (Sutent) and Pazopanib (Votrient) (better safety)
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Bladder cancer
Worldwide shortage of BCG
 Cystectomy + neobladder (formation of neo-bladder out of
small bowel)
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Laparoscopic surgery
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Nephrectomy and nephro-ureterectomy
Lap assisted partial nephrectomy (Hall)
Adrenalectomy
Bladder diverticulectomy
Pyeloplasty
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?funding for robot one day …..
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QUESTIONS?