Urology in Primary Care Mr Shiv Bhanot Consultant Urological Surgeon Shiv Bhanot February 2013

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)

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 Shiv Bhanot

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

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 Shiv Bhanot

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 Shiv Bhanot

The urological basis of LUTS Two special muscles of urinary tract Bladder Detrusor (always resting except) Prostate Sphincter Shiv Bhanot (always active except) Urethra

What can you do for LUTS Shiv Bhanot 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 Shiv Bhanot

Shiv Bhanot

Drug Treatment Shiv Bhanot Indication Treatment Review LUTS Alpha bocker at 4-6 weeks then 6-12 m OAB Anticholinergic >30gm, PSA>1.4 5 alpha reductase inhibitor at 3-6 m then 6-12 m High IPSS, >30gm, PSA>1.4 5 ARI + alpha blocker Symptoms despite treatment with alpha blocker Add anticholinergic Shiv Bhanot

LUTS Indications for referal to hospital Bothersome symptoms UTIs Retention Renal impairment Suspected urological cancerhaematuria, sterile pyuria and raised PSA Stress urinary incontinence Shiv Bhanot

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 Shiv Bhanot

An alternative to surgery for Retention Done under local anaesthetic, can be easily reversed Shiv Bhanot

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 Shiv Bhanot

When to offer a PSA Test offer 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 Shiv Bhanot

Pre PSA Test Information Shiv Bhanot

PSA Video Shiv Bhanot

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 Shiv Bhanot

Early Prostate Cancer PSA <20, T1 and T2 Active surveillance Surgery Radiotherapy HIFU Brachytherapy Cryotherapy Hormonal treatment Shiv Bhanot

EPC Treatment, Patient Choice Age and Life Expectancy Risks vs Certainty Possibilty of second and third treatment Intensity of follow up Shiv Bhanot

Surgery for Early Prostate Cancer Open Radical Prostatectomy Laparoscopic Radical Prostatectomy (Pure or Robotically assisted) Shiv Bhanot

Single 1 cm port op Shiv Bhanot British Journal of Urology International March 2011 Shiv Bhanot

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 Shiv Bhanot

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 Shiv Bhanot

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 Shiv Bhanot

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 Shiv Bhanot

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 Shiv Bhanot

Shiv Bhanot

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