1. Urology and male health
Eamonn Rogers
Mercy University Hospital
Cork

2. Role of Urologist Cancer Benign Prostatic Hyperplasia
Prostate
Testis
Benign Prostatic Hyperplasia
Erectile Dysfunction
Urinary Incontinence

4. The Prostate –What does it do?
Fertility
secretions added to semen
keep sperm viable
Zinc seems to assist this process

5. The Prostate – Why does it become diseased so often?
Only male organ to enlarge with age
Enlargement impedes urine emptying from bladder
May inhibit ejaculation
Commonest cause of cancer in males

6. Aging and the Prostate
Only 2 known risk factors for developing Prostate Hyperplasia / Neoplasia
Aging
Functional testicular tissue (Testosterone)

7. Ageing Male The Irish LongtituDinal Ageing Study
1999 = 11% > 65 YEARS
2011 = 15% > 65 YEARS
2031 = 19% > 65 YEARS
2035 = 66% > 80 YEARS

8. Benign Prostatic Hyperplasia (BPH) develops deep within the prostate and is more likely to “squeeze” the water passage and cause symptoms
It is much more common than cancer (90%)
It starts in men from the age of 40 and progressively grows
Cancer develops in the outside of the gland and rarely causes symptoms in its early stages until the tumour becomes advanced

9. Structure of the Bladder

12. Incidence of Cancer in Ireland

13. Cancer Mortality in Ireland (2)

14. 30,000 men die from prostate cancer each year in the United States.
American men have about 1 chance in 30 of dying from prostate cancer (Ireland 1 in 16).
This would be higher, if no men opted for early detection and treatment.
30,000 men die from prostate cancer each year in the United States.
1 in 100 prostate cancer deaths in men < 55.
1 in 20 prostate cancer deaths in men age 55-64
2 in 10 in men age 65-74
7 in 10 in men age 75 and older.
However, these deaths usually occur after some period of suffering from metastatic disease.

15. Burden of Prostate Cancer
Emotional and Cognitive
Patient , Partner and Family
Physical
Urinary
Sexual
Bowel
Death

16. Prostate cancer Slow growing but eventually lethal
Most prevalent male cancer
2nd commonest cause of male cancer deaths
85% PSA detetcted cancers will eventually progress (7-10 years)

17. What puts one at risk of prostate cancer?
Family history
Otherwise causes virtually unkown
A) smoking not a risk
B) African origin
C) ? Western diet (Meat and fat!)

18. Can I prevent it? Very little known
? Vitamin A
? Selenium
If really concerned and willing to accept tests, consequences and limits
THEN SCREEN YOURSELF

19. Aging and the Prostate
Only 2 known risk factors for developing Prostate Hyperplasia / Neoplasia
Aging
Functional testicular tissue (Testosterone)

20. 5AR in the prostate Testosterone DHT 5AR type I 5AR type II
The conversion of testosterone to DHT in the prostate is mediated by both types of 5AR isoenzyme, type 1 and type 2.1
Reference
1. Anderson JB et al. Eur Urol 2001; 39: 390–399.
5AR type II
Andriole G et al. J Urol 2004; 172: 1399–1403

21. Role of Stromal Cells

22. Whether a man will die of something else or prostate cancer depends on how aggressive the cancer is, how early it is detected, how effectively it is treated, as well as a man's age and his other medical problems.

23. Histological Differentiation – Gleason Grade /Score

24. Assessing Urine flow - IPSS

25. What should you do if you have bothersome prostatic symtoms?
Seek medical advice
Doctor will ascertain the nature of prostatic problem
Prostate exam
Urine and PSA tests
Mild and early symptoms are easily treated by tablets and surgery is not needed

26. Therefore the only way one can detect early prostate cancer is with
A) a blood test (PSA)
B) feeling the surface of the prostate by means of an internal examination

27. Diagnosis of Prostate Cancer prior to initiating and during TRT
Prior to starting TRT in men with LOH
Biopsy if prostate feels abnormal
Biopsy Prostate irrespective of PSA
Biopsy if PSA abnormal
Total PSA elevated
Free /Total ratio abnormal
PSA velocity increases **
During TRT (*** > 6 months)
Biopsy if any of above PSA parameters change

28. Most doctors feel men with PSA levels greater than 4 should have a biopsy, while others feel men with levels greater than 2.5 should have a biopsy.
Age PSA > 2.5 = Biopsy
Age PSA >4.0 = Biopsy
There is an increasing tendency to focus less on absolute PSA values and to consider changes in PSA over time. There is accumulating evidence that men who have a steady rise in their PSA level are more likely to have cancer, and if the rise is rapid, the cancer is more likely to be life threatening.

29. Role of PSA Velocity
PSAV greater than 2.0 ng/mL per year in the year before diagnosis was independently associated with a dramatically increased risk of prostate cancer death
Carter et al. also found a strong association between survival and higher PSAV as early as 10–15 years before diagnosis
PSA < 4.0
Any rise in PSA > 0.5mg/yr = Biopsy
PSA > 4.0
Any rise in PSA > 1mg /yr = Biopsy

30. Most doctors feel men with PSA levels greater than 4 should have a biopsy, while others feel men with levels greater than 2.5 should have a biopsy.
Age PSA > 2.5 = Biopsy
Age PSA >4.0 = Biopsy
There is an increasing tendency to focus less on absolute PSA values and to consider changes in PSA over time. There is accumulating evidence that men who have a steady rise in their PSA level are more likely to have cancer, and if the rise is rapid, the cancer is more likely to be life threatening.

32. Prostate Cancer
Therefore the only way one can detect early prostate cancer is with
A) a blood test (PSA)
B) feeling the surface of the prostate by means of an internal examination

33. Detecting Prostate Cancer
If the PSA is above advised level of 2.5 or 4.0
A PROSTATE BIOPSY IS NECESSARY TO OUTRULE CANCER
RAISED PSA DOES NOT MEAN THAT A MAN HAS CANCER
*Remember most men get a natural enlargement of the prostate with age (BPH)

34. BIOPSY IS USUALLY CARRIED OUT IN THE XRAY DEPARTMENT USING ULTRASOUND
IT IS A “WALK IN” TEST

36. What happens if prostate has cancer?
We check if cancer is
A) confined within prostate (curable)
B) has spread beyond the prostate into other sites, glands , bone etc
If it is confined we treat the cancer aggressively
A) radical surgery (prostatectomy)
B) radical radiotherapy

37. What happens if prostate has cancer?
If it is advanced we treat the cancer with
A) radiotherapy
B) drugs (hormone therapy)
Good longterm results can be achieved even in advanced cancers

38. MRI

39. BONE SCAN

40. How dangerous is Prostate Cancer?

41. Surgery and Prostate Cancer
Cure
Radical Retropubic Prostatectomy (RRP)
Radical Perineal Prostatectomy
Laparoscopic Prostatectomy
Hand assisted
Robotic
Palliate
TURP

42. Prostate Cancer – DRE Findings

43. Pathological Stages of CAP
Localised (T1a; T1b; T1c; T2 N0 M0)
Organ Confined
Locally advanced (T3; T4 N0 M0)
Capsule penetrated
Seminal Vesicle Invasion
Distant spread (Tx N1-3 M1-2)
Lymph node metastases
Distant organ metastases

44. Histological Differentiation – Gleason Grade /Score
In multivariate analysis the most important clinical parameter predicting the NATURAL HISTORY OF PROSTATE CANCER i.e.
Rate of progression
Prognosis

45. Histology – Gleason Grade 3

46. Histology – Gleason Grade 5

47. Histological Differentiation – Gleason Grade /Score
5 Gleason grades (1-5) based on histological aggression of tissue
Architecture
Cytology
Gleason score estimates the 2 most prevalent patterns (e.g. 3+4 = 7; 2+2 = 4)

48. Histological Differentiation – Gleason Grade /Score

49. Histological Differentiation – Gleason Grade /Score
Well differentiated = Gleason score(2,3,4)
Mod. differentiated = Gleason score(5,6,7)
Poor differentiation = Gleason score(8,9,10)

50. Natural History - Histology
Well differentiated / Gleason score(2,3,4)
10% metastases at 10 years
Mod. differentiated = Gleason score(5,6,7)
42% metastases at 10 years
Poor differentiation = Gleason score(8,9,10)
74% metastases at 10 years

51. Radical Retropubic Prostatectomy 1

52. Radical Retropubic Prostatectomy 2

53. Radical Retropubic Prostatectomy 3

54. Radical Retropubic Prostatectomy 4

55. Nerve Sparing? Absolute Contraindications
Locally advanced disease (T3C)
Palpable disease at apex
Gleason grade 5 disease
PSA>20ng/ml
Preoperative impotence

56. Nerve Sparing? Relative contraindications
Intraoperative difficulty with NVB
Palpable localised disease other than at apex
PSA 10 – 20ng/ml
>50% Gleason 4 on biopsy
Perineural invasion*
Cancer in 3 needle cores from same lobe (side)

57. Adjuvant Radiotherapy

58. Complications - Intraoperative
Haemorrhage
Mean blood loss 800 – 1500mls
Rectal Injury
Risk of fistula
Ureteral injury
Nerve injury
Obturator
Femoral

59. Complications - Perioperative
Medical
DVT, MI etc
Surgical
Delayed haemorrhage
Catheter dislodgement
Anastomotic leakage
Lymphocoele

60. Complications - Longterm
Bladder neck contracture
Impotence
Urinary Incontinence
Sphincter =Stress
Bladder

61. Robotic Prostatectomy 1

62. Robotic Prostatectomy 2

63. Robotic Prostatectomy 3

64. Robotic Prostatectomy 4

65. Robotic Prostatectomy 5

66. Laparoscopic or Open Very user dependent
Robotic promising but extremely expensive
No prospective trial comparing modalities with longterm cancer specific survival
Potency better ?
Positive margin rates
Open = 9%
Lap = 14%