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

2. 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)

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. Shiv Bhanot

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. Pre PSA Test Information
Shiv Bhanot

17. PSA Video
Shiv Bhanot

18. 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

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

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

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

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

23. 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

24. 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

25. 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

26. 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

27. Surgical Experience, 20 years
> 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

28. Shiv Bhanot

29. Urology, when to refer ?
Follow the guidelines When in doubt please call or NHS Private
Shiv Bhanot