1. Managing the side effects of a radical prostatectomy
Mr Rohan Hall
Goldfields Urology

2. Stages of diagnosis Receiving a result of an elevated PSA
Referral to urologist
Prostatic biopsy (TRUS or transperineal)
Receiving the diagnosis
Staging
Receiving results
Discussing management of localised prostate cancer
Discussing the side effects of each treatment option
Anxiety
Depression
Loss of autonomy
Futility
Anger

3. Managing the “trifecta”
Oncology
Pre-op
Post-op
Review appointments
Continence
Pre-op lower urinary tract symptoms
Pre-op preparation
Post-op expectations
Erectile Function
Pre-op erectile function
Social circumstances
Medical comorbidities
Intra-operative variation

4. Post-op
Wound
IDC
Pain
Scrotal oedema
Driving
Cycling

5. Urinary Continence
Male continence mechanism

6. Urinary Continence
Pre-op pelvic floor education benefits post-op return to continence
Post-op pelvic floor exercises – when to start
What level of continence is normal in the post-operative period
3/12 – 1 pad/day
12/12 – 1 pad/day
2% of patients will be wet, wet, wet
Other factors affecting ability to be continent:
Chronic cough
Obesity
Diuretics
What if continent, then new incontinence?

7. Behavioural modifications
Decrease fluid intake
Void frequently
Avoid caffeine, alcohol
Avoid activity that increases intraabdominal pressure

8. Urinary Continence
What next – formal urodynamics to rule out over active bladder, also can assess ALPP.
Bulking agents
Considered successful 17% of the time for post radical prostatectomy SUI
Pro’s - minor procedure
Con’s – may need to be repeated
Can set up local chronic inflammatory response making further treatment difficult

9. Urinary incontinence

10. AdVance™ Male Sling
Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control
Procedure:
Spinal or general anesthesia can be used
Three small incisions: 1 under the scrotum, 2 over groin creases
Specially designed surgical tools are used to position the sling
Sling is gently tensioned
Incision closed

11. Artificial Urinary Sphincter (AUS)
The Gold Standard for treatment of moderate to severe incontinence
60± minute outpatient procedure
92% of patients would have the device placed again
96% of patients would recommend it to a friend
Device is placed completely in the body, providing simple, discreet control
- Requires dexterity for use of pump

12. Erectile Dysfunction
“The inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance”
Prevalence of ED: 52% men older than 40 have some degree of erectile dysfunction
“Mandropause”
Age 60 – 20% ED
Age 70 – 70% ED
Set expectations
“The best erection they will achieve post-op is 70% of there pre-op erection, and this may be with the aid of a PDE5-I”

13. Erectile dysfunction Aetiology
Vasculogenic: arteriogenic vs veno-occlusive dysfunction
Neurogenic
Psychogenic – depression, stress, anxiety, psychiatric disorder
Endocrinologic – hyperprolactinemia, thyroid disorder, hypogonadism
Medications (b-blockers,antidepressants,spironolactone,sedatives, phenytoin

14. Erectile Dysfunction PDE5-I Penile Pump Intra-urethral suppository
Intracavernosal injection

15. Erectile dysfunction PDE5-inhibitors Contraindications
How to use these tablets?

16. Erectile dysfunction Penile Rehabilitation - Daily cialis
Aim to achieve 3 erections per week
High dose PDE5-I
Intracavernosal injections
Alprostadil (caverject)
Trimix
Theoretically makes sense
Lack of evidence
Expensive

17. Erectile dysfunction – penile implants
Ideal for men who have tried other treatments without success
On the market for over 30 years
25,000 penile implants per year
Over 300,000 implants to date
High patient and partner satisfaction

18. Types of Penile Implants
One-piece non-inflatable
Two-piece inflatable
Three-piece inflatable

19. One - Piece Non-Inflatable Penile Implant
Advantages
Easy for you or your partner to activate
Good option for men with limited dexterity
Totally concealed in body
The simplest surgical procedure
Least expensive prosthesis
Disadvantages
Stays firm when not in erect position
May “show” through clothing

20. Three – Piece Inflatable Penile Implant
Advantages
Simple to use
Fast and simple one-step deflation
Totally concealed in body
Acts and feels more like a natural erection
Expands the girth of the penis
More firm and full than other implants
Feels softer and more flaccid when deflated
Disadvantages
Requires some manual dexterity
Possibility of leakage or malfunction
Possibility of unintentional erections 20

21. Questions?