Urology and male health Eamonn Rogers Mercy University Hospital Cork

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

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

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

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

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

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

Structure of the Bladder

Incidence of Cancer in Ireland

Cancer Mortality in Ireland (2)

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.

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

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)

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!)

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

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

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

Role of Stromal Cells

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.

Histological Differentiation – Gleason Grade /Score

Assessing Urine flow - IPSS

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

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

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

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 40-55 PSA > 2.5 = Biopsy Age 55-70 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.

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

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 40-55 PSA > 2.5 = Biopsy Age 55-70 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.

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

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)

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

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

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

MRI

BONE SCAN

How dangerous is Prostate Cancer?

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

Prostate Cancer – DRE Findings

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

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

Histology – Gleason Grade 3

Histology – Gleason Grade 5

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)

Histological Differentiation – Gleason Grade /Score

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)

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

Radical Retropubic Prostatectomy 1

Radical Retropubic Prostatectomy 2

Radical Retropubic Prostatectomy 3

Radical Retropubic Prostatectomy 4

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

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)

Adjuvant Radiotherapy

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

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

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

Robotic Prostatectomy 1

Robotic Prostatectomy 2

Robotic Prostatectomy 3

Robotic Prostatectomy 4

Robotic Prostatectomy 5

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%