1. Mr Jim Adshead MA MD FRCS (Urol) Consultant Urological Surgeon Lister Hospital, Stevenage Spire Hospital Harpenden E mail: j.adshead@nhs.netj.adshead@nhs.net Connect Meeting Men's Health November 20th 2008 Urology Update

2. Update to include MTOPS study Times study Erectile dysfunction update 2 cases to discuss Da Vinci Robotic Prostatectomy

3. MTOPS worth a look MTOPS Medical treatment of prostate symptoms 4 arms 3000 men randomised to doxazosin finasteride placebo or both But needed to treat 52 men to prevent 1 AUR 27 men to prevent 1 TURP Very expensive Back to the risk of progression again 2 options 1 Dual therapy for >40 ml prostates or PSA above 4 and severe symptoms 17/35 2 Maybe we could stop the alpha blocker after 9 months

4. 5-alpha reductase inhibitors Finasteride 5mg daily -type 1 activity Dutasteride 0.5mg daily -type 1 and 2 Warnings –Avoid blood donation(teratogenic) –Females of child-bearing age shouldn’t touch the tablet (teratogenic) MTOPS study –dual therapy Combat study -2 yr data

5. Sexual function and LUTS from MTOPS Worse IPSS worse IIEF irrespective of age –Unknown why More RX along the MTOPs pathway –Worse ED All 3 PDEi improve IPSS as much as a blockers –Lots of papers coming out of daily PDEis –Watch out for alpha blockers and PDEis –Flomax ok

6. How do we differentiate the Symptoms?

9. Erectile dysfunction

10. Case study 1 58 man presents with LUTS or a headache What is the likelihood of finding prostate cancer in these men? PSA is 9.8 - what to do Biopsy result 6 months later PSA 10.9

11. The Discovery of PCA3 The PCA3 gene was discovered by Dr. Marion Bussemakers while working with Dr. Jack Schalken at the University of Nijmegen in the Netherlands and in the laboratory of Dr. William Isaacs at Johns Hopkins University in Baltimore

12. PCA3 test 58% positive predictive value 90% negative predictive value

13. Case study 2 82 man with AF presents with obstructed LUTS DRE hard craggy prostate PSA 27 What to do

14. Antiandrogens to all? Newly diagnosed prostate cancer patients who received ADT for at least 1 year were found to have a 20% higher risk of serious cardiovascular morbidity compared with similar men who did not receive ADT. Subjects began incurring this higher risk within 12 months of treatment.

15. The Da Vinci Robotically Assisted Laparoscopic Radical Prostatectomy Mr James M Adshead MA MD FRCS (urol) Consultant Urological Surgeon Lister Hospital

16. Prostate cancer 2 nd commonest Male cancer now –neglected ct breast Explosion of incidence of early cancer 18% US 9% in UK Gold standard for early cancer is surgery Biggest Longest studies Best cure rates Back up plan

17. The search for minimally invasive treatments Radiotherapy HIFU Cryotherapy Why has surgery been unpopular –More bleeding –higher incontinence –Likely erectile dysfunction –May not die anyway

18. July 2008, p29…. “For the same illness, open surgery leaves patients in hospital for several weeks where keyhole surgery enables them to go home in just a few days. With advances in robotics, patients can look forward to scar-free surgery”… Earlier return to work is generally achievable with robotic assisted surgery which benefits the economy as a whole. As Lord Darzi, Health Minister, said this week (quoted in The Sunday Times 6th July 2008) “ We need robot technology. The cost may appear high but let us not forget that currently patients are in recovery for 6 weeks – which is a huge cost for them personally”. High Quality Care for all- NHS Next Stage Review

19. da Vinci Prostatectomy access Open Surgical Incisionda Vinci ® Prostatectomy Incision 80% 5 yrs ago in US80% last year in US

20. The surgeon directs the instruments Surgeon directs the instrument movements using Console controls

21. Goals of prostatectomy Remove the cancer Preserve urinary function Preserve erectile function X X X

22. Why are patients demanding robotic surgery Fewer complications Less blood loss, transfusions Less postoperative pain Quicker return to normal activities Faster recovery Shorter length of hospital stay Shorter catheterization Less scarring

23. Potential benefits of da Vinci ® Prostatectomy Improved cancer control Faster return to continence Faster return potency

24. Wrist and finger movement

26. Thank you Connect Meeting Men's Health November 20th 2008 Urology Update