Urological Cancer Indicators & Innovations in Prostate Disease Management

Marc Laniado MD FEBU FRCS(Urol) Consultant Urological Surgeon

Specialising in prostate cancer and BPH

Nuada Medical

ml@nuadamedical.com

Three main areas of interest

Visible haematuria: suspected cancer referrals

• >45 years

• unexplained visible haematuria without UTI or

• visible haematuria that recurs after UTI treatment

Non-visible haematuria (NVH) is + or more blood on urinalysis

Non-visible Haematuria (3 urine dipstick over 2 to 3 weeks)

Symptomatic “s-NVH”

Significant if ≥1 of 3 samples dipstick +, ++, +++

Asymptomatic “a-NVH”

Significant if ≥ 2 of 3 urine samples dipstick +, ++, +++

> 60 years old

• non-visible haematuria AND

• dysuria

OR

• WBC elevated [NEW CG27, 2015]

Bladder cancer: suspected cancer referral

Non-urgent referral for NVH if < 60 years old

<40 years 40-60 years >60 years

Asymptomatic: risk factors for significant disease ! refer to haematuria clinic, otherwise monitor

Routine referral to haematuria clinic

Urgent Referral under 2 week wait

Symptomatic: Routine referral to haematuria clinic

Non-urgent referral for haematuria/bladder cancer clinic

Recurrent UTI & > 60 y old

Prostate cancer testing?Symptomatic men Asymptomatic men

• Consider PSA & do prostate examination for

[1.6.2]

Symptoms of concern - urological evaluation

• unexplained weight loss [1.13.2]

• Carry out evaluation symptoms/signs/findings to clarify which cancer

• Suspected cancer referral [new 2015] • PSA > age specific reference range PSA [1.6.3] • Abnormal DRE [1.6.1]

PSA thresholds vary…

Age Range

Public Health England & PCRMP*

BAUS Prostate Cancer UK

45 to 49 2.7 2.5 + risk factors

50 to 59 3 3.960 to 69 3 5.070 to 79 7.2≧ 80

❋Prostate Cancer Risk Management Programme 2016, Consensus Statement

Prostate cancer testing?Symptomatic men Asymptomatic men

PCRMP guidance states that "The PSA test is available free to any man aged 50 or over who requests it, after careful consideration of the

implications".

Don’t test PSA if recent UTI, ejaculation, cycling, prostate stimulation

Always repeat the PSA 2 to 4 weeks later

PSA

Freq

uenc

y

50% of abnormal PSA values ARE NORMAL on retest

PSA testing in asymptomatic men

Prostate Cancer Risk Management Programme, Public Health England 2016

If risk factors for PCa, refer with PSA below threshold in some situations

Pan

Pr

Pr PanBr

Br

PrPr

O

C

Family History

Black men

Obesity

Old pathway for investigation

Cancer

Many flaws….

Treatment Options are Broad & Unclear

?

10 y Prostate Ca mortality same when compared by original treatment allocation

NEJM 2016

Ave age 62, (life expectancy 17 y)

20% progressed if randomised to active monitoring

NEJM 2016

Surgery/RTActive

monitoring

Over 50% of monitoring group eventually needed treatment as misclassified

NEJM 2016

Prebiopsy MRI & MRI-targeted transperineal biopsies correctly stratify patients (& no infections)

Cancer

Monitor PSA & no biopsy if normal MRI

Radical prostatectomy

Conventional whole prostate treatments cannot assure good functional outcomes

Radical radiotherapyActive monitoring

Solution is to treat only that part of the prostate with significant cancer - Focal Therapy

Prostate cancer on right side Half the prostate

scheduled for treatment ∴ fewer side-effects

MRI-targeted HIFU @ PMH

Post HIFU MRI shows ablation

Ablated area

Unaffected Prostate

Prostatic Urethral Lifts - symptom relief & normal

ejaculation

Marc Laniado MD FEBU FRCS(Urol) Consultant Urologist

BPH affects all older men

30 40 50 60 70 80

100%

50%

0%

Age

Perc

enta

ge o

f men

affe

cted

Here today to learn about for BPH - your patients have read it in the Daily Mail!

Current treatments for BPH cause sexual dysfunction

Surgery: HOLEP

Drugs: 𝝰 blocker

….men don’t want sexual side-effects

Functional anatomy of the male genitourinary tract

Normal ejaculation requires an intact bladder neck

UroLift implant designed to compress prostate lobes

Implant

Delivery Device

UroLift retract prostate lobes without affecting bladder neck

Urinary symptoms score drops by 11 points after UroLift

UroLift

TURP

Sonksen 2015 Eur Urol

UroLifts relieve symptoms by 4 weeks, last at least 4 years

IPSS

Poi

nts

4 years

Storage symptoms

Voiding symptoms

14

1210

864

2

0

Roehrborn 2015 Can J Urol

Faster quality of life recovery after UroLift compared to TURP

TURP

UroLift

Sonksen 2015 Eur Urol

Antegrade wet ejaculation & better sex after UroLift compared to TURP

UroLift

TURP

Ejac

ulat

ory

& Se

xual

Fun

ctio

n

Sonksen 2015 Eur Urol

Side effects are transient (2 weeks) & well tolerated

UroLift Controls

Dysuria 34% 17%

Hematuria 26% 5%

Pelvic pain 18% 5%

Urge Incontinence 4% 2%

UTI 3% 2%

UroLift fits well into the existing pathway

Man with persistent LUTS due

to BPH

Ejaculation important

?

Tamsulosin

Alfuzosin

≦80 g No Median lobe PVR < 150 ml

N

Y

still bothered

still bothered

Y

N

UroLift

HoLEP