Urology Dine and Learn: Erectile Dysfunction & Benign Prostatic Hyperplasia Iain McAuley September 15, 2014 Overview Review of the most recent guidelines for ED and BPH ED Guidelines CUA 2006 AUA 2011 EAU 2014 BPH Guidelines CUA 2009 AUA 2010 EAU 2014 1
Grade Nature of Recommendations A - Based on clinical studies of good quality and consistency that addressed the specific recommendations, including at least one randomised trial. B - Based on well-conducted clinical studies, but without randomised clinical trials. C - Made despite the absence of directly applicable clinical studies of good quality. ED Evaluation Medical and psychosexual history (use of validated instruments, e.g. IIEF) Identify other than ED sexual problems Identify common causes ED Vasculogenic Neurogenic: Central & Peripheral Anatomical Hormonal Drug-induced Psychogenic Trauma Identify reversible risk factors for ED Assess psychosocial status 2
Focused physical examination Penile deformities Prostatic disease Signs of hypogonadism Cardiovascular and neurological status Laboratory tests Glucose-lipid profile Total testosterone Treatment algorithm for determining level of sexual activity according to cardiac risk in ED Exercise ability Low risk (able to perform exercise of modest intensity) - Advice, treat ED High risk (moderate-tosevere symptomatic heart disease) Cardiologist Intermediate risk - Stress test Low or high risk 3
B - Clinical use of validated questionnaire related to ED may help to assess all sexual function domains and the effect of a specific treatment modality. B - Physical examination is needed in the initial assessment of men with ED to identify underlying medical conditions that may be associated with ED. B - Routine laboratory tests, including glucose-lipid profile and total testosterone, are required to identify and treat any reversible risk factors and lifestyle factors that can be modified. B - Specific diagnostic tests are indicated by only a few conditions. Treatment of ED Identify and treat curable causes of ED Lifestyle changes and risk factor modification Provide education and counselling to patients and partners Identify patient needs and expectations, Shared decision-making, Offer conjoint psychosocial and medical treatment 4
PDE5 inhibitors Intracavernous injections, Vacuum devices, Intraurethral alprostadil Assess therapeutic outcome: Erectile response, Side-effects, Treatment satisfaction Consider penile prosthesis implantation A - Lifestyle changes and risk factor modification must precede or accompany ED treatment. A - Pro-erectile treatments have to be given at the earliest opportunity after RP. B - When a curable cause of ED is found, it must be treated first. A - PDE5Is are first-line therapy. B - Inadequate prescription and poor patient education are the main causes of a lack of response to PDE5Is. C - A VED can be used in patients with a stable relationship. B - Intracavernous injection is second-line therapy. C - Penile implant is third-line therapy. 5
BPH in the RED words A - A medical history must always be taken from men with LUTS. B - A validated symptom score questionnaire with QoL question(s) should be used for the routine assessment of male LUTS in all patients and should be applied for re-evaluation of LUTS during treatment. B - Micturition frequency volume charts (FVC) or bladder diaries should be used to assess male LUTS with a prominent storage component or nocturia. B - FVCs should be performed for the duration of at least 3 days. B - Physical examination including DRE should be a routine part of the assessment of male LUTS. A* - Urinalysis (by dipstick or urinary sediment) must be used in the assessment of male LUTS. (* Upgraded by Panel consensus) A - PSA measurement should be performed only if a diagnosis of PCa will change the management or if PSA can assist in decision-making in patients at risk of progression of BPE. A* - Renal function assessment must be performed if renal impairment is suspected, based on history and clinical examination or in the presence of hydronephrosis or when considering surgical treatment for male LUTS. B - Measurement of post-void residual (PVR) in male LUTS should be a routine part of the assessment. 6
B - Imaging of the upper urinary tract (with US) in men with LUTS should be performed in patients with a large PVR, haematuria or a history of urolithiasis. B - When considering medical treatment for male LUTS, imaging of the prostate (either by TRUS or transabdominal US) should be performed if it assists the choice of the appropriate drug. B - Urethrocystoscopy should be performed in men with LUTS to exclude suspected bladder or urethral pathology and/or prior to surgical therapies if the findings may change treatment. 7
Treatment A - Men with mild symptoms are appropriate for watchful waiting A - Men with LUTS should always be offered lifestyle advice prior to or concurrent with treatment A - Alpha1-blockers can be offered to men with moderate-to-severe LUTS A - 5a-Reductase inhibitors can be offered to men who have moderate-to-severe LUTS and an enlarged prostate (>40 ml) A - 5a-Reductase inhibitors can prevent disease progression with regard to acute urinary retention and the need for surgery B - Muscarinic receptor antagonists may be used in men with moderate-to-severe LUTS who predominantly have bladder storage symptoms C - Carefulness with muscarinic receptor antagonists is advised in men with BOO A - PDE type 5 inhibitors reduce moderate-to-severe (storage and voiding) LUTS in men with or without erectile dysfunction. Only tadalafil (5 mg once daily) has been licensed for the treatment of male LUTS in Europe No recommendations were made about phyotherapy 8
A - Vasopressin analogue can be used for the treatment of nocturia due to nocturnal polyuria A - Combination treatment with an a1-blocker together with a 5areductase inhibitor can be offered to men with bothersome moderate-to-severe LUTS, enlarged prostate and reduced Qmax (men likely to develop disease progression) B - Combination treatment with an a1-blocker together with a muscarinic receptor antagonist may be used in patients with bothersome moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug B - Combination treatment with anti muscarinics should be prescribed with caution in men who may have BOO Surgery A - TURP is the current surgical standard procedure for men with prostate sizes of 30-80 ml and bothersome moderate-to-severe LUTS secondary of BPH. TURP provides subjective and objective improvement rates superior to medical therapy. A - Open prostatectomy or holmium laser enucleation (HoLEP) is the first choice of surgical treatment in men with prostate sizes > 80 ml and bothersome moderate-to-severe LUTS secondary to BPH needing surgical treatment. A - Open prostatectomy is the most invasive surgical method with significant morbidity. 9
A - HoLEP and 532-nm laser vaporization of the prostate are alternatives to TURP in men with moderate-to-severe LUTS due to BPO leading to immediate, objective, and subjective improvements comparable with TURP. A - The intermediate-term functional results of 532-nm laser vaporization of the prostate are comparable with TURP. A - With regard to intra-operative safety, 532-nm laser vaporization is superior to TURP. B - 532-nm laser vaporization should be considered in patients receiving anticoagulant medication or with a high cardiovascular risk. C - Intraprostatic BTX injections for men with bothersome moderateto-severe LUTS secondary to BPH or men in urinary retention are still experimental and should be performed only in clinical trials. GreenLight Laser Day surgery vs 1-2 day stay Low bleeding risk since the vessels are coagulated during the procedure No risk of TURP syndrome (dilutional hyponatremia) since the vessels are sealed Works about as well at conventional TURP 10
GreenLight Laser Propaganda from AMS GreenLight laser therapy uses laser light rather than thermal or electrical energy to remove obstructive tissue. 3 GreenLight 532nm wavelength vaporizes prostate tissue without charring and limits penetration, leaving a thin rim of coagulated tissue that aids in hemostasis.1 3 GreenLight laser therapy utilizes a non-contact, liquid cooled fiber to protect the fiber from tissue damage. This reduces the possible need to use multiple fibers during a procedure. 3 GreenLight laser therapy is not contraindicated for patients with pacemakers, defibrillators or neuro-stimulators. The GreenLight laser system is contraindicated for patients who have calcified tissue, require hemostasis in >2mm vessels and have uncontrolled bleeding disorders. See Operator s Manual and any accompanying instructions for use for a complete listing.2 3 GreenLight has been found to cost less than TURP while providing similar clinical outcomes.3, 8 3 Randomized controlled studies have shown that GreenLight has low complication rates, and short catheterization and hospitalization times.4, 5, 6, 7, 8 Possible risks and complications include, but are not limited to, irritative symptoms (dysuria, urgency, frequency), retrograde ejaculation, urinary incontinence, erectile dysfunction, hematuria - gross, UTI, bladder neck contracture/outlet obstruct, urinary retention, perforation - prostate, urethral stricture.2 3 TUR syndrome is not a postoperative complication with GreenLight.7, 8, 9 3 The GreenLight procedure has no overall deleterious impact on sexual function.10 3 GreenLight can be used for patients on anticoagulants, in urinary retention or who have large glands >100 ml.9, 11 3 GreenLight requires no post procedure irrigation or morcellation to remove tissue fragments as part of the procedure. 3 All costs incurred in getting the patient to a BPH symptom-free status should be considered (total economic impact of any treatment = procedural costs, costs associated with hospital length of stay, and the number of reinterventions). 11