WHAT’S NEW IN UROLOGY?GP UPDATE
16th October, 2014
Miss Janelle Brennan
Mr. Rohan Hall
Learning Objectives
Describe the various treatments for overactive bladder
To be able to safely prescribe new therapeutic agents for overactive bladder
To understand new treatment modalities for BPH
To be familiar with new treatments for metastatic prostate cancer
To be aware of current controversies in prolapse surgery
Overactive bladder (OAB)
First line treatment Anticholinergics
Oxybutynin (regular or prn, therapeutic dose limited by dry mouth)
Oxytrol patches (PBS, can use 1.5 patches, skin irritation)
Vesicare (solifenacin) - ~$50, 5 or 10mg, main S/E is constipation
Enablex (darifenacin) - ~$50, 7.5 or 15mg, ?<cognitive S/Es
Second line treatment Mirabegron (Betmiga)
Mirabegron (betmiga)
Became available in Australia in April 2014, ~ $57/month Beta 3 adrenergic agonist
B3 receptors in bladder induce detrusor relaxation (esp around trigone) increasing bladder storage capacity
Starting dose 25mg BUT 50mg dose more effective & same price
Use low dose if: Renal or liver impairment, uncontrolled hypertension
Side effects Hypertension Urinary retention
Drug interactions/contra-indications Mild prolongation of QT interval – care with sotalol, amiodarone,
haloperidol, erythromycin, clarithromycin CYP2D6 inhibitors e.g. fleicanide, metoprolol Digoxin Pregnancy/breast feeding/paediatrics
Botox
PBS approval for neurogenic bladder 2013 – 200IU Strict criteria:
MS, Spinal cord injury, cerebral palsy Urodynamic confirmed DO > 14 incontinence episodes/week, 50% improvement with
treatment, day case Willing to perform CISC Registered urologist with MBS/ S100 scheme
Botox for idiopathic detrusor overactivity (DO) Likely available on 1/11/14 100IU, usually lasts 6/12 Wide availability to urologists
If non approved ~ $475 for 100 IU Side effects – 6% urinary retention, 10% failure
Sacral Nerve Stimulation
Medtronic Electrode in S3 nerve root
Urinary frequency/urgency/incontinence Urinary retention Faecal urgency/incontinence
2 stages – lead then implantable generator Unable to have spinal MRI 70% chance of 50% improvement for OAB and 50%
chance of 50% improvement for urinary retention (Even better success with faecal incontinence)
Unable to have MRI spine (although can have MRI head, 1.5T magnet)
Follow up clinic available in Bendigo (need GP referral)
Sacral nerve stimulation
Female urology Prolapse
FDA mesh warning – July 2011 Class action(Aust) vs J&J (prosima) – October 2012 Very litiginous so need informed consent/appropriate training Indications – recurrent prolapse esp vault, multiple co-morbidities Move to sacrocolpopexy (open/lap/robot) – this mesh is OK!
Stress urinary incontinence (SUI) Bulkamid (98% water, hydrogel) most common agent
Macroplastique is less popular, contigen not available
No issues with mesh slings Recurrent UTIs
Cranberry, Hiprex, Keflex 250mg nocte (Streamline code 4243) Ellura – high dose cranberry supplement
~$50 month Equivalent to 70g of fresh cranberries, standardised to provide the
recommended dose of 36mg bioactive proanthocyanidins (PACs) in each capsule
BPH/bladder outlet obstruction – Medical Therapy
Alpha blockers Prazosin – up to 2mg bd Tamsulosin (generic now available for ~ $30, flowmaxtra
supposedly more selective to alpha1a receptor so less postural hypotension)
Duodart Must have baseline PSA due to risk of high grade prostate
cancer – expect 50% PSA reduction at 6 months Risk of low libido/erectile dysfunction (not always reversible)
PDE5 inhibitors Cialis 5mg daily
PDE5 enzymes in prostate and bladder & known to cause smooth muscle relaxation - ?mechanism of action
~$160/month
BPH – surgical therapy
Gold standard TURP
Green light laser Available in Melbourne Day case or overnight stay Can stay on anticoagulants BUT 20% risk of repeat surgery at 5 years, post
op dysuria Urolift
Lateral lobe enlargement Only rebatable in private
Urolift
Day case
No significant median lobe
Can have TURP if unsuccessful
No sexual side effects
Early prostate cancer - phi
Phi = Prostate Health Index Available through Melbourne Pathology ~ $90
Mathematical formula that combines total PSA, free PSA and [-2] proPSA Outperforms individual components for
prediction of overall and high grade prostate cancer on biopsy
~10% improved accuracy with greater specificity AUC – PSA 0.53, %fPSA 0.65, PHI 0.70
Performs best in PSA 2-10 range
Early prostate cancer - MRI
Available at Bendigo Health, ~ $250 Indications
Persistently elevated PSA despite negative biopsies
Active surveillance Pre-operatively to
plan nerve sparing
mp-MRI
Early prostate cancer – TP biopsy
Almost zero risk of sepsis Increased risk urinary
retention (~2%, up to 10%)
Up to 30% improved cancer detection (apex)
Available at SJOG (hopefully soon available at Castlemaine/Rochester for uninsured patients)
General anaesthetic MRI fusion
Transperineal prostate biopsy
Advanced prostate cancer - metastatic
Firmagon (degarelix) LHRH antagonist (as opposed to agonist) Avoids tumour flare so no need for anti-
androgen treatment Rapid decrease in testosterone Monthly injection – 240mg loading dose
then 80mg monthly Improved cardiovascular side effect profile BUT injection site reaction
Advanced Prostate Cancer – Castrate Resistant
Abiraterone (Zytiga) Castrate resistant prostate cancer & Post
docetaxol chemotherapy (for PBS) Inhibits 17 a-hydroxylase/C17,20 lysase in
testicular, adrenal & prostate tumour tissues Decreases circulating levels of testosterone by
blocking androgen synthesis Given with daily prednisolone Side effects – HT, low K, peripheral edema
Carbazitaxel (Jevtana) 2nd line chemotherapy
Enzalutamide – targets androgen receptor (?coming soon)
Other urological cancers
Kidney cancer Active surveillance/renal biopsy Partial nephrectomy
Laparoscopic assisted ?improved long term cardiovascular morbidity with nephron
sparing TKIs for metastatic disease
?role of cytoreductive nephrectomy Sunitinib (Sutent) and Pazopanib (Votrient) (better safety)
Bladder cancer Worldwide shortage of BCG Cystectomy + neobladder (formation of neo-bladder out
of small bowel)
Laparoscopic surgery
Nephrectomy and nephro-ureterectomy Lap assisted partial nephrectomy (Hall) Adrenalectomy Bladder diverticulectomy Pyeloplasty
?funding for robot one day …..
QUESTIONS?