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Download Managing the side effects of a radical prostatectomy
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MANAGING THE SIDE EFFECTS OF A RADICAL PROSTATECTOMY Mr Rohan Hall Goldfields Urology STAGES OF DIAGNOSIS • Receiving a result of an elevated PSA • Referral to urologist • Prostatic biopsy (TRUS or transperineal) • Receiving the diagnosis • Staging • Receiving results • Discussing management of localised prostate cancer • Discussing the side effects of each treatment option • Anxiety • Depression • Loss of autonomy • Futility • Anger MANAGING THE “TRIFECTA” • • • Oncology • Pre-op • Post-op • Review appointments Continence • Pre-op lower urinary tract symptoms • Pre-op preparation • Post-op expectations Erectile Function • Pre-op erectile function • Social circumstances • Medical comorbidities • Intra-operative variation • Post-op expectations POST-OP • Wound • IDC • Pain • Scrotal oedema • Driving • Cycling URINARY CONTINENCE • Male continence mechanism URINARY CONTINENCE • Pre-op pelvic floor education benefits post-op return to continence • Post-op pelvic floor exercises – when to start • What level of continence is normal in the post-operative period • • • 3/12 – 1 pad/day • 12/12 – 1 pad/day • 2% of patients will be wet, wet, wet Other factors affecting ability to be continent: • Chronic cough • Obesity • Diuretics What if continent, then new incontinence? BEHAVIOURAL MODIFICATIONS • Decrease fluid intake • Void frequently • Avoid caffeine, alcohol • Avoid activity that increases intraabdominal pressure URINARY CONTINENCE • What next – formal urodynamics to rule out over active bladder, also can assess ALPP. • Bulking agents • Considered successful 17% of the time for post radical prostatectomy SUI • Pro’s - minor procedure • Con’s – may need to be repeated • Can set up local chronic inflammatory response making further treatment difficult URINARY INCONTINENCE ADVANCE™ MALE SLING • Sling restores urethra to its proper anatomical position for optimal sphincter function, restoring urinary control • Procedure: – Spinal or general anesthesia can be used – Three small incisions: 1 under the scrotum, 2 over groin creases – Specially designed surgical tools are used to position the sling – Sling is gently tensioned – Incision closed ARTIFICIAL URINARY SPHINCTER (AUS) • The Gold Standard for treatment of moderate to severe incontinence • 60± minute outpatient procedure • 92% of patients would have the device placed again • 96% of patients would recommend it to a friend • Device is placed completely in the body, providing simple, discreet control - Requires dexterity for use of pump ERECTILE DYSFUNCTION • “The inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance” • Prevalence of ED: 52% men older than 40 have some degree of erectile dysfunction • “Mandropause” • Age 60 – 20% ED • Age 70 – 70% ED • Set expectations • “The best erection they will achieve post-op is 70% of there pre-op erection, and this may be with the aid of a PDE5-I” ERECTILE DYSFUNCTION • Aetiology • Vasculogenic: arteriogenic vs veno-occlusive dysfunction • Neurogenic • Psychogenic – depression, stress, anxiety, psychiatric disorder • Endocrinologic – hyperprolactinemia, thyroid disorder, hypogonadism • Medications (b-blockers,antidepressants,spironolactone,sedatives, phenytoin ERECTILE DYSFUNCTION • PDE5-I • Penile Pump • Intra-urethral suppository • Intracavernosal injection ERECTILE DYSFUNCTION PDE5-inhibitors Contraindications How to use these tablets? ERECTILE DYSFUNCTION • Penile Rehabilitation • - Daily cialis • Aim to achieve 3 erections per week • High dose PDE5-I • Intracavernosal injections • Alprostadil (caverject) • Trimix • Theoretically makes sense • Lack of evidence • Expensive ERECTILE DYSFUNCTION – PENILE IMPLANTS Ideal for men who have tried other treatments without success • On the market for over 30 years • 25,000 penile implants per year • Over 300,000 implants to date • High patient and partner satisfaction TYPES OF PENILE IMPLANTS One-piece non-inflatable Two-piece inflatable Three-piece inflatable ONE - PIECE NON-INFLATABLE PENILE IMPLANT Advantages • Easy for you or your partner to activate • Good option for men with limited dexterity • Totally concealed in body • The simplest surgical procedure • Least expensive prosthesis Disadvantages • Stays firm when not in erect position • May “show” through clothing THREE – PIECE INFLATABLE PENILE IMPLANT Advantages • Simple to use • Fast and simple one-step deflation • Totally concealed in body • Acts and feels more like a natural erection • Expands the girth of the penis • More firm and full than other implants • Feels softer and more flaccid when deflated Disadvantages • Requires some manual dexterity • Possibility of leakage or malfunction • Possibility of unintentional erections QUESTIONS?
