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Transcript
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?