Slide 1

Urology in Primary Care Mr Shiv Bhanot Consultant Urological Surgeon

Slide 2

Advances in Urology Practice, a historical perspective 1995 TRUS biopsies and open radical prostatectomy 1996 Urodynamics 1997 Uro-Gynecology service 1997 Laser Prostatectomy (Neodymium Yag) 1998 Smiley Incision open radical prostatectomy 1999 TVT colposuspension 2000 PCNL service for kidney stones 2002 Model for Evaluation of Dynamics of Prostate Cancer 2003 Specialist MDT 2004 Laparoscopic Nephrectomy 2004 Laparoscopic Radical Prostatectomy 2005Laparoscopic Pyeloplasty 2006 Robotic Arm LRP 2007 Laparoscopic Partial Nephrectomy 2008 PCA3 Urine Test for early diagnosis of Prostate Cancer 2009 Holmium Laser for stones 2010 Single 1 cm technique of LRP 2011 Template prostatic biopsies 2011 Zero ischaemia partial nephrectomy 2011 HOLEP for BPH 2013 Hand Assisted Laparoscopic Radical Prostatectomy( under evaluation)

Slide 3

Why Urology in primary care Ageing population Dignity, aesthetics and quality of life Urological cancers Cost of pads and appliances Cost of falls and orthopaedics operations

Slide 4

Urology Service at BHRT Comprehensive Service Based at KGH, Cancer centre Clinics at Queens and in the community 6 Consultants 8 middle grade urologists 3 CNSs Acute Receiving Unit

Slide 5

What will be covered ? What is LUTS Assessment and treatment of LUTS When to refer for LUTS When to do a PSA When to refer for raised PSA Early Prostate Cancer Treatment Kidney Stones Urinary Incontinence

Slide 6

LUTS Lower urinary tract symptoms Frequency, urgency and nocturia Hesitancy Weak or interrupted flow of urine Incomplete bladder emptying Post micturition dribbling * Dysuria and pain are not LUTS

Slide 7

The urological basis of LUTS Two special muscles of urinary tract Detrusor (always resting except) Sphincter (always active except) Bladder Prostate Urethra

Slide 8

What can you do for LUTS General medical history Physical examination, DRE Urine test Frequency volume chart Reassurance, life style advice Offer serum creatinine Offer IPSS Offer PSA Offer drug treatment Offer specialist referal

Slide 9

Slide 10

Drug Treatment IndicationTreatmentReview LUTSAlpha bockerat 4-6 weeks then 6-12 m OABAnticholinergicat 4-6 weeks then 6-12 m >30gm, PSA>1.45 alpha reductase inhibitorat 3-6 m then 6-12 m High IPSS, >30gm, PSA>1.45 ARI + alpha blockerat 4-6 weeks then 6-12 m Symptoms despite treatment with alpha blocker Add anticholinergicat 4-6 weeks then 6-12 m

Slide 11

LUTS Indications for referal to hospital Bothersome symptoms UTIs Retention Renal impairment Suspected urological cancer haematuria, sterile pyuria and raised PSA Stress urinary incontinence

Slide 12

Who is fit for surgery (TURP) for LUTS Good head Good legs The vast majority can tolerate TURP, selection is the key to success for surgery

Slide 13

An alternative to surgery for Retention Done under local anaesthetic, can be easily reversed

Slide 14

PSA Test Very good tumour marker No positive or negatives for diagnosis Marker of prostatic size in BPH Truly speaking not a test but a measure Measure of probability and not diagnostic of Ca Allows diagnosis of early prostate cancer 20% of all prostate cancers have normal PSA

Slide 15

When to offer a PSA Test offer information, advice and time to decide ( Pre Test PSA info sheet ) Suspect benign prostatic enlargement or BPH Prostate feels abnormal Patient concern regarding prostate cancer

Slide 16

Pre PSA Test Information

Slide 17

PSA Video

Slide 18

Diagnosis of Prostate Cancer PSA Rectal Examination Free PSA* pCA3 gene test* MRI, MRI Spectroscopy and diffusion weighted imaging* Transrectal ultrasound guided biopsies Transperineal biopsies* * Not routinely available yet

Slide 19

Early Prostate Cancer PSA

Surgical Experience, 20 years > 1200 major cases of kidney, bladder and prostate cancer Other interests, Female Urology, TVT, Stones Since 2004 all kidney and prostate cancer operations done laparoscopically

Slide 28

Slide 29

Urology, when to refer ? Follow the guidelines When in doubt please call or email NHS 0208 970 8138 Private 07711335083 shiv.bhanot@nhs.net