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?