MANAGING THE SIDE EFFECTS OF A RADICAL PROSTATECTOMY

MANAGING THE SIDE EFFECTS OF A RADICAL PROSTATECTOMY Mr Rohan Hall Goldfields Urology

STAGES OF DIAGNOSIS • • Receiving a result of an elevated PSA • • • Anxiety 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 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 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 PDE 5 -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 • PDE 5 -I • Penile Pump • Intra-urethral suppository • Intracavernosal injection

ERECTILE DYSFUNCTION PDE 5 -inhibitors Contraindications How to use these tablets?

ERECTILE DYSFUNCTION • Penile Rehabilitation • - Daily cialis • Aim to achieve 3 erections per week • High dose PDE 5 -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 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?