1. Urology and male health Eamonn Rogers Mercy University Hospital Cork

2. Role of Urologist • Cancer • Prostate • Testis • Benign Prostatic Hyperplasia • Erectile Dysfunction • Urinary Incontinence

4. The Prostate – Why does it become diseased so often? • Only male organ to enlarge with age • Enlargement impedes urine emptying from bladder • May inhibit ejaculation • Commonest cause of cancer in males

5. Aging and the Prostate • Only 2 known risk factors for developing Prostate Hyperplasia / Neoplasia • Aging • Functional testicular tissue (Testosterone)

6. Ageing Male • The Irish LongtituDinal Ageing Study • 1999 = 11% > 65 YEARS • 2011 = 15% > 65 YEARS • 2031 = 19% > 65 YEARS • 2035 = 66% > 80 YEARS

7. Benign Prostatic Hyperplasia (BPH) develops deep within the prostate and is more likely to “squeeze” the water passage and cause symptoms • It is much more common than cancer (90%) • It starts in men from the age of 40 and progressively grows • Cancer develops in the outside of the gland and rarely causes symptoms in its early stages until the tumour becomes advanced

8. Structure of the Bladder

11. Prostate cancer • Slow growing but eventually lethal • Most prevalent male cancer • 2nd commonest cause of male cancer deaths • 85% PSA detetcted cancers will eventually progress (7-10 years)

12. Therefore the only way one can detect early prostate cancer is with • A) a blood test (PSA) • B) feeling the surface of the prostate by means of an internal examination

13. Histological Differentiation – Gleason Grade /Score • In multivariate analysis the most important clinical parameter predicting the NATURAL HISTORY OF PROSTATE CANCER i.e. • Rate of progression • Prognosis

14. Histology – Gleason Grade 3

15. Histology – Gleason Grade 5

16. Histological Differentiation – Gleason Grade /Score • 5 Gleason grades (1-5) based on histological aggression of tissue • Architecture • Cytology • Gleason score estimates the 2 most prevalent patterns (e.g. 3+4 = 7; 2+2 = 4)

17. Histological Differentiation – Gleason Grade /Score

18. Histological Differentiation – Gleason Grade /Score • Well differentiated = Gleason score(2,3,4) • Mod. differentiated = Gleason score(5,6,7) • Poor differentiation = Gleason score(8,9,10)

19. Natural History - Histology • Well differentiated / Gleason score(2,3,4) • 10% metastases at 10 years • Mod. differentiated = Gleason score(5,6,7) • 42% metastases at 10 years • Poor differentiation = Gleason score(8,9,10) • 74% metastases at 10 years

20. Radical Retropubic Prostatectomy 1

21. Radical Retropubic Prostatectomy 2

22. Radical Retropubic Prostatectomy 3

23. Radical Retropubic Prostatectomy 4

24. Complications - Longterm • Bladder neck contracture • Impotence • Urinary Incontinence • Sphincter =Stress • Bladder

25. Robotic Prostatectomy 1

26. Robotic Prostatectomy 2

27. Robotic Prostatectomy 3

28. Robotic Prostatectomy 4

29. Robotic Prostatectomy 5

30. Laparoscopic or Open • Very user dependent • Robotic promising but extremely expensive • No prospective trial comparing modalities with longterm cancer specific survival • Potency better ? • Positive margin rates • Open = 9% • Lap = 14%