Articles tagged with: urology

30
November
2014

Enzalutamide available on the PBS

Enzalutamide available on the PBS

From 1 December 2014, a new drug for advanced prostate cancer will be available and listed on the PBS. Enzalutamide is an oral drug used for advanced prostate cancer (metastatic castration resistant prostate cancer). It works by inhibiting binding of androgens (such as testosterone) to the androgen receptor (AR), as well as inhibiting the AR from entering the cell nucleus and from binding to DNA. It has had encouraging results in clinical trials.


What are the PBS criteria for enzalutamide?

The treatment cannot be used in combination with chemotherapy (docetaxel in the common chemotherapy agent used in advanced prostate cancer)

AND

The patient must have failed treatment with docetaxel due to resistance (this generally means progression of disease or non-response to docetaxel) or intolerance

OR

The patient must be unsuitable for docetaxel treatment on the basis of predicted intolerance to docetaxel

AND

Patient must have a World Health Organisation Performance Status of 2 or less (this means good performance)

AND

The patient must not receive PBS-subsidised treatment with this drug if progressive disease develops while on this drug

AND

The patient must not have received prior treatment with abiraterone

OR

Patient must have developed intolerance to abiraterone of a severity necessitating permanent withdrawal of abiraterone.

Categories: Updates, Prostate Cancer

28
November
2014

Should I have a PSA test?

Should I have a PSA test?

This short article may help you with the decision about having a PSA test (also known as PSA screening) to look for prostate cancer

Australia has one of the highest rates of prostate cancer in the developed world. The PSA test is the first investigation that can be done to look for prostate cancer. It is not a perfect test, and there are problems associated with the test, which is why you should be as well informad as possible about PSA.

Information for Patients Considering Prostate Cancer Screening

Background

  • Prostate cancer is common. Most men will develop prostate cancer if they live long enough. Despite this, only about 3% of all men will die of prostate cancer.

  • This indicates that most prostate cancers do not cause trouble in a man’s lifetime (‘low-risk’ or ‘indolent’ cancers). However, there are some more aggressive cancers that can cause trouble, and these benefit from detection and treatment.

  • Screening studies do show that the number of prostate cancer deaths can be reduced by screening with PSA. However, quite a large number of men need to be diagnosed by screening and treated to prevent one prostate cancer death.

  • One study (the Goteborg study) showed that 12 men need to be diagnosed to prevent one prostate cancer death. That means that 11 men were unnecessarily diagnosed. Another larger study demonstrated that (ERSPC) that 781 men need to be screened and 27 men need to be diagnosed to prevent one prostate cancer death. Thus 26 men are unnecessarily diagnosed.

  • Screening will detect many of these indolent cancers, and if they are detected, they may go on to be treated, perhaps unnecessarily.

  • Treatment is associated with long term complications in men, such as incontinence, erectile dysfunction (impotence) and bowel problems. Therefore, some men (indolent cancers that are treated) may have unnecessary treatment and suffer side effects.

The aim of screening

  • The aim of screening should be to identify aggressive or high-risk prostate cancers early, before they have spread beyond the prostate.

  • Some men are at higher risk of aggressive prostate cancer than others. These are men with a family history of prostate cancer, or with a strong family history of breast or ovarian cancer in females of the family, men of African-American decent, and men who have been exposed to some environmental agents (fire-fighters possibly, and veterans exposed to Agent Orange).

  • Most prostate cancers found by screening are low risk and do not need to be treated, and can just be closely followed by active surveillance (click for link to AS).

  • If you choose to be screened, there is a reasonable chance you will be diagnosed with low-risk prostate cancer, and may be in a position where you have to consider treatment that may be unnecessary.

Your decision to be screened – what sort of person are you?

  • If you have risk factors for prostate cancer (see above), your risk of prostate cancer may be higher than the general population, and this may impact your decision to be screened.

  • If you are the sort of person who would be uncomfortable not being treated if low risk prostate cancer was discovered, screening may not be the right decision for you.

  • If you are the sort of person who would accept treatment for aggressive prostate cancer, but would be happy to observe (active surveillance) things if you just had low risk prostate cancer, then you may be a good candidate for screening.

Categories: Updates, Prostate Cancer

29
April
2014

Stereotactic Ablative Body Radiotherapy (SABR)

Stereotactic Ablative Body Radiotherapy (SABR)

Our First Guest Blog for May 2014 is by Dr Shankar Siva, a Radiation Oncologist from The Peter MacCallum Cancer Centre in Melbourne. He discusses the new technique of Sterotactic Ablative Body Radiotherapy for kidney cancer in patients who are not medically fit for surgery. This new approach is still in a study period, but may offer cancer control to patients who do not have other treatment options.


Shankar, can you explain what Stereotactic Ablative Body Radiotherapy (SABR) is, and what advantages it has over other forms of radiotherapy?


Stereotactic ablative body radiotherapy (SABR) is a high precision radiotherapy technique that involves between 1 and 5 treatments. This is very different from conventional radiotherapy that involves daily radiotherapy for up to 8 weeks. It is non-invasive, painless, delivered without any need for anaesthetic, and conveniently does not require in-patient hospitalisation. SABR requires high-tech radiotherapy equipment for safe delivery, such as motion management for the tumour, accurate image guidance, and robust immobilisation. When delivered correctly, SABR can achieve submillimetre accuracy. Because of its precision, the SABR technique allows for much higher biological doses than can be safely delivered using conventional radiotherapy techniques. As such, most studies in sites such as the brain, lung and spine report cancer control rates in the order of 90% or greater after SABR.


Sterotactic radiotherapy for some other types of tumour has been around for some time. Why has it only recently been looked at for kidney tumours?


Stereotactic radiotherapy was first devised for brain tumours by Swedish neurosurgeon Lars Leksell in 1951, who termed it “radiosurgery”, so yes, it has been around for a very long time! Cranial "radiosurgery" was performed by using a rigid frame around the skull which allowed for accurate delivery of the radiation dose. However, tumours in other organs such as the lung, liver, and kidney are all highly mobile due to normal breathing or from the pumping of the heart. Only recently have technological advances allowed us to account for and manage tumour motion during radiotherapy delivery. The kidney in particular is a challenging organ, as it is quite mobile and surrounded by many sensitive organs.


Which group of patients is likely to be suitable for this treatment for kidney tumours?


Surgery is still the standard of care for patients with kidney cancer. However, kidney cancer is typically a disease of the older population, with the average age of diagnosis being 65 years of age. Some patients have other medical conditions which make invasive procedures potentially risky, particularly those patients who may have significant pre-existing kidney dysfunction, are risky anaesthetic candidates, or have heart disease and are reliant on blood thinners. In light of this risk, other procedures such as SABR and radiofrequency or microwave ablation have emerged as treatment alternatives for inoperable patients. In contrast to SABR, the disadvantage of radiofrequency ablation and microwave ablation is that those techniques can typically treat only treat smaller tumours, require the insertion of electrodes through the skin into the kidney (invasive), and are not as effective when tumours are close to blood vessels. On the other hand, the disadvantage of SABR is that it is typically restricted to patients who have not previously received radiotherapy to the upper abdomen. Otherwise, we expect that most patients who are not suitable for surgery on medical grounds may be eligible for treatment using the SABR technique.


What are the potential side effects?


In the early period after treatment, we expect that most patients feel tired. There may be some nausea, or loose bowel actions. Some patients may experience some reflux or heartburn. We typically prescribe preventative medications to help with these side effects. There may be a mild skin reaction, similar to a very light sunburn, particularly around the back. These side effects usually resolve within the first 2-3 weeks, and we expect all of these side effects to be resolved by around 6 weeks post treatment. The longer term effects of SABR in the kidney are less well understood. There is a potential for decline in kidney function, rise in blood pressure, scarring or narrowing of the bowel, or very rarely ulceration of the bowel or stomach. To date, studies have shown that the risk of severe side effects to be less than 5%.


This treatment is currently part of a study at the Peter Mac. What do you think the future holds for this treatment for kidney tumours?


We have pioneered this technique in Australia through the FASTRACK clinical trial, one of the few clinical trials using SABR for localised kidney cancer in the world. This study is expected to be complete later in 2014, and to date the results have been very promising. We would like to make this treatment accessible to all patients in Australia. However, the problem is that technology is very complex and varies from centre to centre. The Peter Mac is one of the largest radiation oncology institutions in the southern hemisphere and an Australian leader in the SABR technique, so we are not certain whether our results can be immediately reproduced in other institutions across Australia.

The next phase in our research program is to lead a multicentre study of SABR for kidney cancer involving multiple cancer centres across Australia. All the treatment plans will be centrally reviewed by our team at the Peter Mac for quality assurance, in order for this new treatment to be safely introduced across Australia. If this study is successful, I imagine that stereotactic radiotherapy will become a readily available treatment alternative for inoperable patients with primary kidney cancer.


Click this link to display a news item and video on the SABR technique.


Dr Siva is a Radiation Oncologist, Research Staff Specialist and NHMRC Scholar at the Peter MacCallum Cancer Centre in Melbourne. His major research interests are in high-tech radiation delivery and radiation biology. He is the lead clinician of the stereotactic body radiotherapy program at the Peter MacCallum Cancer Centre, and coordinates the first dedicated Stereotactic Ablative Body Radiotherapy (SABR) clinic in Australia. He published the first original research using the SABR technique in Australia. He serves on the Radiation Oncology Research Committee (RORC) of the Royal Australian and New Zealand College of Radiologists, on the renal subcommittee of the Australian and New Zealand Urogenital and Prostate (ANZUP) trials group, and as the radiation oncologist on the Management Advisory Committee (MAC) of the Australasian Lung Cancer Trials Group (ALTG). He is the principal investigator of multiple radiotherapy clinical trials of SABR in the context of lung, kidney and prostate malignancies.

Follow this link for more information on Dr. Shankar Siva


Categories: Video, Updates, Kidney Cancer

04
January
2014

Radical Prostatectomy or Surveillance in Older Men – Which is Better?

Radical Prostatectomy or Surveillance in Older Men – Which is Better?

This is an abridged, written version of an invited lecture Nick Brook gave to the Clinical Oncology Society of Australia in November 2013. It covers a common clinical dilemma in a changing medical and surgical environment; the older man with organ confined prostate cancer….is surgery or surveillance the best option?

Has anyone noticed a storm of controversy surrounding the diagnosis and treatment of prostate cancer? This centres on concerns about the overtreatment of prostate cancer, and may have particular relevance in older men, who mostly have a shorter life expectancy than their younger counterparts. But men are living longer and in better health, perioperative management has advanced, and minimally invasive surgical treatments have lessened the acute physiological impact of treatment. Dogma has been that there should be a cut-off at 70 years of age when considering curative treatment for prostate cancer, but the tired catchphrase - ‘physiological not chronological age’ - is actually a very useful one, and has relevance to this topic.

Why worry?

It’s worth examining why we worry about treating localised prostate cancer with curative intent in older men. The reasons are four-fold:

  • These men may not benefit from treatment, as they may die of other causes before their prostate cancer becomes clinically relevant
  • Treatment may not be tolerated, and may cause morbidity and, rarely, mortality
  • Most men with curable disease who are left untreated do not die from prostate cancer within 10 years of diagnosis
  • For those who die within 10 years of diagnosis, the disease was probably incurable at diagnosis

These last two points are taken from a recent presentation by Patrick Walsh, and reflect an understanding of the natural history of prostate cancer, and its heterogeneity.

With changes in demographics and treatments, should we be pushing for surgical treatment in older men with localised prostate cancer, or is this overtreatment? Are these men better off on surveillance/watchful waiting? Before we can answer these questions, some basic points need reviewing:

Prostate cancer is not one disease

First, prostate cancer as a disease is heterogeneous in its classification and behavior. Gleason grading is absolutely central to determining how the cancer is likely to behave. We know that this classification trumps other variables in predicting outcomes, whether these are positive margin rates, extra-capsular extension, seminal vesicle invasion, lymph node status, recurrence after treatment, or prostate cancer mortality.

We can use the Albertson tables to indicate likely mortality from prostate cancer and non-prostate cancer causes over a period of time for a given Gleason score and age at diagnosis. It is really quite simple; when we ask “does it matter if we treat or not?”, we get an indication that a man in his early 60s with Gleason 6 disease has a very different proportional chance of dying from prostate cancer in the next 15 years than a man in his early 70s. Likewise, a man in his 70s with Gleason 7 (a weakness of the tables is that 3+4 and 4+3 are combined) is, of course, proportionally more likely to die of another cause than he is to die of prostate cancer, but this is not true for a man in his 60s at diagnosis.

Albertson Table

So, age and Gleason score are combined in these tables to give us a reasonably powerful tool when we grapple with the question of whether to treat or not. These Albertson tables have been around for a long time, have recently been updated, and are greatly underused.

Active surveillance or watchful waiting?

Second, the terms ‘surveillance’ and ‘watchful waiting’ are separate entities that are often confused.

Watchful waiting is based on the premise that some patients will not benefit from treatment of their primary cancer. The decision is made at the outset to forgo definitive treatment, and instead provide palliative intervention for local progression or metastasis if/when it occurs.

Active surveillance is very different, and is based on the understanding that some but not all patients may benefit from localised treatment. The idea is to monitor closely and

  1. identify those men with localised cancers that are likely to progress, providing timely treatment for them
  2. to avoid treatment and associated treatment-related complications in men with cancers that are unlikely to progress
Active surveillance or watchful waiting - Man at a microscope

If we consider again the Albertson tables, we can see why active surveillance makes sense for those cancers that are less likely to cause trouble, but also makes sense for older patients, perhaps with intermediate risk cancer.

A number of different active surveillance protocols are in use. They vary slightly (some have stricter criteria), and include the Johns Hopkins, Toronto, Miami, and UCSF protocols. The one we are encouraged to use in Australia as part of an international protocol study is PRIAS (Prostate Cancer Research International Active Surveillance).

Results of active surveillance

What do we know about outcomes from active surveillance? Klotz’s group in Toronto reported on 450 men followed with active surveillance, about 50% of whom were over 70 years at diagnosis, most with 3+3=6 but 17% of men had 3+4=7. Importantly 10-year cancer specific survival was 97%. There was no difference in prostate cancer mortality for those men on AS over or under 70 years of age at diagnosis. Obviously though, non-prostate cancer death in those over 70 at diagnosis and commencement of AS was much greater than those under the age of 70. This provides further evidence that age does matter; we already know our older patients are more likely to die of other causes. It also substantiates the idea that for carefully selected patients, AS is a sensible option.

What factors should we consider when choosing radical prostatectomy or ‘surveillance’ in older men?

When we are considering RRP in older men, there are three key questions we should consider:

  1. In this man’s lifetime, will cancer control be an issue, i.e. do we need to perform radical prostatectomy to control his cancer or will surveillance (or watchful waiting) suffice?
  2. Is the perioperative risk higher than is acceptable, and is it higher than in younger men? Does his age/co-morbidity preclude safe surgery?
  3. Is his risk of long-term side effects that affect quality of life (incontinence and erectile dysfunction) too high, and is this higher than in younger men?

Let’s look at some evidence for these three areas:

Cancer Control

The two randomised studies that we have were of watchful waiting (rather than surveillance) versus radical prostatectomy:

The Scandinavian Prostate Cancer Group 4 Study randomised 695 men, 75 years old or less, with localised prostate cancer to radical prostatectomy or watchful waiting (not surveillance). The intervention for progression in the WW group was hormone ablation. Median follow-up was 12.8 years. Briefly, compared to watchful waiting, radical prostatectomy reduced prostate cancer deaths in men under 65 years (51% RR reduction, p=0.008), but not in those over 65 years (17% RR reduction, NS). Likewise, occurrence of metastasis (itself, an important endpoint) was significantly reduced in the radical prostatectomy group in under 65s, but not in the over 65s. This randomised study suggests that age does matter when considering the effect of RRP on cancer control.

The PIVOT study (Prostate Intervention Versus Observation Trial) looked at a similar number of men, randomised to RRP or observation (essentially watchful waiting, with palliative therapy or chemotherapy on progression). At 12 year follow up, there was no benefit of radical prostatectomy over observation, and there was no age effect. This study has been heavily criticised as it was underpowered (the study was initially powered for 2000 men but only 731 were randomised), and for the very small number of prostate cancer deaths in each arm. There were far fewer deaths overall in PIVOT, and the men as a cohort had more co-morbid conditions than SPCG4. Difference in outcomes from the two studies may also be because the SPCG4 men were mostly PSA naïve, whereas the PIVOT cohort came from the early PSA testing era.

Perioperative risk in older men

Can we safely take older men through an operation and the perioperative period? Do the (generally) age-associated co-morbidities impart too much risk?

An excellent retrospective study from Ontario of 11,000 men who underwent RRP helps address this question. Importantly, it showed the following:

  • Increasing age is associated with increased medical/surgical complications
  • There is a small but significant increase in 30-day mortality with age, even when adjusted for comorbidity
  • The number of co-morbidities is more important than age in determining mortality risk.

My reading of this is that age does matter, but medical fitness is more important in determining post radical prostatectomy complications and death. Older men who are fit (with minimal co-morbidities) are low risk and can be considered for surgery.

Long term side effects that affect quality of life – continence and erectile function in older men.

Lets conclude by looking at the potential long-term side effects of radical prostatectomy (incontinence and erectile dysfunction) that can have a major impact on quality of life. Is there any evidence for an age effect?

Many of the papers reporting side effects from radical prostatectomy are set about with bias, uncertainties and confusing definitions of continence and erectile function. However, a stand out paper from Massachusetts General Hospital looked at 430 men treated for localised prostate cancer with different modalities, and reported pre- and 36-month post-treatment sexual and continence function. Importantly, the authors stratified post-op outcomes according to pre-treatment function. Looking at erectile function, for nerve sparing radical prostatectomy (the gold-standard for erectile preservation), we see a remarkable reduction in sexual function. For those men with normal erectile function pre-op, only 8% were normal 36 months post-operatively. 28% of men deteriorated from normal to intermediate function, and 64% went from normal to poor. If we look at those who were intermediate before surgery, the figures post-op figures are worse. The paper did not examine an age effect, but we can extrapolate from population studies of non-prostate cancer men. We know that erectile function deteriorates with age, and it is therefore likely that a cohort of older men will have worse pre-op function, and are therefore more likely to have worse post-surgery erectile function.

Illustration of a man's body with the prostate highlighted

Admittedly there are weaknesses in this argument; the extrapolation and presumption, and the possibility that men with poor erectile function pre-operatively may not be concerned about post-operative erectile function, i.e. that factor may not affect their quality of life.

The paper reports a much less severe reduction in continence after surgery. However, but the outcomes are poorer for men who had less-than normal continence pre-operatively.

Some recent data is available on the effect age on continence after robotic radical prostatectomy; this indicates that although early continence 3-6 months after surgery is slower to recover in men >70 years, after that time the results are equal to men <70 years.

Summary

This is a complex dilemma and a common clinical issue we struggle with regularly. As life expectancy increases, the likelihood of prostate cancer clinical progression increases. Less invasive surgery and improved perioperative management have expanded the pool of men that can be safely treated. We need to carefully examine the rationale for radical prostatectomy, watchful waiting and surveillance in this dynamic demographic of ‘older’ men, but we are becoming more sophisticated in our decision making in this area.

For cancer control, one randomised trial suggests that men over the age of 65 do not benefit from RRP compared to WW. In carefully selected men, true active surveillance seems safe, and it is likely to be particularly safe for men over 70. We may even be able to extend surveillance criteria in these older men. In terms of surgical safety, age does matter but it is not as important as co-morbidity. For those long-term side effects of radical prostatectomy that impact on quality of life, it is likely that older men have worse potency outcomes than younger men. Low-level evidence indicates that continence outcomes may be equivalent in older and younger men.

You can follow Nick Brook on:

You can navigate Nick’s website by clicking the ‘Home’ link at the top of this page, or by following this link www.nickbrookurology.com

Categories: Prostate Cancer

12
November
2013

Kidney stones - prevention and treatment

Kidney stones - prevention and treatment

Matthew Bultitude is a consultant urological surgeon practising at Guy's and St. Thomas' Hospital in London. He has a subspecialist interest in stone disease, and in this article he answers questions about the common problem of kidney stones.


Matt, how did you become interested in urological stone disease?

I was fortunate to work as a junior doctor in the stone unit at Guy's and St. Thomas' Hospital and following on from that I was offered a research position which I gladly took up. I undertook a number of clinical projects during that period including an MSc thesis assessing the safety of flexible ureteroscopy. I really enjoyed the challenges that stone disease creates and this has carried on throughout my career.


Do you see an increasing rate of stone disease in the UK, and what is the cause of this?

There is no doubt that there has been a steady increase in the number of stone cases in the western world and the UK is no exception. The lifetime risk may now be as high as 12% (American data) and although more common in men, they are becoming increasingly prevalent in women. This is essentially due to a combination of increasing obesity with poor diets (high in animal protein, fizzy drinks, processed foods, salt etc) and low fluid intake.


What have been the major developments in surgery for stone disease in the last few years?

I remember (as a boy with a urological father) when the first public lithotripter arrived in the UK (St. Thomas' Hospital) in the 1980's. This revolutionised stone treatment and continues to be a common treatment. What has changed over the last decade has been the development of smaller (diameter) and more robust instruments allowing us to pass telescopes up the urinary tract to the kidney to treat stones (flexible ureteroscopy). For large stones percutaneous surgery (PCNL) remains the standard and recent developments have seen some interesting changes to how this is done with smaller and smaller instruments and also in new surgical positions with many surgeons now choosing the supine position (so lying on side) rather than prone (lying on front).


Does shock wave therapy have an ongoing role in stone management?

There is no doubt that shock wave lithotripsy has been on the decline but in my opinion it is still a useful treatment for many patients. Choosing the correct stone for this treatment is important and as it works better in a thin patient with a smaller stone, rather than trying it in everyone. However I increasingly find patients prefer the more definitive choice of surgery with ureteroscopy to fragment the stone with a laser as although it is more invasive, the outcomes are more predictable.


Calcium oxalate stones are the most common kind of kidney stones. What is your advice to someone who has had a stone like this, to prevent future stone formation?

I often give quite detailed advice about stone prevention, although the summary of this is a normal healthy diet with lots of fluid (which is what we should all be doing!). In principal we should aim for a diet with:

- Enough fluid to produce at least 2 litres of urine per day. The actual amount will be different for everyone but usually a minimum of 2.5 litres in per day is required. This is the most important advice.

- Limited animal protein (meat and fish)

- Low salt

- Plenty of fruit and vegetables

- High fibre

- A normal calcium intake - so cutting back is often the wrong thing to do.

For calcium oxalate stone formers there are some foods high in oxalate and limiting intake of these may also help.


What developments do you see on the horizon for kidney stone treatment?

I think surgery will continue to improve with better quality and smaller instruments becoming available. Shockwave lithotripsy will probably continue to decline (as discussed above). What would be a game changer is the development of effective medication that could reduce the chance of stones growing in urine although I suspect we are many years away from this!


You can read more about Matt Bultitude by following these links to the Guy's and St. Thomas' Hospital website and the London Bridge Hospital website.

Click here for a link to his personal website.

You can also follow Matt Bultitude on twitter


Categories: Kidney Stones

12
October
2013

Helping with Impotence (Erectile Dysfunction)

Helping with Impotence (Erectile Dysfunction)

Impotence (erectile dysfunction) is a common problem in men, and can be caused by many factors. Medical problems such as diabetes, high blood pressure, cardiac disease and peripheral vascular disease can all make erectile dysfunction more likely, and smoking is a major risk factor. The number of men with impotence increases with age.

Impotence is a common problem after treatments for prostate cancer. The impact of treatments depends on a number of factors including:

  • Type of treatment (surgery, brachytherapy, external radiation, hormones)
  • Time since treatment
  • Your erectile function before treatment
  • Other medical conditions that you may have

Many men are not aware that treatments are available. Another problem with getting treatment is that impotence can be a difficult topic for men to discuss, but urologists are aware of the problem and are used to talking about it. Sometimes the problem may be related to stress or anxiety and this can be helped as well.

Tablet treatments for erectile dysfunction

For men who need treatment, it is usual to start with oral medications (trade names for available drugs are Cialis, Levitra and Viagra). These treatments require the presence of functioning nerves to work, and so are unlikely to be effective if you have had prostate surgery that has affected the nerves. However, some recovery is possible even if nerves have been damaged, so tablets are a sensible place to start.

There are side effects associated with these tablets, and they cannot be taken if you also take nitrates or GTN spray. Talk to your doctor if this is the case. These side effects include back pain, indigestion and headache.

If the tablets do not help (you are encouraged to try them on a number of occasions) then the next steps to consider are injection therapy or a vacuum device.

Injection treatment for erectile dysfunction

This form of treatment involves self-injection with a very small needle near the base of the penis a short time before you wish to have intercourse. Once you have been taught how to do it, it is easy and results can be very good.

Injection treatment for erectile dysfunction (impotence)

Vacuum device for erectile dysfunction

The vacuum erection device is another method of obtaining erections. It looks cumbersome, but once you get the hang of how to use it, it can be a good method. The device creates a vacuum which draws blood into the penis, and a temporary rubber constriction ring is then placed around the base of the penis. When you wish the erection to subside, you simply remove the ring.

Vacuum device for erectile dysfunction (impotence)

Inflatable penile prosthesis for erectile dysfunction

Insertion of a penile prosthesis is an operation for erectile dysfunction that has not responded to other forms of treatment. Although recovery from the operation is generally quite quick, it should be considered very carefully as if the device is removed, you would not be able to get an erection again with another form of treatment.

The device is reasonably complex, and highly engineered. It consists of three parts, as shown in the diagram below. Essentially, the device uses fluid to fill two rods, and these give an artificial erection.

Inflatable penile prosthesis for erectile dysfunction (impotence)

The two rods are inserted into the penis, and these are connected to a fluid reservoir (inserted into the lower abdomen), and to a pump (inserted into the scrotum).

Penile prosthesis for erectile dysfunction (impotence)

By squeezing the pump, fluid is moved from the reservoir to the rods, which lengthen (and some devices also expand). When you no longer wish to have an erection, pressing the small button on the pump causes fluid to move from the rods back to the reservoir, and the erection goes away.

The link below takes you to a video animation of how the device works.

Penile prosthesis video

What is the erection like with an inflatable prosthesis?

It is important to have realistic expectations of the results of surgery, and a urologist will discuss this with you in detail. Although this operation can allow you to regain an active sex life, the erections are not spontaneous, and need to be initiated by you pressing the pump. Also, although most sensation during intercourse comes from the glans (head) of the penis, which is relatively unaffected by the operation, both partners report different sensations than they used to feel when erections were spontaneous. For men, sensation may be reduced, and for women, it is common to report that the penis feels ‘cold’ during intercourse. The implant will not make your penis larger. An approximate guide to erect penile length after the operation can be given by putting the flaccid penile on full stretch.

Potential side effects and complications of an inflatable prosthesis

All procedures have the potential for side effects. Although these complications are well recognised, the majority of patients do not have problems after the operation. Listed below are some of the complications that can occur. This is not an exhaustive list, and should not be considered as advice; you need to discuss these issues in a consultation with a urologist.

Common complications of a penile prosthesis include:

  • Pain after the procedure, in the penis, scrotum and wounds. This is usually well controlled.
  • Some bruising around the scrotum. This should be minimal.

Rare complications of a penile prosthesis include:

  • Intra-operative complications, which require halting the procedure, and re-booking for a later date. These will be discussed with you, but include injury to the urethra, and perforation of the corporal bodies (where the cylinders are put in).
  • Early or late infection of any part of the device. Because the device is a foreign body, if it gets infected the whole device will need to be removed and a new one reinserted at a later date.
  • Erosion of part of the device through the skin. This normally requires removal of the entire device, as infection is usually present.
  • Early or late failure of the device (see figures below for a rough guide)

To give an idea of complication rates, a study of 955 penile prostheses implanted in an Australian Centre showed the following results:

  • An intraoperative complication rate up to 3%
  • Infection on the prosthesis requiring removal =1%
  • 90% of the implanted prostheses still work at 5 years
  • 85% of the implanted prostheses still work at 10 years
  • 90% of men are satisfied with the outcome, to the point that they would make the same decision again.

Reference: Chung E, Van CT, Wilson I, Cartmill RA. Penile prosthesis implantation for the treatment for male erectile dysfunction: clinical outcomes and lessons learnt after 955 procedures. World J Urol. 2013 Jun;31(3):591-5.

Nick Brook would be pleased to discuss these treatment options with you. Please follow this link to the contact page


Disclaimer

The author of this article does not endorse the use of any particular device or treatment for erectile dysfunction. This information is intended as an educational guide only, and is here to help you as an additional source of information, along with a consultation from your urologist. The information does not apply to all patients. Not all potential complications are listed, and you must talk to your urologist about the complications specific to your situation.

Categories: Impotence (erectile dysfunction)

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