George Yardy Consultant Urologist The Ipswich Hospital NHS Trust

CCG Educational meeting
Ipswich Urology Dept
Mr Rob Brierly
And
Mr George Yardy
11th September 2014
2week Wait referrals
Haematuria and PSA
11th September 2014
Mr Robert Brierly
Consultant Urologist
Associate Medical Director Medical Education
Ipswich Hospital NHS Trust
Urology Update
2WW referrals
• Haematuria and 2ww referral
• Asymptomatic microscopic haematuria
(AMH)
• PSA and prostate screening
• PSA and 2ww referral
• Review of Urology 2ww criteria
Haematuria
2 Week Rule
• Patients with Frank
(visible) Haematuria
25% Cancer
• Microscopic (Invisible)
haematuria (>50years)
1-8.3% Cancer
Blood in Pee Campaign
Blood in Pee Campaign ran from 15th
October 2013 to 20th November 2013
Regional Pilots – 28% increase in
2WW referrals
Ipswich Hospital – 27% increase in
2WW referrals over 6 week period
Pilot 48% increase in bladder and
renal cancer diagnoses (Tyneside)
To be repeated Autumn 2014
Asymptomatic Microhaematuria
(AMH)
•
A few RBCs can be found in
the urine of most normal
people
•
So what is significant?
•
When to refer
•
How to follow-up
Significant Microhaematuria
RBCs / HPF (High powered field)
500,000 RBCs/12H = 3 RBCs / HPF
No standard
» Time of
centrifuge
» Speed of
centrifuge
» Volume of
resuspension
» Volume
examined
» Definition of HPF
AUA consensus 2009
• Automated urine
analyser
• Flow cytometry
• Cells per microlitre
• 3RBCs / HPF = 16.5
cells
IQ200 Analyser
• Automated urine
analyser
• Flow cytometry
• Cells per microlitre
• 3RBCs / HPF = 16.5
cells
IQ200 Analyser
Ipswich lowest report category
<20 RBCs / microlitre
Dipstick Haematuria
• Test for haemoglobin
• Oxidation of organic
peroxide
• Peroxidase activity of
Hb
• Intact RBCs
Punctate
• Free Hb
Uniform stain
Dipstick Haematuria
• Trace can be
considered as
negative
• ≥1+ is Positive
Can you ignore +ve Dipstick and
-ve Microscopy?
20% patients significant urinary tract
pathology
5% malignancies
Lynch T BJU 1994
Repeat Testing
• 1000 asymptomatic Israeli airforce
personnel
• Regular testing
15 years
• 38.7% Positive for Microhaematuria
Froom BMJ 1984
How common is microhaematuria
Author
Number of patients
Definition
% Microhaematuria
Wright (1959)
6000
2RBCs
<2%
Alwal (1973)
2643
3RBCs
3.9%
Male
5.7%
Female
1.0%
Male
2.0%
Female
0.6%
Male
1.4%
Female
7RBCs
11RBCs
Ritchie (1986)
10,050
Dipstick
2.5%
Carel (1987)
21,000
Dipstick
2.6%
Male
8.1%
Female
Hiatt (1994)
20,571
Dipstick
4.3%
Iseki (1996)
107,192
Dipstick
2.8%
Male
11.0%
Female
2ww referral haematuria
• Painless macroscopic haematuria any age
• Persistent/ recurrent UTI assoc with haematuria
(>40years)
• Persistent Asymptomatic microscopic haematuria
(>50years)
• Defined as : 2 out of 3 1+ dipsticks or MSU
+ve microscopy done at weekly intervals over
a period of 1 month
What about the <50year old?
Think about
renal
disease and
monitor
BAUS and renal
association guideline
Haematuria learning points
• Refer all Frank haematuria as 2ww.
• Microhaematuria is not uncommon with repeat
testing.
• +ve dipstick cannot be ignored because of –ve
microscopy.
• 2ww referral AMH over 50years:
2 out of 3 1+ dipsticks or significant RBCs
on microscopy/ MSU done at weekly
intervals over a period of 1 month
• For <50ys think renal (can always refer as
non 2ww)
Prostate Cancer and
PSA
• PSA Testing and Screening for Prostate
cancer.
• 2ww referral
PSA
A 50 y old fit and healthy male solicitor
visits you. He is totally asymptomatic,
but has heard about the PSA test and
is worried about having prostate
cancer. He requests the test, for
‘peace of mind’. There is no Family
history.
Please advise the patient
What would you do?
• A) Refuse the test on the basis that he has
no symptoms.
• B) Perform rectal examination which is
entirely normal and refuse test on this
basis
• C) Following rectal exam discuss the pros
and cons of opportunistic screening and
agree to arrange PSA if patient still keen.
Does screening reduce prostate
cancer mortality?
The Prostate, Lung, Colon, and Ovary (PLCO) Trial
National Cancer Institute
No difference in prostate cancer deaths at 7-10 years of followup when comparing those screened to those that were not.
(Andriole
2009).
European Randomized Study of Screening for Prostate Cancer
(ERSPC)
29 percent relative reduction in prostate cancer deaths among those
screened when compared to those that were not at 11 years
(Schroder 2012).
Screening
ERSPC trial 2009
To prevent 1 Prostate cancer death over
10years:
1410 men would need to be screened
48 men treated
PSA
• 63 year old fit and well man has
longstanding mild lower urinary tract
symptoms (LUTS). DRE moderately
enlarged (25cc) smooth benign feeling
prostate. Annual PSA for last 3years have
been normal around 3.0.
• Now PSA 6.1
• What will you do?
Age-related PSA
Age (years)
40-49
50-59
60-69
70+
Reference range (ng/ml)
0-2.5
0-3.5
0-4.5
0-6.5
PSA is an unreliable marker
• Prostate specific but
not cancer specific
• Transient rise:
–
–
–
–
–
Infection
Ejaculation
Instrumentation
Urinary retention
Non-infective
inflammation related to
BPH
– Bicycles
• Fluctuations in annual PSA measurements
occur frequently. Isolated elevation in PSA
should be confirmed several weeks later.
•
Eastham , JAMA 2003
• “The PSA level should be verified after a
few weeks by the same assay under
standard conditions”
•
EAU Guideline 2014
PSA
• 63 year old fit and well man has longstanding
mild lower urinary tract symptoms (LUTS). DRE
moderately enlarged (25cc) smooth benign
feeling prostate. Annual PSA for last 3years
have been normal around 3.0.
• Now PSA 6.1
• Urine dip is NAD.
• You repeat PSA after 3 weeks 6.0
• Refer as 2 ww
PSA
The Diagnostic Triad
in Prostate Cancer
All Options
Active
surveillance
Current Pathway
Initial GP
Appointment
Initial
OPA
<2w
Rpt
PSA
PSA
Biopsy
MDT
and
OPA
Further Consultation
and Referral
Stage
MRI
and
BS
62 Days!
OPA
Referral
to
tertiary
centre
OPA
tertiary
centre
Treat
RT
RP
AS
2ww referral for suspicion of Ca
Prostate
• Any irregular feeling prostate on rectal exam (Please
check PSA to accompany the referral).
• A raised age-specific PSA with or without lower urinary
tract symptoms. For an isolated raised PSA please
arrange repeat test after a few weeks before referral.
•
If there is clinical or bacteriological evidence of urinary
tract infection, PSA repeated after treatment might be
appropriate.
•
• A high PSA (>20) with symptoms
Learning points
• Discuss pros and cons of PSA testing and gain
consent before arranging test.
• Indications for testing include:
– Patient request
– Symptoms
– Irregular examination
• PSA measurements can fluctuate and an
isolated rise after excluding infection should
have a repeat test after a few weeks before
referral.
Adult Female Urinary Incontinence
IESCCG pathway
George Yardy
Consultant Urologist
The Ipswich Hospital NHS Trust
Trinity Park
11th September 2014
local incontinence pathway - treatment
•Lifestyle advice for all patients
• wt loss if BMI>30
• caffeine reduction
• avoid excessive or small quantities of fluid
• 6-8 glasses water / day
• smoking cessation
• 3 day bladder diary
•Then categorise incontinence
- Stress UI
- Overactive Bladder (OAB) with or without
urge UI
- Mixed UI – treat predominant Sx
Midurethral slings
Urethral Bulking Agents
local incontinence pathway – OAB treatment
•Lifestyle advice for all patients
•Bladder retraining / pelvic floor muscle
exercises
- Patient.co.uk advice page
•Drug treatment
•More invasive treatments available in
secondary care
Drug treatment – NICE CG171, Sept 2013
• First line:
•
oxybutynin immediate release – not for frail older women
•
tolterodine immediate release
•
darifenacin once daily
• If first treatment not effective / well-tolerated, offer another drug with the lowest
acquisition cost
• Offer a transdermal OAB drug to women unable to tolerate oral medication
• For guidance on mirabegron for treating symptoms of OAB, refer to Mirabegron
for treating symptoms of overactive bladder
NICE technology appraisal guidance 290
Mirabegron for OAB, NICE TA290, June 2013
• 1.1 Mirabegron is recommended as an option for
treating the symptoms of overactive bladder only for
people in whom antimuscarinic drugs are
contraindicated or clinically ineffective, or have
unacceptable side-effects
Drug treatment - IESCCG
Drug treatment - IESCCG
More invasive treatments available in secondary care
•Sacral neuromodulation
•Percutaneous posterior tibial nerve
stimulation
•Bladder botox injections
•“Clam” cystoplasty
•Ileal conduit urinary diversion
Sacral neuromodulation
Sacral neuromodulation
PTNS: percutaneous posterior tibial nerve stimulation
Botox
Botox
Administration of Botulinum toxin
•
•
•
•
•
•
•
•
Flexible cystoscope
Instillagel
Bladder filled to 100ml
1050mm 27G needle
Into submucosa or detrusor, not beyond
100-300 units BTX-A
20-30 sites injected with ~1ml each
Spare trigone ? -  pain, VUR
Harper, BJUi 2003
Clam, conduit
Clam, conduit
local incontinence pathway – treatment
•Lifestyle advice
•Bladder retraining / pelvic floor muscle
exercises
•Drug treatment
•More invasive treatments available in
secondary care
Thank you