nick brook urology newsletter january 2014 v2
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New Services in 2014The practice has been busy, and has ex-panded clinics to cope with the workload and to maintain a rapid access service for urology patients who need to be seen quickly. In 2014, we will be introducing the following services to increasingly provide a medical practice that is fully re-
sponsive to patients’ need:
• Telemedicine consulting for distant/rural/country patients.
• Regular out-of hours consulting on request, so that patients can see a Urologist at a time that suits them, and minimise the impact of clinic
times on their schedule. • A scheduled Nurse-led telephone
service, to check patients are recov-ering well after treatment.
• Employment of further administrative staff tomanage the verybusyback-officeandreceptionworkload.
We very much look forward to working together with you and providing a firstclass service in 2014. Thanks again for your support.
NEWSLETTERNicholas Brook Urology
January/February 2014For Appointments Call : 08 8267 2200
LatestUrology NewsWelcome to the Nicholas Brook Urology newsletter January 2014.
The Ward Street practice has been open for seven months, and we would like to pass on our many thanks to patients, GPs and specialists for their support in 2013.
Nick Brook Urology on Ward Street
High Quality Care with Rapid Access for PatientsNicholas Brook Urology provides the range of urological investigations and manage-ment for kidney stones, prostate cancer, kidney and bladder cancer, incontinence and impotence treatment, laser surgery, vasectomy, vasectomy reversal and TURP.
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A small number of men who have a va-sectomy want the operation reversed at some point in the future. Vasectomy reversal (vaso-vasostomy) is a surgical operation to re-join the two ends of the vas on both sides, to re-establish the pas-sage for sperm.
The ProcedureThe operation is performed under gener-al anaesthetic, with the aid of a powerful operating microscope. A cut is made in the scrotum and the cut ends of the vasa areidentified.Scartissueisremovedandthe ends are joined together with very finesutures.
The procedure takes about one and a half hours, and can be done as a day case procedure.
Success RatesThe success rate is measured as ‘paten-cy’. Patency is said to be restored if sperm reappear in the ejaculate (measured by semen analysis). Patency is dependent on a number of factors, including the length of time since vasectomy, the dis-tance left between the ends of the vas at the time of vasectomy (a larger distance canmeanatechnicallymoredifficultva-sectomy reversal with lower chance of success), and the degree of scar tissue
around the vasa.
However, the true measure of success after vasectomy reversal is pregnancy. The longer the time since vasectomy, the lower the quality of sperm, and the lower the pregnancy rate. A major factor, irrespective of the others, is the fertility status of the man’s partner.
Careful ConsiderationsThese issues need careful consideration, and can be discussed at length with your urologist. Please note that patency and pregnancy may not be achieved after this operation, despite the best effortsof your surgeon. For more information, please contact the Nick Brook Urology Practice on 08 8267 2200.
A vasectomy reversal is an operation to re-join the vasa (the tubes from the tes-tes) in a man who wishes to attempt further pregnancies after a vasectomy.
Vasectomy Reversal
New LocationsNickBrooknowofferspatientstheoptionof services at St. Andrew’s Private Hospital, 350 South Terrace, Adelaide and at Flinders Private Hospital, 1 Flinders Dr, Bedford Park, Adelaide.
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Guest SpeakersSpeakers will be Dr Anthony Lowe, CEO of the Prostate Cancer Foundation of Australia (his topic is “Development of National Clinical Guidelines for Prostate Cancer and the Melbourne Consensus
Statement on Prostate Cancer Testing”) and A/Prof Ganesh Raj, Urology Sur-geon and Researcher, University of Texas SouthWesternMedicalCentre,USA and2014 FFCMH Visiting Lecturer (“Drug de-velopment – Targeting the critical driver of
prostate cancer”). Further information is available on this website http://blogs.ad-elaide.edu.au/mens-health/2013/12/19/public-seminar-on-prostate-cancer-mon-17-feb-2014-dr-anthony-lowe-and-assoc-prof-ganesh-raj/ where you can also register for the seminar. This will be an excellent session, and you are encour-aged to come along.
Nick is chairing a public seminar on Prostate Cancer on the 17th February, run by the Freemason’s Foundation Centre for Men’s Health.
mpMRI in the Diagnosis of Prostate Cancer
Prostate Cancer Seminar on the 17th February 2014
Standard ApproachThe standard approach to diagnosis of prostate cancer has consisted of a PSA blood test and, if necessary, a prostate TRUS biopsy. These tests, when com-bined,canbeeffectivebutdoleadtoanelement of ‘overdiagnosis’ & ‘overtreat-ment’ and occasionally more aggressive cancers can be missed.
There has been a lot of interest recently in the use of MRI to help with the diag-nosis of prostate cancer. The hope has been that by using MRI (known as mul-tiparametric MRI, or mpMRI) along with PSA tests (and possibly biopsy), the chance of overdiagnosis, or of missing aggressive cancers, can be reduced.
It is believed that the characteristics of
aggressive prostate tumours may be unique on multiparametric MRI. By iden-tifying the presence or absence of these MRI characteristics, biopsy may be tar-geted more accurately, or even avoided.
As well as identifying aggressive tumours, MRI may be useful for:• Finding the location of tumours, and
measuring tumour volume• Staging of prostate cancer• Helping to guide biopsy to increase
accuracy
Experience NeededIt is important to recognise that mpMRI is not perfect, and there is a good deal of debate about its exact role in the di-agnosis of prostate cancer. It is certainly clear that it should be performed in ex-
perienced centres, and that the report-ing needs to be standardised.
Further InformationIf you would like more information on mpMRI, please contact the Nick Brook Practice on 08 8267 2200.
The diagnosis of prostate cancer is plagued by two issues. The first is the poten-tial to ‘overdiagnose’ cancer, which means that small, low-grade cancers that may never cause problems are detected, and then potentially treated (also know as ‘overtreatment’). The second problem is that some more aggressive cancers may be missed with investigation. Unfortunately, these two problems are part and parcel of all tests in medicine.
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PROSTATE CANCERThe Role of the Clinical Psychologist
The Psychological impact of prostate cancerA prostate cancer diagnosis, like all diag-noses of cancer, can have a significantimpact on psychological and emotional wellbeing. Many men speak about the shock, fear, uncertainty and anxiety they experienced when told they had pros-tate cancer. Many men also speak about the diagnosis as feeling like it ‘came out of the blue’ as many men are diagnosed with localised prostate cancer without any symptoms of warning. Unfortunately many men experience periods of depres-sion or anxiety following a diagnosis of prostate cancer and emerging data indi-cates that men with prostate cancer have a higher risk of suicide than other men their age. This indicates the significantemotional impact that prostate cancer can have on some men.
Prostate cancer can have a very personal impactWhile the initial shock of a cancer diag-nosis can take its toll it is often the side-effectsofprostatecancertreatmentthatmenfindthemostchallenging.Unfortu-nately all treatment options come with their shareof sideeffects, butdifferenttreatments will have different side-ef-fects. All treatments will have an impact on sexual and erectile functioning includ-ing changes or loss of ejaculation, chang-es in orgasm sensation, loss of penile length and changes to penile sensitivity butatdifferentlevelsandratesdepend-ing on the treatment type. These side effects can have a significant personalimpact for many men as well as a direct impact on their intimate relationships.
For many men the loss of sexual func-tioning can be even more difficult be-cause of remaining normal sexual desire and this can compound the significantloss and associated impact on masculin-ity and self-esteem. Urinary incontinence can also have a very personal impact in
terms of self-esteem, ability to maintain social connections and the experience of anxiety. Self-esteem, masculine identity and self-confidence can be significantlyimpacted on by the experience of pros-tatecancerandtreatmentsideeffects.
Managing these challengesWe know from the research literature that one of the biggest predictors of psy-chological distress post prostate cancer treatment is unrealistic expectations pre-treatment. That is, men who are not fully informed and counseled, pre-treatment, about the impact of treatment on their physical functioning (particularly the sex-ual impact) will experience much higher levels of distress post-treatment. While this isn’t rocket science the delivery of adequate information and support prior to treatment in preparation for these side-effectssurprisinglydoesn’toccurallthe time. Many men report feeling ill-in-formed, and unsupported, in navigating lifewiththesesideeffects.
So what role does a psycolo-gist play in prostate cancer?As a clinical psychologist I have the privi-lege of hearing the very personal experi-encesofmenaffectedbyprostatecancerand their partner or spouse. My role in working with these men and couples is to explore the personal impact of their experience and help them weave a new way of living, whether that be a new way of being intimate, a new outlook on life or a new level of emotional awareness.
A large part of my role is to help men and their partners explore what it might mean to experience the side effects oftreatment before they have treatment. I try and speak with both members of the couple before treatment to help them plan and prepare for life after treatment and to ensure they fully understand how this might impact on them personally and as a couple. These issues are also
the focus of much of my work after treat-ment.
A clinical psychologist will also be looking out for symptoms of anxiety and depres-sion and other mental health concerns and will provide psychological counseling that focuses on reducing these symp-toms and improving emotional wellbeing.
How to access a psychologistSeeing a psychologist is not routine in most practices but there are many psy-chologists available in Australia. Ask your specialist or nurse for a referral. If they don’t know of anyone in your local area, checkwithyourGP. Ifyoustillcan’tfindthe right person there is an excellent listing of psychologists on the Australian Psychological Society website - www.psychology.org.au/findapsycholo-gist/
If you would like to read more from this article, please visit www.NickBrookUrolo-gy.com/urology-information/latest-news
Dr Addie Wootten is a Clinical Psychologist with Australian Prostate Cancer Re-search and The Department of Urology, Royal Melbourne Hospital. She talks about the psychological impact of prostate cancer on men, and what can be done to help.
Dr Addie Wootten Clinical Psycholo-gist with Australian Prostate Cancer Research and The Department of Urology, Royal Melbourne Hospital.
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CYTOREDUCTIVE NEPHRECTOMYIn Clinical Practice
David, can you explain what is meant by cytoreductive ne-phrectomy?Cytoreductive nephrectomy refers to the removal of the primary kidney tumour in patients who have metastatic disease. Historically it had been noted that occa-sional patients experienced spontaneous regression of metastatic disease when this was performed. This however only occurred in a very small number of cases and general opinion was that cytoreduc-tive nephrectomy as the overwhelming majority died within 12-18 months from metastatic disease. In the late 1980’s and early 1990’s, drugs which stimulated the immune system(immunotherapy) had an effectonmetastatickidneycancer.
Small trials with 2 agents interferon-alpha (IFN-a) and interleukin-2 (IL-2) showed response rates better than what
had been observed with conventional cy-totoxic chemotherapy. Analysis of these studies suggested that patients who had a nephrectomy performed prior to treatment resulted in a better response to both INF-a and IL-2. The basis for this was uncertain with possibilities including aselectionbiaswithonlyfitterpatients,who would otherwise expect to live lon-ger, having nephrectomy. Alternatively it was also proposed that cytoreductive nephrectomy may exert some biological effectimprovingtheeffectivenessofim-munotherapy and thus overall survival.
Which patients with meta-static kidney cancer are suit-able for cytoreductive ne-phrectomy?Cytoreductive nephrectomy is really only an appropriate option for patients who are otherwise well. Patients whose per-formance status is impaired are at high risk of complications from major surgery and also generally have poor survival that is not improved with cytoreductive ne-phrectomy. Therefore patients who have notedsignificantweightloss,areanemicor who feel tired and generally unwell are not considered candidates for cyto-reductive nephrectomy. Some patients may present with significant symptomsincluding pain and bleeding for which nephrectomy is recommended. This is regarded as a palliative intervention to control symptoms rather than a cytore-ductive nephrectomy which is performed with the expectation that it may improve survival.
Can you outline the evidence that cytoreductive nephrecto-my can be beneficial in some patients?There are 2 trials – one performed in Eu-rope and another in the United States that have demonstrated a survival ben-efit with cytoreductive nephrectomy inpatients who are subsequently treated
with IFN-a. These were both randomised controlled trials - in which patients, who all received IFN-a were randomly allocat-ed to either cytoreductive nephrectomy or no surgery. Comparing the 2 groups which were of equal size revealed that patients undergoing cytoreductive ne-phrectomy had a median survival of 14 months compared to 8 months without. These studies also reinforced the lack of benefit in patients with poor perfor-mance status.
This is obviously difficult sur-gery. Are complication rates much higher compared to other forms of kidney cancer surgery?Patients with metastatic kidney cancer usually have quite large primary tumours with a rich blood supply being a common feature. Both of these factors can make surgeryverydifficultandassociatedwitha higher risk of complications, particu-larly major bleeding, compared to other forms of kidney cancer surgery. Most pa-tients with kidney cancer have relatively small tumours and are able to have sur-gery performed either laparoscopically or robotically with low risk of complica-tions. In contrast cytoreductive nephrec-tomy, in almost all cases, requires major open surgery as minimally invasive pro-cedures are usually neither feasible nor safe. Patients with metastatic cancer are also generally at higher risk of complica-tions with major surgery. Deep venous thrombosis and pulmonary embolism are2specificexamplesofthis.
Further InformationIf you would like to read more from the Cytoreductive Nephrectomy in Clinical Practice article by Professor David Ni-col, please visit the Nick Brook Urology website at www.NickBrookUrology.com/urology-information/latest-news
David Nicol is a Consultant Urological Surgeon at the Royal Marsden Hospital in London where he is also Chief of Surgery. His clinical work deals with complex kidney and testis cancer including surgery in patients with advanced and metastatic disease. Here, he explains the use of cytoreductive nephrectomy in metastatic kidney cancer.
Professor David Nicol, Consultant Urological Surgeon at the Royal
Marsden Hospital, London
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Cancer Australia - http://canceraustralia.gov.au 1800 624 973
Kidney Cancer Australia - http://kidneycancer.org.au 1800 454 363
Prostate Cancer Foundation of Australia (PCFA) - http://www.prostate.org.au 1800 220 099
The Continence Foundation of Australia - http://www.continence.org.au 1800 330 066
Andrology Australia - https://www.andrologyaustralia.org 1300 303 878
Australian Prostate Cancer Research (3D videos) - http://vimeo.com/album/2184688
Macmillan Cancer Information (UK) - http://www.macmillan.org.uk
Jane Favretto – Practice AdministratorJane has been working in administration since 1987. In more re-cent years worked as a Special Events and Community Relations Co-ordinator for the Royal Adelaide Hospital Research Fund – the fundraising arm for the RAH and Hanson Institute. She has broad experience in administration and fundraising man-agement and brings to the practice her skills and knowledge in providing a professional, friendly and comfortable setting for patients and their families.
Meet the Staff
Support Groups and Urological Information
Matt Carlaw – Practice Finance ConsultantMatt has been working as an Accountant in Adelaide since 1997. He has a bachelor of Economics, a Graduate Diploma in Accounting and has been a member of the Institute of Char-tered Accountants in Australia since 1999. From 1997 to 2011 he worked in a number of medium sized accounting practices providing business and taxation advice to a wide range of small and medium sized businesses. Since 2011 he has been working and consulting as a Management Accountant to a small num-ber of Adelaide businesses. He likes to keep things simple and organized.
Stuart Perryman - Communication ConsultantStuart is a web designer, online marketer and back-end web de-veloper with over twelve years of professional experience in the web development and online marketing industry. As the own-er of Web Designers Adelaide, a locally based web design and development company, Stuart specialises in creating websites thatbuildcompanyprofiles,utilisingarangeofonlinemarket-ing strategies. Stuart has extensive experience in server-side and client-side programming, search engine optimisation and search engine marketing. Stuart is a keen advocate for mobile web design and web accessibility.
OUR LOCATION
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Disclaimer: 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, and this document cannot be considered to contain all information on urology conditions. Not all potential treat-mentcomplicationsarelisted,andyoumusttalktoyoururologistaboutthecomplicationsandimplicationsspecifictoyoursituation.
Nick Brook Urology175 Ward Street, North Adelaide, Adelaide, SA 5006
Telephone: 08 8267 2200Fax: 08 8267 5664
Email: [email protected]: nickbrookMDWebsite: www.nickbrookurology.com
FIND US175 Ward Street, North Adelaide,
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Since the practice opened in June 2013, the website has been central to providing information for patients and GPs. Stuart Perryman, our Digital Communication Consultant, has helped keep the website fresh and current.
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