412.3 🩺 內科專科考前版

412.3.0.1 📌 䞀頁重點

  • 22E: TRAVERSE 2023 (TRT CV non-inferior); Stockholm3 prostate biomarker; oral testosterone undecanoate (Jatenzo); minimally invasive BPH (UroLift, Rezum); shared decision making for prostate
  • Taiwan: 健保 PSA + DRE; 健保 tamsulosin + dutasteride/finasteride; 健保 tadalafil 條件; 健保 testosterone IM/gel 條件; 健保 TURP / laser; CTAOH/TES + Taiwan Andrology Society 指匕

412.3.0.2 🌟 Pearls (10)

  1. TRAVERSE trial 2023 (NEJM): TRT in middle-aged + older men with hypogonadism — non-inferior major CV events
  2. Stockholm3 (newer prostate biomarker): combines PSA + protein + clinical + genetic; potentially more specific than PSA alone
  3. Free PSA + 4Kscore + PHI for PSA elevation workup
  4. MRI prostate: PI-RADS standard; precedes targeted biopsy
  5. MRI-targeted biopsy > systematic random biopsy (PRECISION trial)
  6. Active surveillance for low-risk prostate CA: PSA + MRI + selective biopsy
  7. PSMA PET-CT (¹⁞F or ⁶⁞Ga): revolutionizing prostate CA staging + recurrence
  8. ¹⁷⁷Lu-PSMA-617 (Pluvicto): theranostic for metastatic prostate CA (FDA 2022)
  9. Oral testosterone undecanoate (Jatenzo, FDA 2019): hepatically bypassed; alternative to IM/gel
  10. HPV vaccine men ≀ 26 yr (ACIP); some 27-45 SDM

412.3.0.3 📍 Taiwan + 健保

  • 健保 PSA + DRE (條件 + 自費 health check)
  • 健保 free PSA (條件)
  • 健保 tamsulosin (Harnal) + alfuzosin
  • 健保 dutasteride (Avodart) + finasteride (Proscar)
  • 健保 tadalafil 條件 (BPH + ED)
  • 健保 mirabegron (Betmiga)
  • 健保 testosterone IM (Nebido) + gel (Tostran) 條件
  • 健保 TURP, HoLEP, GreenLight laser
  • PSMA PET 自費 倚 (新, 醫孞䞭心)
  • Pluvicto 自費
  • 健保 prostate MRI (條件)
  • 健保 prostatic urethral lift (UroLift), water vapor (Rezum) — 限制 / 自費

412.3.0.4 🎓 內專必懂 (10)

  1. CV recognition + comprehensive risk modification
  2. Prostate CA SDM + biomarker (Stockholm3, free PSA, 4Kscore, PHI)
  3. MRI prostate + targeted biopsy (PRECISION)
  4. PSMA PET (22E) for staging + recurrence
  5. ¹⁷⁷Lu-PSMA-617 (Pluvicto) for metastatic
  6. BPH medical + minimally invasive ladder
  7. LOH / andropause: TRAVERSE outcome
  8. TRT formulations + monitoring + fertility consideration
  9. Mental health + suicide screening
  10. Vaccination + preventive care

412.3.0.5 ⚙ BPH Treatment Decision Tree (內專)

IPSS Severity:
- Mild (0-7): observation + lifestyle
- Moderate (8-19): medical
- Severe (20-35): medical → surgical

Medical Therapy:
- α-blocker (1st line): tamsulosin 0.4 mg / alfuzosin 10 mg
  - Onset: 2-4 wk
  - Effect: symptom relief
- 5α-reductase inhibitor (large prostate > 30-40 g):
  - Finasteride 5 mg or dutasteride 0.5 mg
  - Onset: 6 mo for max
  - Effect: shrink + slow progression
- Combination α + 5αRI for moderate-severe + large
- Tadalafil 5 mg daily: BPH + ED dual

Specific Subgroups:
- LUTS + ED: tadalafil
- LUTS + OAB: + mirabegron or anticholinergic
- LUTS + nocturia: limit fluid + double-voiding

Surgical / Minimally Invasive:
- Refractory medical
- Acute urinary retention recurrent
- Recurrent UTI / hematuria / stone / renal failure

Procedures (smallest invasive first):
1. Prostatic urethral lift (UroLift) — small to moderate prostate
2. Water vapor (Rezum) — moderate
3. Laser (HoLEP, GreenLight) — moderate to large
4. TURP — moderate to large (gold standard)
5. Open prostatectomy — very large (rare now)

412.3.0.6 ⚙ Prostate Cancer Workup + Management (內專)

Screening + Diagnosis:
- PSA + DRE (SDM 55-69)
- Elevated PSA workup:
  - Repeat PSA
  - Free PSA % (lower = more concerning)
  - 4Kscore, PHI, Stockholm3 (newer)
  - MRI prostate (PI-RADS)
  - Targeted biopsy (PRECISION)

Risk Stratification:
- Very low / low: observation / active surveillance
- Intermediate: surgery / RT / brachytherapy
- High: combined modality + ADT

Treatment:
- Active surveillance (low-risk):
  - PSA + DRE q3-6 mo
  - MRI + repeat biopsy q1-3 yr
- Localized:
  - Radical prostatectomy (open, laparoscopic, robotic)
  - External beam RT (EBRT) ± brachytherapy
- Locally advanced:
  - Combined RT + ADT
  - Radical prostatectomy + adjuvant RT/ADT
- Metastatic:
  - ADT (LHRH agonist/antagonist + antiandrogen)
  - Chemo (docetaxel)
  - Novel: enzalutamide, abiraterone, apalutamide, darolutamide
  - PSMA-targeted: ¹⁷⁷Lu-PSMA-617 (Pluvicto)
  - Cabazitaxel for refractory

Monitoring:
- PSA trends
- DRE
- Imaging (MRI / PSMA PET) per stage + treatment

⚠ AI 草皿。