Predicting Prostate Surgery Outcomes from Standard Clinical Assessments of Lower Urinary Tract Symptoms To Derive Prognostic Symptom and Flowmetry Criteria

Five-year Follow-up of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods-A Noninferiority Randomised Controlled Trial of Urodynamics

BACKGROUND AND OBJECTIVE

Lower urinary tract symptoms (LUTS) are a key indication for surgery in older men. The Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) study evaluated the diagnostic pathway for men considering surgery to treat LUTS and reported the outcomes at 18 mo. This long-term follow-up study reports the symptoms and rates of prostate surgery at 5 yr.

METHODS

UPSTREAM participants who had consented to long-term follow-up received postal questionnaires at 5 yr after randomisation (October 2019-December 2021). The primary outcome was the patient-reported International Prostate Symptom Score (IPSS, scale 0-35). Rates of surgery, derived from the National Health Service (NHS) England routine data, were a key secondary outcome. An intention-to-treat analytic approach was utilised.

KEY FINDINGS AND LIMITATIONS

At 5 yr, 211/427 (49.4%) participants in the intervention group and 204/393 (51.9%) in the routine care group completed the questionnaires, with routine data obtained for 801/820 (97.7%). The mean IPSS at 5 yr did not differ between randomised groups (adjusted difference 0.41, 95% confidence interval -1.10, 1.93), nor did the rates of surgery (0.96 [0.71, 1.28]). Urinary and sexual symptoms also showed no differences between the randomised groups. The main limitation is the reduced numbers of men in follow-up. In UPSTREAM, men were randomised to routine care diagnostic tests plus invasive urodynamics (intervention) or routine care only for LUTS. Treatment choice was made by the participants, advised by their clinicians.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Five-year follow-up does not support the routine use of invasive urodynamics in reducing LUTS or rates of prostate surgery. Urodynamics should be used selectively in the evaluation of uncomplicated LUTS.

The urinary and prostatic microbiome in non-neurogenic male LUTS/BPH: A systematic review

INTRODUCTION

Despite advancements in the treatment of benign prostatic hyperplasia (BPH), the mechanisms underlying BPH development and progression remain elusive and lacks a one-size-fits-all therapeutic solution. Prostatic inflammation contributes to BPH and lower urinary tract symptoms (LUTS), but the initial trigger remains unknown. Current research suggests dysbiosis of the urinary microbiome as a potential culprit. This systematic review explores the emerging field of the male urinary and prostatic microbiome and its relationship with BPH/LUTS.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A systematic search in the Pubmed and Scopus databases was performed using specific terms. Inclusion criteria considered male non-neurogenic patients with LUTS due to BPH with analyses of urinary microbiome, concerning evaluation of English-language publications with relevance.

RESULTS

Among seven articles involving 542 patients, there was an association between male LUTS/BPH and the urinary microbiome. Findings indicate a correlation between urinary microbiome dysbiosis and LUTS severity, with specific bacterial genera such as Streptococcus and Haemophilus linked to higher International Prostate Symptom Score (IPSS) scores and PSA levels. The fecal microbiome may be associated with LUTS, although contradictory findings are reported. The review also highlights methodological inconsistencies, small sample sizes, few negative controls and a lack of comprehensive clinical data as major limitations.

CONCLUSIONS

While there is an undeniable correlation between the microbiome and LUTS/BPH, future research should aim to standardize sampling techniques and expand the score to include functional microbiome characterization, potentially leading to novel, microbiome-targeted therapeutic strategies for BPH.

Bladder Outlet Obstruction Relief and Symptom Improvement Following Medical and Surgical Therapies for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Systematic Review

BACKGROUND AND OBJECTIVE

Symptomatic benefit and urodynamic obstruction relief represent relevant outcomes of therapies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). We summarized evidence from studies concurrently assessing variations in terms of symptoms severity and invasive urodynamic measures of obstruction following medical and surgical therapies for LUTS/BPH.

METHODS

We performed a systematic review of PubMed, Scopus, and Web of Science in June 2023.

KEY FINDINGS AND LIMITATIONS

We identified 29 publications: 14 (872 patients) and 15 (851 patients) studies addressing medical and surgical therapies, respectively. The mean percentage total International Prostate Symptom Score (IPSS) improvements ranged from -2.5% to 56.3% and from 35.1% to 82.1% following medical and surgical therapies, respectively. The corresponding mean percentage Bladder Outlet Obstruction Index (BOOI) improvements ranged from 7.8% to 53.5% and from 22.4% to 138.6%, respectively. Holmium laser enucleation of the prostate (HoLEP) provided IPSS improvements in the higher range and the greatest BOOI reduction.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Globally, based on available evidence, more pronounced symptomatic benefits are observed following treatments providing greater deobstructive effect. In detail, patients undergoing surgery exhibit greater IPSS and BOOI improvements than those receiving medical therapy.

Diagnoses and Treatment Recommendations-Interrater Reliability of Uroflowmetry in People with Multiple Sclerosis

BACKGROUND

Uroflowmetry (UF) is an established procedure in urology and is recommended before further investigations of neurogenic lower urinary tract dysfunction (NLUTD). Some authors even consider using UF instead of urodynamics (UD). Studies on the interrater reliability of UF regarding treatment recommendations are rare, and there are no relevant data on people with multiple sclerosis (PwMS). The aim of this study was to investigate the interrater reliability (IRR) of UF concerning diagnosis and therapy in PwMS prospectively.

METHODS

UF of 92 PwMS were assessed by 4 raters. The diagnostic criteria were normal findings (NFs), detrusor overactivity (DO), detrusor underactivity (DU), detrusor-sphincter dyssynergia (DSD) and bladder outlet obstruction (BOO). The possible treatment criteria were as follows: no treatment (NO), catheter placement (CAT), alpha-blockers, detrusor-attenuating medication, botulinum toxin (BTX), neuromodulation (NM), and physiotherapy/biofeedback (P/BF). IRR was assessed by kappa (κ).

RESULTS

κ of diagnoses were NFs = 0.22; DO = 0.17; DU = 0.07; DSD = 0.14; and BOO = 0.18. For therapies, the highest κ was BTX = 0.71, NO = 0.38 and CAT = 0.44.

CONCLUSIONS

There is a high influence of the individual rater. UD should be subject to the same analysis and a comparison should be made between UD and UF. This may have implications for the value of UF in the neuro-urological management of PwMS, although at present UD remains the gold standard for the diagnostics of NLUTD in PwMS.

Models to predict the surgical outcome of mini-ECIRS (endoscopic combined intrarenal surgery) for renal and/or ureteral stones

To establish a safer and more efficient treatment strategy with mini-endoscopic combined intrarenal surgery (ECIRS), the present study aimed to develop models to predict the outcomes of mini-ECIRS in patients with renal and/or ureteral stones. We retrospectively analysed consecutive patients with renal and/or ureteral stones who underwent mini-ECIRS at three Japanese tertiary institutions. Final treatment outcome was evaluated by CT imaging at 1 month postoperatively and stone free (SF) was defined as completely no residual stone or residual stone fragments ≤ 2 mm. Three prognostic models (multiple logistic regression, classification tree analysis, and machine learning-based random forest) were developed to predict surgical outcomes using preoperative clinical factors. Clinical data from 1432 ECIRS were pooled from a database registered at three institutions, and 996 single sessions of mini-ECIRS were analysed in this study. The overall SF rate was 62.3%. The multiple logistic regression model consisted of stone burden (P < 0.001), number of involved calyces (P < 0.001), nephrostomy prior to mini-ECIRS (P = 0.091), and ECOG-PS (P = 0.110), wherein the area under the curve (AUC) was 70.7%. The classification tree analysis consisted of the number of involved calyces with an AUC of 61.7%. The random forest model showed that the top predictive variable was the number of calyces involved, with an AUC of 91.9%. Internal validation revealed that the AUCs for the multiple logistic regression model, classification tree analysis and random forest models were 70.4, 69.6 and 85.9%, respectively. The number of involved calyces, and a smaller stone burden implied a SF outcome. The machine learning-based model showed remarkably high accuracy and may be a promising tool for physicians and patients to obtain proper consent, avoid inefficient surgery, and decide preoperatively on the most efficient treatment strategies, including staged mini-ECIRS.