Medical Management of BPH: The Debate Continues

Clinical relevance of urethral stents (Urospiral 2™) placement in patients with prostatic obstacle and concomitant high-risk surgical status or neurological diseases: a feasibility and safety study

AIMS

To review the indications and to assess the functional outcomes after placement of a new temporary urethral stent (TUS) in men with lower urinary tract dysfunction.

METHODS

We retrospectively reviewed the data of men with prostate obstruction and concomitant high-risk surgical status or neurological diseases between 2006 and 2008. TUS placement was performed with Urospiral 2™ which is a temporary, non-expanding, transprostatic stent. Success was defined as follows: when TUS placement allowed patients to void spontaneously and/or when surgery was made feasible after the period of relative contraindication (therapeutic group) or when TUS placement allowed physicians to define the role of prostate obstruction in the patients' voiding disorders and therefore to make an appropriate therapeutic decision (diagnosis group).

RESULTS

We included 94 men with a mean age of 73.3 ± 9 years (48-99) and 5 of them were lost to follow-up. The mean follow-up was 148 ± 100 days (2-1,046) and the mean duration of TUS placement was 155 ± 90 days (2-1,045). After a mean hospital stay of 4.8 ± 3 days (1-31), 84 patients (89%) had recovered spontaneous micturition. In the therapeutic group and the diagnosis group, 23 patients (92%) and 45 patients (70%) voided spontaneously, respectively.

CONCLUSIONS

TUS placement may be proposed temporarily in selected patients with static bladder outlet obstruction due to an enlarged prostate as it allows patients to avoid the use of an indwelling catheter.

Placebo-controlled dose-ranging phase 2 study of subcutaneously administered LHRH antagonist cetrorelix in patients with symptomatic benign prostatic hyperplasia

BACKGROUND

Pilot studies with daily dosing suggested the use of the luteinizing hormone-releasing hormone antagonist cetrorelix (CET) for the treatment of symptoms from benign prostatic hyperplasia (BPH).

OBJECTIVE

To assess efficacy and safety of three dosing schemes of CET in patients with symptomatic BPH.

DESIGN, SETTING AND PARTICIPANTS

After a run-in period with 4 weekly injections of placebo, 140 patients with an international prostate symptoms score (IPSS) > or =13 and a peak urinary flow rate (PFR) 5-13ml/s were randomly allocated to 4 treatment groups; patients with residual urine volume of >350ml were excluded.

INTERVENTION

Patients received either CET at dosages of 5mg/wkx4, 10mg/2 wkx2 or 10mg/wkx4 or placebo.

MEASUREMENTS

IPSS, PFR and mean uroflow, residual urinary volume, prostate volume, plasma testosterone, quality of life, and sexual function were evaluated over a total of 20 wk after randomization.

RESULTS AND LIMITATIONS

Of 140 randomized patients, one patient did not complete treatment, 5 others dropped out off-treatment, before week 12 evaluation of the primary end point. In all CET groups a rapid improvement in mean IPSS was obtained, with a peak effect of -5.4 to -5.9 (placebo: -2.8). After all dosages of CET given, changes from baseline and differences to placebo were statistically significant up to week 20. Similarly, secondary parameters showed a significant, rapid, and persistent improvement for all CET dosages. All dosage regimens were well tolerated. The study evaluated a single treatment course only; further studies with repeated treatment courses will be required to establish a dose regimen for long-term disease management.

CONCLUSIONS

At all dosage regimens tested, CET was safe and effective in patients with symptomatic BPH, with a trend towards a more rapid onset of effect for the CET 10mg/wkx4 regimen. Response persisted up to the end of follow-up, 16 wk after the last dose.

The Long-Term Outcome of Medical Therapy for BPH

OBJECTIVES

The lack of cure with medical therapy implies life-long treatment emphasising the need for a thorough understanding of the long-term outcome. We review the natural history, markers for progression, placebo effect, efficacy, pharmacoeconomic aspects, and preventive measures.

METHODS

Literature review with particular reference to long-term controlled studies using plant extracts, alpha1-blockers, 5alpha-reductase inhibitors (5-ARIs), and combination therapy.

RESULTS

There is a long-lasting (>or=12 mo) placebo response of symptoms (20% decrease) and maximum flow rate (10% rise). The five long-term controlled trials of plant extracts are inconclusive and therefore their role in contemporary medical management is still controversial. The alpha1-blockers provide fast amelioration of symptoms yet have no relevant impact on the risk of acute urinary retention or surgery. Combination therapy should be reserved for moderately or severely symptomatic patients with a high risk of progression; in the majority of patients the alpha1-blocker can be safely stopped after 6-12 mo. The preventive use of 5-ARIs in men with no or mild symptoms at risk of progression is scientifically sound yet not generally accepted mainly for economic reasons.

CONCLUSIONS

A sharp contrast exists between the duration of the longest controlled trial (4.5 yr) and the situation in real life with treatment periods up to one or two decades of life. Real-life and registry data will be the only source of this important information in the future.