Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures

Local anesthesia for Rezūm™: a narrative review of the literature

INTRODUCTION

This narrative review analyzed current practices and protocols for local anesthesia in Rezūm™ and evaluated the feasibility, pain management, and patient comfort associated with this approach.

EVIDENCE ACQUISITION

We included studies reporting the use of local anesthesia in Rezūm™, focusing on patient comfort and pain levels during the procedure. The literature search was performed in June 2024 using Medline, Cochrane, and Embase databases to identify relevant studies published from January 2015 to June 2024. Searches were restricted to publications in English. Owing the heterogeneity of study outcomes and the non-standardized quality appraisal, a narrative synthesis rather than a quantified meta-analysis of data was performed.

EVIDENCE SYNTHESIS

Four studies were included. Various local anesthesia methods, including transurethral intraprostatic anesthesia with the Schelin catheter and prostatic nerve block associated with cold anesthetic gel, are effective in managing pain and can facilitate the performance of Rezūm™ in outpatient settings. Functional outcomes, including improved Qmax, reduced IPSS and QoL scores, and high catheter independence rates, were reported, with minor complications.

CONCLUSIONS

Rezūm™ performed under local anesthesia is feasible, offering significant advantages in terms of patient comfort and potential for outpatient application. However, the lack of standardized protocols and the need for further research on long-term outcomes and comparative efficacy are critical areas for future investigation. Addressing these challenges could optimize Rezūm™, making them more accessible and cost-effective and potentially shifting BPH management toward more office-based procedures.

Which improvements does Rezum bring to BPH management? A network meta-analysis and comparison of water vapor therapy and conduction ablation techniques

INTRODUCTION

This study evaluated the effectiveness and safety of Rezum water vapor thermal therapy (Rezum) and compared them with those of traditional conduction ablation methods for the management of benign prostatic hyperplasia.

EVIDENCE ACQUISITION

A comprehensive review of studies from the PubMed, Cochrane, and EMBASE databases was performed. Only randomized clinical trials that reported the outcomes of thermal ablation treatments, including transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), and Rezum, were included. A network meta-analysis was performed to compare these treatments.

EVIDENCE SYNTHESIS

Sixteen studies comprising 1622 patients were included. Rezum did not show efficacy superior to that of traditional conduction ablation methods in terms of the International Prostate Symptom Score, quality of life, peak urinary flow rate, and postvoid residual volume. The incidence of acute urinary retention associated with Rezum was similar to that associated with other conduction ablation methods of TUMT and TUNA and transurethral resection of the prostate. Regarding ejaculatory dysfunction, Rezum resulted in outcomes comparable to those of sham treatment. According to the surface under the cumulative ranking curve, Rezum resulted in the lowest incidence of ejaculatory dysfunction.

CONCLUSIONS

Rezum provides functional outcomes of urinary symptoms that are comparable to those of conduction ablation therapies. Notably, among the minimally invasive thermal ablation therapies evaluated during this study, Rezum resulted in the lowest incidence of ejaculatory dysfunction.

Current management of patients affected by benign prostatic hyperplasia: a multi-institutional study from a contemporary large Italian cohort

BACKGROUND

Despite a large amount of literature focused on pharmacologic and surgical therapy for benign prostate hyperplasia (BPH), little is known about clinical presentation and management of outpatient clinic patients. We aimed to conduct a tailored analysis of BPH-affected patients, comparing men with known BPH versus newly diagnosed. The analysis was made through International Prostate Symptom Score (IPSS) and BPH Impact index (BII).

METHODS

"Intensive prostate benefit" project working group designed a questionnaire prospectively administered by urologists to patients affected by lower urinary tract symptoms (LUTS) related to BPH.

RESULTS

Overall, 3198 (64%) patients were previously diagnosed with BPH versus 1800 (36%) received a first diagnosis. Patients previously diagnosed with BPH were older (median 69 vs. 66 years) and more comorbid (P<0.001). Moreover, median IPSS score was higher in these patients (16 vs. 14), who also experienced a higher rate of severe symptoms (32.0% vs 21.5%, P<0.0001). At BII, concerns for one's health and time lost due to urinary problems were higher in patients previously diagnosed with BPH (P<0.0001). In these patients, a BPH-specific therapy was already established (88.5% vs. 75.1%) and a higher rate of therapy adherence (55.0% vs. 27.0%, P<0.0001) was observed. Roughly 90% of patients already taking BPH therapy changed their therapy after urological examination. In these patients, supplements/phytotherapeutics, alpha blockers, 5-alfa-reductase inhibitors, were prescribed in 32.8%, 37.4%, 17.4%, respectively.

CONCLUSIONS

Patients with prior BPH diagnosis have severe LUTS that worsen over time, affecting quality of life despite treatment. LUTS management in primary care is crucial, emphasizing counseling for a healthy lifestyle, cardiovascular risk control, and medication adherence.

Comparison of Durability Between Rezum Water Vapor Therapy and UroLift in Treating Benign Prostatic Hyperplasia: A Multicenter Propensity Score-Matched Analysis

Background Rezum water vapor therapy and UroLift are among the minimally invasive surgical therapies (MISTs) gaining popularity in the treatment of benign prostatic hyperplasia (BPH). This study aims to evaluate and compare the reintervention rates, a measure of durability, for Rezum water vapor therapy and UroLift as MISTs for BPH. Methods We conducted a retrospective cohort study using data from the TriNetX Global Collaborative Network, a large database of electronic health records from January 2014 to June 2024. Current Procedural Terminology (CPT) and International Classification of Diseases 10th Revision codes (ICD-10) were used to build the cohorts of men aged over 18 years who underwent either Rezum water vapor therapy or UroLift. Reintervention rates and complication profiles were evaluated over a follow-up period of up to five years. Results Cumulative reintervention rates were collected for both Rezum water vapor therapy and UroLift at the 1st, 3rd, and 5th years (2.83% vs. 3.59%, 5.99% vs. 8.76%, 6.81% vs. 10.85%). The average annual increase rate was 1% for Rezum water vapor therapy compared with 1.82% for UroLift, respectively. Most complications were more prominent in the Rezum water vapor therapy group, with urinary retention accounting for 23.42%. Discussion Rezum water vapor therapy demonstrates a more durable effect with lower reintervention rates compared to UroLift, based on this large multicenter cohort study. The higher reintervention rate observed with UroLift may reflect differences in the mechanisms of action between the two procedures. Conclusions These findings elucidate the superiority of Rezum water vapor therapy in sustaining the therapeutic effect over the long term compared to UroLift. However, more complications were noted in the Rezum water vapor therapy group. Thus, clinicians should take into account the durability and complication profiles in shared decision-making when considering MISTs for BPH.

A flexible cystoscopy device prototype for mechanical tissue ablation based on micro-scale hydrodynamic cavitation: Ex vivo and in vivo studies

Minimally invasive methods were sought for faster recovery from benign prostatic hyperplasia (BPH) and lower urinary tract (LUTS) symptoms. For this, the search for effective, low-side-effect methods for tissue ablation, particularly for managing BPH and certain bladder pathologies, has been continued to advance. In this regard, the energy released during the formation of hydrodynamic cavitation bubbles offers an alternative treatment method. In this study, we present the feasibility of the use of hydrodynamic cavitation with a flexible cystoscopy device prototype designed for the treatment of LUTS-related diseases. The developed flexible cystoscopy device prototype allows easy access to the urinary bladder through urethra with minimal pain, demonstrating its suitability as a minimally invasive approach. Precisely targeted cavitation exposure prevents prostatic capsule and bladder perforation. Moreover, an automatic actuating mechanism supports steering for real-time visual feedback. The developed device prototype was first tested on an ex vivo human bladder and then on an in vivo porcine bladder. Histopathological analyses were performed after both species were tested. For both analyses, significant tissue ablation at the targets was observed upon exposure to cavitating flows. Finally, the temperature profile on the device was obtained using a thermal camera. Accordingly, it was observed that the temperature increase during the procedure was not significant. The developed device prototype can thus realize mechanical ablation-based therapy, avoids unintended heat deposition which might appear in laser ablation and leads to fewer side effects such as uncontrolled tissue damage and low target area effectiveness that might occur in minimally invasive tissue ablation methods.

Construction of a nomogram to predict urethral stricture after transurethral resection of the prostate: A retrospective cohort study

BACKGROUND

To investigate the risk factors for urethral stricture (US) in patients with benign prostatic hyperplasia (BPH) after transurethral resection of the prostate (TURP) and to construct a nomogram model with predictive features.

METHODS

Clinical data of 400 patients with BPH who underwent TURP between June 2020 and June 2023 at Chengdu University Hospital were retrospectively collected. The data were divided into US group and no US group. Univariate and multivariate logistic regression analyses were performed sequentially to identify independent risk factors associated with US. Based on the results of the multivariate analysis, a nomogram model predicting the risk of US was constructed. We assessed the discriminatory power and calibration of the models using the C index, ROC curves, and calibration plots. In addition, we performed a decision curve analysis to validate the clinical utility of the model.

RESULTS

Data from a total of 400 patients were included in this study, and 35 (8.75%) were diagnosed with US. The results of univariate and multivariate analyses indicated that the following five factors age, prostate size, Preoperative indwelling catheter, Preoperative urethral dilation, Postoperative indwelling catheter time were independent influences on the risk of US. Nomogram model of US was constructed using these independent influences. The area under the curve (AUC) of the subject's operating characteristic was 0.916 (95% CI: 0.868-0.959), and after internal validation, the corrected C-index remained at 0.916. This further validates the accuracy and reliability of the predictive model. Calibration plots and decision curve analyses demonstrated the good clinical value of the column-line diagram model.

CONCLUSIONS

The nomogram model we constructed can have some guidance in clinical work.

Assessing β-Sitosterol Levels in Dietary Supplements for Benign Prostatic Hyperplasia: Implications for Therapeutic Efficacy

Introduction Benign prostatic hyperplasia (BPH) is a prevalent condition among aging men that affects their life quality due to urinary symptoms. Current pharmacologic treatments, often lead to sexual dysfunction, so dietary supplements (DS) containing plant-based compounds such as β-sitosterol (SIT) are preferred. DS are highly accessible and widely used, but poorly regulated, so often patients are victims of fraud. The use of DS to treat BPH symptoms is questionable, and this may be due not to the efficacity of the active compound but to the quality of commonly available DS. Aim This study aimed to assess the concentration of SIT in DS available on the market and evaluate whether the concentration of the active compound at the recommended dosage is sufficient to elicit beneficial effects in BPH. Method An HPLC-UV method based on direct saponification and acid hydrolysis was developed for the quantification of free and conjugated SIT in DS. The concentration of SIT in various DS was determined and compared with the one declared on the label. Results The chromatographic analysis confirmed the presence of SIT in all the DS but also showed a considerable variability of SIT content among DS, with only one product meeting the necessary concentration to bring potential benefits in BPH. Conclusion The study highlights inconsistencies in SIT content among DS and the importance of DS containing a standardized extract of SIT. Quality control measures are imperative to ensure that consumers receive effective and safe SIT-based DS to manage BPH symptoms. Further research is needed to establish standardized dosages and to evaluate their long-term efficacy and safety.

Integrating spatial transcriptomics and single-cell RNA-sequencing reveals the alterations in epithelial cells during nodular formation in benign prostatic hyperplasia

OBJECTIVE

Proliferative nodular formation represents a characteristic pathological feature of benign prostatic hyperplasia (BPH) and serves as the primary cause for prostate volume enlargement and consequent lower urinary tract symptoms (LUTS). Its specific mechanism is largely unknown, although several cellular processes have been reported to be involved in BPH initiation and development and highlighted the crucial role of epithelial cells in proliferative nodular formation. However, the technological limitations hinder the in vivo investigation of BPH patients.

METHODS

The robust cell type decomposition (RCTD) method was employed to integrate spatial transcriptomics and single cell RNA sequencing profiles, enabling the elucidation of epithelial cell alterations during nodular formation. Immunofluorescent and immunohistochemical staining was performed for verification.

RESULTS

The alterations of epithelial cells during the formation of nodules in BPH was observed, and a distinct subgroup of basal epithelial (BE) cells, referred to as BE5, was identified to play a crucial role in driving this progression through the hypoxia-induced epithelial-mesenchymal transition (EMT) signaling pathway. BE5 served as both the initiating cell during nodular formation and the transitional cell during the transformation from luminal epithelial (LE) to BE cells. A distinguishing characteristic of the BE5 cell subgroup in patients with BPH was its heightened hypoxia and upregulated expression of FOS. Histological verification results confirmed a significant association between c-Fos expression and key biological processes such as hypoxia and cell proliferation, as well as the close relationship between hypoxia and EMT in BPH tissues. Furthermore, a strong link between c-Fos expression and the progression of BPH was also been validated. Additionally, notable functional differences were observed in glandular and stromal nodules regarding BE5 cells, with BE5 in glandular nodules exhibiting enhanced capacities for EMT and cell proliferation characterized by club-like cell markers.

CONCLUSIONS

This study elucidated the comprehensive landscape of epithelial cells during in vivo nodular formation in patients, thereby offering novel insights into the initiation and progression of BPH.

A prospective, randomized, open-label, parallel trial comparing the efficacy of α-blocker or 5α-reductase inhibitor withdrawal to continued combination therapy on the maintenance of lower urinary tract symptoms in men with benign prostatic hyperplasia

BACKGROUND

It is uncertain how long combination therapy should be continued in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). We investigated the withdrawal effects of α1-adrenergic receptor blocker (AB) or 5α-reductase inhibitor (5ARI) following successful combination therapy.

METHODS

This prospective, randomized, open-label, parallel trial enrolled 222 patients with BPH/LUTS who showed at least a seven-point improvement in International Prostate Symptom Score-total (IPSS-T) and a ≥ 20% reduction in prostate volume (PV) following the initiation of combination therapy. Patients were randomized in a 1:1:1 ratio into continued-combination, AB-withdrawal, and 5ARI-withdrawal groups. IPSS, overactive bladder symptom score, EuroQol-five-dimensional questionnaire (EQ-5D-5L), EuroQol-visual analog scale (EQ-VAS), prostate volume (PV), maximal flow rate, postvoid residual urine (PVR), and prostate-specific antigen level were assessed every 6 months for 24 months. The predictors of IPSS-T deterioration were evaluated.

RESULTS

At Month 24, IPSS-T deterioration (≥2 point) was observed in 20/72 (27.8%) and 19/72 (26.4%) patients in the AB- and 5ARI-withdrawal groups, respectively. Among them, 4/72 (5.6%) and 4/70 (5.7%) patients required readdition of the withdrawn drug (p = 0.868). In the continued combination group, EQ-VAS improved at Month 24 compared to baseline (p = 0.028). At Month 24, the AB-withdrawal group showed improvements in EQ-5D-5L, EQ-VAS, and PVR (all p < 0.005), while the 5ARI-withdrawal group showed improvement in IPSS-S (p = 0.011). Diabetes mellitus was associated with IPSS-T deterioration at Month 24 (p = 0.020).

CONCLUSIONS

In patients with BPH/LUTS who are reluctant to continue combination therapy, AB or 5ARI withdrawal may be offered in men with improvement in IPSS-T by at least seven points and reduction in PV by at least 20%.

A correlation study between prostate necrosis rate calculated by 3D Slicer software and clinical efficacy of prostatic artery embolization, along with an analysis of predictors of clinical success after prostatic artery embolization

PURPOSE

To analyze the correlation between the prostate necrosis rate at 1-month after prostatic artery embolization (PAE) and the clinical efficacy at 1-year after PAE, and to explore potential predictors of clinical success after PAE for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH).

METHODS

The prostate magnetic resonance imaging data at 1-month after PAE were imported into 3D Slicer software for calculating the prostate necrosis rate and thus analyzing the relationship between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after PAE. The 151 patients with PAE technical success were divided into a clinical success group (n = 126) and a clinical failure group (n = 25). Independent predictors of clinical success after PAE were analyzed by multifactorial logistic regression, and the predictive performance of each factor was evaluated by applying the receiver operating characteristic curve and the area under the curve (AUC).

RESULTS

There was a linear negative correlation between the prostate necrosis rate at 1-month after PAE and the efficacy score ratio at 1-year after surgery (P < 0.001). In the clinical success group, both the initial prostate volume (PV) and the prostate necrosis rate at 1-month after PAE were significantly higher than in the clinical failure group (P < 0.001), and acute urinary retention (AUR) and adenomatous-dominant BPH were also associated with clinical success (P < 0.05). Multifactorial logistic regression analysis revealed that larger initial PV, a higher prostate necrosis rate at 1-month after surgery, and AUR were independent predictors of clinical success after PAE. The AUC values for these three indicators and their combination were 0.720, 0.928, 0.599, and 0.951, respectively, in which the prostate necrosis rate at 1-month after PAE demonstrating a high predictive value.

CONCLUSION

The higher the prostate necrosis rate at 1-month after PAE, the better the clinical efficacy at 1-year after PAE is likely to be, and the prostate necrosis rate at 1-month after PAE is expected to become a predictor of clinical success after PAE.

Management of lower urinary tract symptoms in Parkinsonian disorders

INTRODUCTION

The aim of the study was to present a narrative review of the literature on the management of lower urinary tract symptoms (LUTS) in patients presenting Parkinsonian disorders (PD).

MATERIAL AND METHODS

We carried out a literature search in PubMed and Embase database, without time restriction. We used keywords and free-text words around "Parkinsonian disorders" AND "lower urinary tracts symptoms" without language restriction. We focused mainly on papers less than 10 years old. We included all studies evaluating LUTS in patients with PD.

RESULTS

For the diagnostic management, authors emphasized the importance of differentiating Parkinson's disease with symptoms of bladder overactivity from multiple system atrophy with symptoms of bladder hypoactivity. Urodynamic evaluation was noted as the key element of diagnostic management. The therapeutic management proposed was symptomatic, based on functional urology techniques for the treatment of LUTS, both with drugs (especially anticholinergics) or surgery (intradetrusor injections of botulinum toxin, neuromodulation). Moreover, it was pointed out that it is always necessary to take into account the existence of a possible associated uropathy (prostate adenoma or pelvic prolapse).

CONCLUSION

Urodynamic evaluation is the cornerstone of diagnostic management of LUTS in patients with PD. Therapeutic management is above all symptomatic and must be done in a collegial way involving the urologist, neurologist, gynecologist, and physical medicine and rehabilitation physician.

Cervi Parvum Cornu complex for men with lower urinary tract symptoms: a multicenter, randomized, double-blind, placebo-controlled trial

Background

To evaluate the efficacy and safety of Cervi Parvum Cornu, Angelicae Gigantis Radix and Glycyrrhizae Radix complex (CAG) in men with moderate lower urinary tract symptoms (LUTS).

Materials and methods

From November 2020 to January 2022, participants with International Prostate Symptom Score (IPSS) of 12-19 in two centers were recruited and randomize into three groups: a CAG 500 mg/day group (CAG 500), a CAG 1000 mg/day group (CAG 1000), and a placebo group (PG). They were treated for 12 weeks. The primary endpoint was change of IPSS at the end of study from baseline. Secondary end points included change of prostate specific antigen (PSA), testosterone, dihydrotestosterone (DHT), maximum urinary flow rate (Q max), post-void residual volume (PVR), International Index of Erectile Function (IIEF), and drug safety.

Results

A total of 103 patients were able to finish the study according to the study protocol. Total IPSS and sub-scores (residual urine sensation, frequency, weak stream, hesistancy, nocturia, and quality of life) in CAG 500 and CAG 1000 were significantly improved at the 12th week compared to those of the PG. Changes of serum PSA, DHT, and testosterone levels at the 12th week from baseline did not show significant differences among the three groups. Q max and PVR changes did not show significant differences among the three groups either. Total IIEF and sub-scores (erectile function, orgasmic function, sexual desire, intercourse satisfaction) in CAG 1000 were significantly improved at 12th week compared to those in PG. No significant adverse events were found.

Conclusions

CAG is well tolerated in patients with moderate LUTS. Treatment with CAG for 12 weeks has a therapeutic effect on moderate LUTS.

Safety and efficacy of tamsulosin 0.4 mg as an initial dose in 1,219 Korean patients with moderate to severe lower urinary tract symptoms: data from a phase IV study

Background

An initial dose of tamsulosin 0.2 mg is frequently prescribed for Asian men. We investigated the safety and efficacy of tamsulosin 0.4 mg as the initial dose in Korean men with moderate to severe lower urinary tract symptoms (LUTSs) in everyday clinical practice.

Materials and methods

A phase IV study was conducted in South Korea. Eligible patients were prescribed tamsulosin 0.4 mg for 6 months. We excluded patients with previous exposure to LUTS drugs and patients with an international prostate symptom score (IPSS) < 8.

Results

The mean total IPSS, storage subscore, voiding symptoms subscore, and quality of life significantly decreased from 18.0, 10.8, 7.2, and 3.8 to 12.8, 7.5, 5.3, and 2.6, respectively, after 6 months of treatment. The number of nocturia episodes significantly decreased from 3.0 to 2.2 in patients who reported at least 2 nocturia events at baseline. A mean reduction in the IPSS was quantitatively equivalent in all age groups. The mean reduction in the IPSS was greater in the IPSS ≥ 20 group than in the IPSS < 20 group (mean reduction in the total IPSS: -2.6 in the IPSS < 20 group; -9.4 in the IPSS ≥ 20 group). All treatment-emergent adverse events were mild. The most frequently recorded treatment-emergent adverse event was dizziness, which was reported in 22 patients (1.8%).

Conclusion

Treatment of LUTS with tamsulosin 0.4 mg as the initial dose for 6 months in Korean men was effective in improving LUTS and showed a favorable safety profile in a real-life setting.

Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement

BACKGROUND

Benign prostatic hyperplasia (BPH) is a non-malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum, is one of several phytotherapeutic agents available for the treatment of BPH.

OBJECTIVES

To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH.

SEARCH METHODS

We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status.

SELECTION CRITERIA

We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events.

MAIN RESULTS

For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short-term follow-up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) -0.90, 95% confidence interval (CI) -1.74 to -0.07; I2 = 68%; 9 studies, 1681 participants; high-certainty evidence). Serenoa repens results in little to no difference in the quality of life at short-term follow-up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD -0.20, 95% CI -0.40 to -0.00; I2 = 39%; 5 studies, 1001 participants; high-certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I2 = 18%; 12 studies, 2399 participants; moderate-certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long-term follow-up (12 to 17 months, IPSS score, MD 0.07, 95% CI -0.75 to 0.88; I2 = 34%; 3 studies, 898 participants; high-certainty evidence). Serenoa repens results in little to no difference in quality of life at long-term follow-up (12 to 17 months, IPSS quality of life, MD -0.11, 95% CI -0.41 to 0.19; I2 = 65%; 3 studies, 882 participants; high-certainty evidence). There were no data on long-term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short-term follow-up (12 to 24 weeks, IPSS score, MD -2.41, 95% CI -4.54 to -0.29; I2 = 67%; 4 studies, 460 participants; low-certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low-certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I2 = 0%; 4 studies, 481 participants; low-certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group.

AUTHORS' CONCLUSIONS

Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents.

Intermittent Fasting Protects Against Age-Induced Rat Benign Prostatic Hyperplasia via Preservation of Prostatic Histomorphology, Modification of Oxidative Stress, and Beclin-1/P62 Pathway

Intermittent fasting (IF) has several beneficial effects on most age-related degenerative changes in the body. Here we aimed to investigate the impact of IF on the biochemical and morphological abnormalities associated with normal aging in rat prostate. Thirty male albino rats were used and divided into three equal groups: adult group, rats aged 3 months; aged group, rats aged 15 months; and IF-aged group, rats aged 15 months maintained on intermittent fasting. After 3 months, prostates were excised and processed for biochemical, histological, and immunohistochemical study. Aging resulted in prostatic histological changes that resemble those of benign prostatic hyperplasia (BPH) with increased malondialdehyde (MDA) level, decreased glutathione (GSH) level, reduction of autophagy, and increased proliferation. Intermittent fasting ameliorated these described age-related prostatic changes. It could be concluded that IF could prevent age-induced BPH. This occurs via its anti-inflammatory and anti-proliferative effects, suppression of oxidative stress, and by improving autophagy via Beclin-1/P62 modulation. These mechanisms underlie the IF-mediated protection against age-related BPH. Because of IF safety and easy availability over BPH medications, it might be promising for managing BPH after further clinical studies.