Guide de prise en charge en médecine générale des symptômes du bas appareil urinaire de l’homme liés à une hyperplasie bénigne de la prostate

[Prostatic hyperplasia: Evaluation of practices in general practice, dissemination, and impact of recommendations]

INTRODUCTION

In 2015, the French Association of Urology, by the male lower urinary tract symptoms Committee, published a practices guideline for the management of prostatic hyperplasia in general practice. Five years after the publication of these recommendation, our objective is to assess their dissemination and their impact in general practice.

MATERIAL

A specially designed questionnaire was distributed online via the departmental councils of the order and to all regional unions of liberal doctors. The distribution to general practitioners was at the discretion of each organisation depending on local policies.

RESULTS

Two hundred and eighty responses were collected. Fifty-five percent of the population was female. 83 % of the general practitioners did not report having knowledge of the practice guideline. 77 % of doctors stated that they had not received training or information on prostatic hyperplasia in the past 5 years. Among the notable results, 51 % of general practitioners declared performing a digital rectal examination. 44 % prescribed an endorectal ultrasound. Only 7 % of doctors were aware of the existence of minimally invasive surgical techniques.

CONCLUSION

The practices guideline for the management of prostatic hyperplasia in general practice proposed in 2015 by the male lower urinary tract symptoms Committee seems to be little known by general practitioners. Dissemination of these recommendations solely through publication in Progrès en Urologie seems ill-suited to consideration by general practitioners, and it seems necessary to consider other modes of dissemination.

LEVEL OF EVIDENCE

4, grade C.

[Alpha-blockers or phytotherapy as first-line treatment of LUTS/BPH in general medicine: The PERSAT non-interventional study]

PURPOSE

The objective of the PERSAT study was to evaluate first-line treatment of BPH-associated LUTS in real-life conditions.

METHODS

This prospective observational study was conducted in France by general practitioners (GP) on patients with moderate to severe LUTS (IPSS ≥12). GPs freely decided to prescribe either an alpha-blocker (AB) or phytotherapeutic treatment (PT). The main criterion was the percentage of responding patients (decrease in total IPSS score ≥3) at 6 months.

RESULTS

Of the 849 patients included, 759 were analysed (381 treated with AB and 378 with PT); 718 were followed up at 6 months, 90% of which had no treatment modification. Their inclusion characteristics were similar between the AB and PT groups (mean IPSS: 18.6±4.5 and 17.8±4.1, respectively). Treatment response rates at 6 months were 94.2% [91.2%; 96.4%] in AB and 92.5% [89.2%; 95.1%] in PT. The IPSS decreased by 10.0±5.6 points, with no difference between groups. The proportion of patients bothered by their LUTS (IPSS-QoL ≥4) evolved from 88.5% to 6.5% at 6 months. The improvement of LUTS was perceived by more than 94% of patients (PGI-I) and doctors (CGI-I), 93% of patients were satisfied with the treatment at 6 months, regardless of the treatment initiated. The most reported adverse reactions were ejaculation disorder (3.9% for AB and 0.9% for PT).

CONCLUSION

PERSAT confirms in current practice the effectiveness of AB and PT treatments, recommended as first-line treatment in LUTS/BPH.

LEVEL OF PROOF

3.

Phytotherapy Adds to the Therapeutic Armamentarium for the Treatment of Mild-To-Moderate Lower Urinary Tract Symptoms in Men

BACKGROUND

Practice guidelines hardly recommend herbal extracts for male lower urinary tract symptoms (LUTS). However, many patients are unsatisfied with first-line synthetic drugs and often prefer herbal medicines because of good tolerability. To improve the decision-making process, which should consider the patients' expectations, it is crucial to reflect on the role of phytotherapy in the treatment of LUTS. We (panel experts) reflected on current guideline recommendations and real practice across various European countries and debated the potential role of plant extracts with a focus on pumpkin seed soft extract investigated over 12 months in two randomised placebo-controlled trials.

SUMMARY

Most guidelines give no clear recommendations on phytotherapy due to the heterogeneity of clinically investigated extracts. Nevertheless, plant extracts are prescribed to patients with mild-to-moderate LUTS. Also, self-medicating patients often handle their complaints with herbal products. Many patients aim to avoid synthetic drugs for fear of sexual functional side effects and a negative impact on their quality of life. For the elderly, vasoactive comedications might become an issue. When taking plant extracts, patients experience an acceptable symptomatic relief similar to that achieved with synthetics but without side effects. Key Messages: In shared decision-making for purely symptomatic treatment, a low risk of side effects takes priority. We propose to consider patient preferences in the treatment of mild-to-moderate LUTS in men with a low risk of disease progression. We found a consensus that pumpkin seed soft extract adds to the therapeutic armamentarium for patients who cannot or do not want to apply synthetic drugs.

Assessment of Learning Curves for 180-W GreenLight XPS Photoselective Vaporisation of the Prostate: A Multicentre Study

BACKGROUND

The learning curve for photoselective vaporisation of the prostate (PVP) has never been assessed accurately.

OBJECTIVE

To compare 180-W GreenLight XPS PVP learning curves for three surgeons with different levels of surgical experience and different institutional backgrounds.

DESIGN, SETTING, AND PARTICIPANTS

A multicentre retrospective study of the first patients treated with PVP by three operators in three different centres (n=152 in group 1, n=112 in group 2, n=101 in group 3) was conducted. Surgeon 1 had performed >600 PVP procedures (120-W GreenLight HPS laser) since 2007, while surgeons 2 and 3 had no previous experience with GreenLight PVP. Surgeon 1 mainly treats both benign prostatic hyperplasia (BPH) and urologic oncology, surgeon 2 primarily focuses on urologic oncology, and surgeon 3 mostly treats BPH. Surgeon experience was analysed as a continuous variable in terms of consecutive procedures performed.

INTERVENTION

PVP using a 180-W GreenLight XPS laser.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The learning curve was analysed in terms of changes over time for the following variables: operative time, the vaporisation time/operative time ratio, and the energy delivered/prostate volume ratio. The primary endpoint was a trifecta of (1) energy delivered >5kJ/ml of prostate, (2) vaporisation time/operative time ratio of 66-80%, and (3) no postoperative complications.

RESULTS AND LIMITATIONS

Patient baseline characteristics differed significantly among the centres in terms of age, prostate volume, and International Prostate Symptom Score (IPSS). Most perioperative outcomes favoured group 1 over group 3 over group 2. Functional outcomes, such as a decrease in IPSS at 1 mo for the first 50 patients (-15 vs -13.6 vs -13.3; p<0.0001) and an increase in maximum flow at 1 mo for the first 50 patients (+14.2 vs. +7 vs. +9.4; p<0.0001), favoured group 1 over group 3 over group 2. The trifecta achievement rate was significantly higher in group 3 over group 1 over group 2 (26.7% vs 14.4% vs 5.4%; p<0.0001). In multivariate analysis adjusting for age, American Society of Anesthesiologists score, and preoperative prostate volume, the only factors predictive of trifecta achievement were surgeon experience (p<0.0001) and surgeon identity (p<0.0001). The study limitations include selection bias, short follow-up, and a lack of consensus regarding learning curve assessment and definition.

CONCLUSIONS

More than 100 PVP procedures were required to reach an intraoperative parameter plateau regardless of surgeon expertise and institutional background. Both surgeon background and expertise seemed to influence perioperative outcomes during the GreenLight XPS PVP learning curve.

PATIENT SUMMARY

Both surgeon background and expertise seem to influence perioperative outcomes during the learning curve when using a GreenLight XPS laser for photoselective vaporisation of the prostate.

[Lower urinary tract symptoms related to benign prostatic hyperplasia and erectile dysfunction: A systematic review]

AIM

To provide a systematic review of epidemiological data regarding the association between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in men.

SEARCH STRATEGY

A research has been conducted on the Medline database using the keywords: ("erectile dysfunction" or "sexual dysfunction") and ("benign prostatic hyperplasia" or "lower urinary tract symptoms"). The eligibility of studies was defined using the PICOS method in accordance with the PRISMA statement. Cross-sectional studies and prospective cohorts assessing the association between LUTS and ED in the primary care setting or in general practice (i.e. exclusion of patients seen in outpatient urology or andrology) were included.

RESULTS

Among 898 reports assessed, seven studies were included in this systematic review (whole cohort: 1,196,393 men). There were five cross-sectional studies and two prospective cohorts. The whole seven studies reported an association between LUTS and ED (range of odds-ratio: 1.52-4.03). Four common pathogenic mechanisms were found in the literature, all of them being somewhat related with metabolic syndrome and cardiovascular risk factors: reduced nitric oxide (NO) pathway signalling, increased RhoA-Rho kinase signalling, autonomic nervous system hyperactivity and pelvic atherosclerosis.

LIMITATIONS

The main limitations of this review were: a possible publication bias, the relatively low number of included studies and the lack of assessment of potential confounders such as factors related to sexual partner.

CONCLUSION

The close epidemiological and pathogenic links between LUTS and ED have given rise to a new nosological entity: the erectile urogenital dysfunction, which should be assessed globally with special considerations to frequently associated comorbidities such as metabolic syndrome and cardiovascular risk factors.