Treatment of benign prostatic hyperplasia by androgen deprivation: effects on prostate size and urodynamic parameters

The effect of short-term use of finasteride versus cyproterone acetate on perioperative blood loss with monopolar transurethral resection of prostate

Background

Perioperative bleeding is the most common complication related to transurethral resection of prostate; the aim of the study was to compare the effect of pre-operative use of finasteride versus cyproterone acetate (CPA) on blood loss with monopolar TURP.

Methods

This prospective randomized controlled study was conducted on (60) patients with BPH underwent monopolar TURP between July 2019 and July 2020. Patients were distributed into three equal groups; CPA group: 20 patients received cyproterone acetate 50 mg tab BID for two weeks before TURP, finasteride group: 20 patients received single daily dose of finasteride 5 mg for two weeks before TURP, control group: 20 patients received no treatment before TURP, all patients underwent monopolar TURP, and then histopathological examination of the resected tissues was done with assessment of the microvascular density of the prostate.

Results

Our study showed that there was significant decrease in intraoperative blood loss and operative time in CPA and finasteride groups in comparison with control group (p = 0.0012) (p < 0.0001), respectively, significant decrease in post-operative Hb and HCT value in finasteride and control groups in comparison with CPA group (p < 0.01), significant increase in specimen weight in CPA group compared to other groups (p < 0.01), and there was also significant decrease in microvascular density in CPA group in comparison with other groups (p < 0.01).

Conclusion

Cyproterone acetate is more effective than finasteride in decreasing perioperative bleeding with TURP by decreasing microvascular density of the prostate.

Adjuvant androgen deprivation therapy for prostate cancer treated with radiation therapy

Radiation therapy is a commonly used curative modality for prostate cancer. The addition of androgen deprivation therapy (ADT) increases the curative potential of prostate radiotherapy (RT) in multiple subsets of patients. In addition to having an independent cytotoxic effect, current evidence suggests that androgen deprivation synergistically works with radiation therapy by preventing DNA repair. Given the wide-ranging toxicities of this therapy, clinicians must judiciously choose which patients may benefit from ADT and also consider the appropriate length of treatment. With recent advances in RT delivery, higher doses of radiation are currently used when compared with the dose used in historic trials, leading to the unanswered question of how RT dose interacts with ADT. Current and future clinical studies are attempting to further define the appropriate indications and patient populations for which ADT represents a clinically appropriate addition to prostate RT.

A synopsis of drugs currently in preclinical and early clinical development for the treatment of benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common disease among men and significantly impacts quality of life by causing lower urinary tract symptoms (LUTS). Current medical therapies are not always adequate in controlling LUTS or slowing disease progression, and there is unmet need for new effective therapeutic options.

AREAS COVERED

The authors review the standard current medical therapies for BPH which include the use of α-1 blockers, 5-α reductase inhibitors, combination therapy and PDE inhibitors. Following this, the authors then discuss new therapies that are currently undergoing preclinical and clinical investigation.

EXPERT OPINION

Existing preclinical and clinical trials have highlighted many promising therapies to treat BPH. Further investigation with larger clinical trials is needed to establish these drugs as standard therapies. As the number of drugs in the arsenal against BPH continues to grow, providers and patients will have to engage in a discussion that weighs the risks and benefits of each therapy.

Androgen receptor and immune inflammation in benign prostatic hyperplasia and prostate cancer

Both benign prostatic hyperplasia (BPH) and prostate cancer (PCa) are frequent diseases in middle-aged to elderly men worldwide. While both diseases are linked to abnormal growth of the prostate, the epidemiological and pathological features of these two prostate diseases are different. BPH nodules typically arise from the transitional zone, and, in contrast, PCa arises from the peripheral zone. Androgen deprivation therapy alone may not be sufficient to cure these two prostatic diseases due to its undesirable side effects. The alteration of androgen receptor-mediated inflammatory signals from infiltrating immune cells and prostate stromal/epithelial cells may play key roles in those unwanted events. Herein, this review will focus on the roles of androgen/androgen receptor signals in the inflammation-induced progression of BPH and PCa.

Dose-ranging study of the luteinizing hormone-releasing hormone receptor antagonist cetrorelix pamoate in the treatment of patients with symptomatic benign prostatic hyperplasia

OBJECTIVE

To compare the efficacy of 4 dosage regimens of cetrorelix pamoate, a sustained release formulation that allows for more convenient dosing, in patients with symptomatic benign prostatic hyperplasia (BPH). Repeated dosing with cetrorelix acetate was shown to be active in the treatment of BPH symptoms.

METHODS

Double-blind, randomized, multicenter study was undertaken among patients with International Prostate Symptom Score (IPSS) ≥ 13. After a single-blind placebo run-in phase of 4 weeks, treatment was administered at 2-week intervals as follows: 30 + 30 mg, 30 + 30 + 30 mg, 60 + 30, 60 + 60 mg cetrorelix pamoate, or matching placebo. Patients were followed-up for 28 weeks after randomization.

RESULTS

A statistically significant overall difference was found with respect to the primary variable, the IPSS (P ≤ .001). Optimal results, a 4-point improvement in IPSS in excess of the changes observed in the placebo group, were achieved with a starting dose of 60 mg cetrorelix pamoate followed by a dose of 30 mg 2 weeks later. In all dosage groups, the symptomatic improvement was paralleled by an increase in uroflow. There was a marked dissociation between only moderate and transient testosterone suppression and the persisting effects on BPH signs and symptoms. Tolerability was good at all cetrorelix dosages.

CONCLUSIONS

Intramuscular injections of 60 and 30 mg of cetrorelix pamoate within 2 weeks provide rapid symptomatic improvements of BPH that are sustained for the following 6 months.

The comparative pressure-flow plot properties of radiological bladder neck and prostatic obstruction

OBJECTIVES

To test the hypotheses that: (i) significant differences should exist in pressure/flow data between radiologically determined bladder neck and prostatic obstruction; (ii) these differences should inform understanding of the pathophysiology of male outflow obstruction. The biomechanics of the voiding/pressure/flow plot imply that a urodynamic assessment trace should identify outflow obstruction and characterise the urethral viscoelastic properties. Micturating cystourethrograms (MCUG) images might provide a useful diagnostic dichotomy for testing these assumptions.

MATERIALS AND METHODS

The pressure/flow data from 71 men who also provided video-urodynamic imaging data that a radiologist could classify unequivocally as showing bladder neck obstruction (42) or prostatic obstruction (29) were analysed. The following variables were recorded: the detrusor pressure at initiation of voiding (P(det.open)); the detrusor pressure at the end of voiding (P(det.close)); the detrusor pressure at maximum flow rate (Q(max)), (P(det.)Q(max)), and Q(max). The urethral resistance relation (URR) was drawn onto the pressure-flow plot and the gradient of the URR, DeltaP(det)/DeltaQ, was calculated.

RESULTS

There were significant between group differences in P(det.open) (95% confidence interval of the difference 5.2-28.6, U = 352, P = 0.003); P(det.close) (0.2-15.0, U = 428, P = 0.034); P(det).Q(max) (0.0-18.9, U = 439, P = 0.05); Q(max) and DeltaP(det)/DeltaQ did not distinguish between the MCUG groups (95% confidence interval of the difference 2.3-18, U = 111; P = 0.004). The best-fit model from linear combinations of the data achieved an area under the receiver operator curve of 0.72 for discriminating between the MCUG groups.

CONCLUSIONS

The urodynamic assessment identified interesting and coherent biomechanical differences, and could distinguish between the obstructions with a moderate degree of accuracy.

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.

Advances in the development of hormonal modulators for the treatment of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a leading disorder of the ageing male population and is characterized by a progressive enlargement of the prostate, resulting in the obstruction of the proximal urethra and hence the disturbance in normal urinary flow and further quality of life of the patients. Therefore, there is an imperative need to develop a therapeutic modality to combat the overgrowth of the prostate with improvements in both the urinary flow rate and the quality of life of the patients. At present, alpha-blockers, which act on the dynamic component of the disease to regulate the increased adrenergic tone of the lower urinary tract smooth muscles, and 5-alpha-reductase inhibitors, which control the overgrowth of the prostate and hence static component by regulating the levels of androgens, are the mainstay of therapies for the treatment of BPH and associated lower urinary tract symptoms. However, each target class has its own limitations in terms of compromised efficacy or tolerability. Therefore, it is pertinent to have an effective and safe therapeutic modality for the further improvement of life of the geriatric male population. Hormone modulators, which regulate the overgrowth of the prostate, represent one of the important categories that have been explored and that is still undergoing certain investigations towards the development of a therapeutic entity for the treatment of BPH. The key lies in achieving the differentiation in terms of improved tolerability with comparable or better efficacy over the existing class of drugs. Gonadotropin receptor modulators and vitamin D receptor agonists may represent promising druggable targets in this therapeutic area, due to the availability of proof of principles and concepts in preclinical animal models and human subjects.

Benign prostatic hyperplasia: an insight into current investigational medical therapies

Benign prostatic hyperplasia (BPH) is a leading disorder of the elderly male population that is characterised by a progressive enlargement of prostatic tissue, resulting in obstruction of the proximal urethra and causing urinary flow disturbances. The pathophysiology of BPH associated with lower urinary tract symptoms is characterised by increased adrenergic tone (dynamic component) leading to smooth muscle contraction and prostatic overgrowth due to androgenic stimulation (static component); therefore, the therapeutic armamentarium of BPH can be broadly divided into antiadrenergic and antiandrogenic approaches. alpha1-Adrenoceptor antagonists and 5alpha-reductase inhibitors are well-established representatives of the two categories, respectively. Other antiandrogenic approaches involve gonadotropin-releasing hormone agonists and antagonists for the treatment of prostate hyperplasia. Apart from these approaches, new approaches with novel targets are emerging. The advent of new therapies is, however, more oriented towards the static component. These involve metabolic factors (hexokinase inhibitor), growth factors (vitamin D3 analogues), oxytocin antagonists and gonadotropin-releasing hormone Gi agonist-based therapies. Gene therapy and photodynamic therapies are other emerging therapies for relieving symptoms in BPH patients. With the initial success of upcoming targets, the unmet need to develop an efficacious and relatively safe therapeutic modality is discussed. Nevertheless, their long-term safety and efficacy needs to be evaluated in large-scale clinical trials. The future also belongs to combination therapies to combat both dynamic and static disease components and for extended indications such as micturition disorder and non-bacterial prostatitis.

Long-term 6-year experience with finasteride in patients with benign prostatic hyperplasia

OBJECTIVES

To summarize the 6-year clinical trial data with finasteride. Benign prostatic hyperplasia is a chronic and progressive disease and therefore assessment of long-term safety and efficacy is important.

METHODS

The North American and International Phase III Finasteride trials enrolled symptomatic men with enlarged prostate glands. The initial 1-year placebo-controlled study was followed by a 5-year open-label extension. In total, 6-year finasteride data were available in 487 patients originally randomized to finasteride, and 5-year data were available on 238 patients originally randomized to placebo.

RESULTS

After 6 years of treatment with finasteride 5 mg, the mean quasi-American Urological Association Symptom Score improved by 4.0 points, the median prostate volume decreased by 24%, and the mean maximal urinary flow rate increased by 2.9 mL/s (P <0.001 for all parameters). Long-term finasteride treatment was well tolerated, with a low incidence of drug-related sexual adverse events occurring during the first year and even fewer occurrences during the 5-year open extension.

CONCLUSIONS

Treatment with finasteride leads to durable improvement in urinary tract symptoms, flow rate, and prostate volume, with no increase in the prevalence of drug-related adverse events over time.

The effects of transdermal dihydrotestosterone in the aging male: a prospective, randomized, double blind study

The objective of the study was to investigate the effects of dihydrotestosterone (DHT) gel on general well-being, sexual function, and the prostate in aging men. A total of 120 men participated in this randomized, placebo-controlled study (60 DHT and 60 placebo). All subjects had nocturnal penile tumescence once per week or less, andropause symptoms, and a serum T level of 15 nmol/liter or less and/or a serum SHBG level greater than 30 nmol/liter. The mean age was 58 yr (range, 50-70 yr). Of these subjects, 114 men completed the study. DHT was administered transdermally for 6 months, and the dose varied from 125-250 mg/d. General well-being symptoms and sexual function were evaluated using a questionnaire, and prostate symptoms were evaluated using the International Prostate Symptoms Score, transrectal ultrasonography, and assay of serum prostate-specific antigen. Early morning erections improved transiently in the DHT group at 3 months of treatment (P < 0.003), and the ability to maintain erection improved in the DHT group compared with the placebo group (P < 0.04). No significant changes were observed in general well-being between the placebo and the DHT group. Serum concentrations of LH, FSH, E2, T, and SHBG decreased significantly during DHT treatment. Treatment with DHT did not affect liver function or the lipid profile. Hemoglobin concentrations increased from 146.0 +/- 8.2 to 154.8 +/- 11.4 g/liter, and hematocrit from 43.5 +/- 2.5% to 45.8 +/- 3.4% (P < 0.001). Prostate weight and prostate-specific antigen levels did not change during the treatment. No major adverse events were observed. Transdermal administration of DHT improves sexual function and may be a useful alternative for androgen replacement. As estrogens are thought to play a role in the pathogenesis of prostate hyperplasia, DHT may be beneficial, compared with aromatizing androgens, in the treatment of aging men.

Effects of finasteride and cyproterone acetate on hematuria associated with benign prostatic hyperplasia: a prospective, randomized, controlled study

OBJECTIVES

To evaluate the influence of two differently acting antiandrogens, finasteride (FIN) and cyproterone acetate (CPA), on the natural history of hematuria associated with benign prostatic hyperplasia (BPH) in a prospective, randomized, controlled study.

METHODS

Forty-two patients with hematuria episodes due to BPH were randomly allocated to three subgroups of 14 patients each and treated daily with either 5 mg FIN or 100 mg CPA or were placed in a watchful waiting arm. Patients were evaluated at 3-month intervals, and 40 patients had at least 1 year of follow-up.

RESULTS

Four patients in the FIN group (30%) and three in the CPA group (23%) presented with recurrent hematuria. In both groups, the bleeding episodes were treated conservatively and required no hospitalization. In the control group, 8 patients (57%) presented with recurrent bleeding; in 4, the bleeding was severe and required some form of intervention (catheterization or transurethral prostatectomy). When the frequency and severity of the hematuria episodes were analyzed over time, a statistically significant difference for FIN versus control was present at 9 and 12 months (analysis of variance, P = 0.035 and P = 0.009, respectively). A similar difference was evident for CPA versus control at 9 and 12 months (P = 0.028 and P = 0.008, respectively). No statistically significant difference was present between the FIN and CPA groups. Interestingly, no statistically significant effect in bleeding recurrence for both CPA and FIN over controls was present at 3 and 6 months of follow-up.

CONCLUSIONS

Both FIN and CPA seem to exert a comparable control in hematuria recurrence in patients with BPH, thus confirming the rationale behind the use of antiandrogens for such a purpose. Our results support the hypothesis that any antiandrogen, irrespective of the mode of action, would alter the natural history of BPH-associated hematuria. Interestingly, our results indicate that the speed of action of FIN may not be as rapid as previously described.

Induction of apoptosis and inhibition of cell proliferation by the lipido-sterolic extract of Serenoa repens (LSESr, Permixon in benign prostatic hyperplasia

BACKGROUND

To determine the mechanism by which prostate volume increases during the development of BPH and to evaluate the effect of LSESr (Permixon), a phytotherapeutic agent, we investigated apoptosis and cell proliferation in the stroma and epithelium of normal prostate and of BPH tissues from patients treated with or without LSESr.

METHODS

MIB-1 staining and the in situ end-labeling assay were used to evaluate the proliferative-apoptotic balance in normal prostates and in BPH tissues. Quantitative assessment was performed using an image analysis system.

RESULTS

In normal prostates, there was no significant difference between apoptotic and proliferative indices. Cell numbers and proliferative indices were higher in BPH than in normal prostates, while apoptosis values were similar. In the BPH treated group, LSESr significantly inhibited proliferation and induced cell death in both epithelium and stroma.

CONCLUSIONS

Induction of apoptosis and inhibition of cell proliferation are likely to be the basis for the clinical efficacy of LSESr.

Relationship between benign prostatic hyperplasia and history of coronary artery disease in elderly men

STUDY OBJECTIVE

To assess the relationship between the occurrence of benign prostatic hyperplasia (BPH), an androgen-dependent disease, and coronary artery disease (defined as history of coronary artery bypass grafting, coronary angioplasty, myocardial infarction) in elderly men.

DESIGN

Retrospective chart review.

SETTING

Urology practice.

PATIENTS

Seven hundred two elderly men aged 65-80 years.

INTERVENTION

The men's charts were reviewed for data pertaining to coronary artery disease, risk factors for coronary artery disease, and serum prostate-specific antigen (PSA) levels. Men who had medical conditions, pharmacologic interventions, or surgical procedures that could alter PSA, and those taking lipid-lowering agents were not included.

MEASUREMENTS AND MAIN RESULTS

PSA levels correlate positively with prostatic volume of BPH. In men with levels under 1.0 pg/L (no BPH) and over 1.0 microg/L (BPH present), the frequency of coronary artery disease was 9% and 29%, respectively (p<0.03). No significant differences were noted between groups in other accepted risk factors for coronary artery disease including age, smoking, diabetes mellitus, or hypertension.

CONCLUSION

Smooth muscle proliferation is an important and possibly androgen-dependent step in the development of atherosclerosis and BPH. Prospective studies are required to assess the effect of antiandrogens on atherosclerosis.

Serenoa repens (Permixon): a 5alpha-reductase types I and II inhibitor-new evidence in a coculture model of BPH

BACKGROUND

The aim of this study was to determine the effect of the phytotherapeutic agent, Permixon, on a novel coculture model of benign prostatic hyperplasia (BPH) in an effort to better understand the mode of action of the drug in vivo.

METHODS

The effect of Permixon, at the calculated therapeutic concentration, on the activity of 5alpha-reductase isoenzymes was evaluated utilizing a pH-specific assay. Prostate-specific antigen (PSA) secretions into the medium were measured in the presence and absence of Permixon and quantified by an ELISA assay. The morphological patterns before and following Permixon treatment were also examined by electron microscopy. All results were compared to controls.

RESULTS

Permixon at a concentration of 10 micrograms/ml (calculated plasma concentration in patient receiving recommended therapeutic dosage) was shown to be an effective inhibitor of both 5alpha-reductase types I and II isoenzymes without influencing the secretion of PSA by the epithelial cells, even after stimulation with testosterone. The morphology of Permixon-treated cells was found to be markedly different from that of untreated controls. Cells which had been treated with the drug demonstrated extensive accumulation of lipids in the cytoplasm and widespread damage of intracellular membranes, including mitochondrial and nuclear membranes.

CONCLUSIONS

Permixon is an effective dual inhibitor of 5alpha-reductase isoenzyme activities in the prostate. Unlike other 5alpha-reductase inhibitors, Permixon induces this effect without interfering with the cells' capacity to secrete PSA, thus permitting the continued use of PSA measurements for prostate cancer screening.

Over-expression of epidermal growth factor receptor and c-erbB2/neu but not of int-2 genes in benign prostatic hyperplasia by means of semi-quantitative PCR

It is well established that activation of cellular genes may trigger uncontrolled cell growth and cancer development. Previous reports suggest that the epidermal growth factor receptor (EGFr), c-erbB2/neu and int-2, fibroblast growth factor-3, may be implicated in the development of benign prostatic hyperplasia (BPH). Using the polymerase chain reaction technique, we have assessed the amplification and expression of these molecular markers in 30 prostate samples from patients with BPH as well as from 5 normal donors. We detected mRNA over-expression of EGFr and c-erbB2/neu in 36% and 63%, respectively, of the BPH samples, but no gene amplification was found. No amplification or over-expression of int-2 was detected in any of the samples analyzed, suggesting that int-2 is not involved in BPH. Our results thus suggest a role for EGFr and c-erbB2/neu but not for int-2 in the development of BPH.

Androgen-independent basal cell re-epithelialization, c-erbB-2 mRNA expression and androgen-dependent EGFr mRNA expression in benign prostatic hyperplasia explant cultures treated with finasteride

We have analyzed the effects of the 5alpha-reductase inhibitor, finasteride (MK906), on the mRNA expression of the epidermal growth factor receptor and c-erbB-2 genes, in benign prostatic hyperplasia explant cultures treated with testosterone and with testosterone plus finasteride. A decrease of the epithelial cell content and an androgen-independent basal cell re-epithelialization was observed during the first 10 days of culture, suggesting a role of basal cells as stem cells involved in androgen-independent epithelial regeneration. Using a semi-quantitative reverse transcription polymerase chain reaction technique, we observed a significant decrease in expression of the epidermal growth factor receptor in the cultures treated with finasteride whereas no effect of finasteride on c-erbB-2 transcription was detected, although the expression of both genes was increased by dihydrotestosterone.

Urodynamic effects of various treatment modalities for benign prostatic hyperplasia

PURPOSE

I studied the effects of various treatments for benign prostatic hyperplasia on urethral resistance.

MATERIALS AND METHODS

I reviewed the literature on urodynamic effects of treatments for benign prostatic hyperplasia. Articles that reported pretreatment and posttreatment values of relevant urodynamic parameters were analyzed. Average before and after treatment values of maximum flow rate and detrusor pressure at maximal flow rate for every study were plotted on an Abrams-Griffiths nomogram and classified as obstructed, equivocal or nonobstructed. Average values of maximum flow rate and detrusor pressure at maximal flow rate were calculated for the total number of patients treated by a certain modality.

RESULTS

Based on this analysis, the rank order of urodynamic efficacy was that open prostatectomy is more effective in reducing urethral resistance than is transurethral prostatectomy. These treatments diminish obstruction better than laser treatment or transurethral incision of the prostate, which again are more effective than balloon dilation, alpha-blockers or transurethral microwave thermotherapy. Finally, androgen deprivation performs better than placebo treatment.

CONCLUSIONS

The rank order of urodynamic efficacy as determined in this analysis shows a high level of agreement with reported rank order of symptomatic efficacy of various modalities. After placebo treatment there is no significant change in urethral resistance. This finding indicates that pressure-flow studies are a sensitive way to compare active to placebo treatment and that pressure-flow studies have excellent long-term reproducibility.

Cyproterone acetate monotherapy in advanced prostatic carcinoma

Cyproterone acetate was given as monotherapy to 18 patients with advanced prostatic carcinoma at a weekly dose of 300 mg. Progression was observed in all of the patients; median time to progression was 35 months and median survival time was 48 months. Partial response, stabilization, progression and exitus rates by years also showed favourable results, as compared with other forms of therapy in advanced prostatic carcinoma.

Relative and total volume of histological components in benign prostatic hyperplasia: relationships between histological components and clinical findings

To investigate the correlation between histological differences and clinical findings in patients with benign prostatic hyperplasia (BPH), quantitative morphometrical analysis on prostate was performed on 26 specimens obtained by TURP. The relative and total volume of each histological component were obtained. In this series, the proportion of fibrous tissue element showed a weak positive correlation with prostatic volume (r = 0.499, P = 0.0087). The relative volume of the smooth muscle component showed an inverse correlation with prostatic volume (r = -0.488, P = 0.0105). Patient age and symptom score showed no relationship with the relative volume of histological components. The total volume of all histological components increased with prostatic volume. However, an increase in the fibrous tissue element appeared to be predominant in prostatic enlargement (r = 0.970, P < 0.0001). Although the total volume of all histological components increased with prostatic size, fibrous tissue appeared to play a major role in prostatic enlargement in BPH.

Androgen receptor modulation in benign human prostatic tissue and prostatic adenocarcinoma during neoadjuvant endocrine combination therapy

Modulation of androgen receptor (AR) expression during neoadjuvant endocrine therapy in human prostates of patients with localized prostate cancer was investigated by immunohistochemistry. In 8 of 15 untreated prostatectomy specimens, the majority of prostatic glandular cells displayed nuclear immunostaining for AR, whereas only 1 of 26 pretreated cases displayed a similar glandular AR expression. Expression of AR in the prostatic stromal compartment of nontreated cases proved to be quite heterogeneous, since 4 of the 15 (27%) examined specimens did not show stromal AR expression. After preoperative neoadjuvant therapy, this value was 68%, although this difference did not reach statistical significance. Prostatectomy specimens of the treated patients contained carcinomas with a higher Gleason score than those of untreated patients. AR expression in carcinomas of treated patients was diminished (P= 0.05), which may be attributed to their relatively lower differentiation grade. The data strongly suggest that neoadjuvant hormone therapy reduces AR expression by nonneoplastic prostatic glandular cells and carcinoma cells by a selective, but incomplete, elimination of AR-positive cells.

A dose-response study of the effect of flutamide on benign prostatic hyperplasia: results of a multicenter study

OBJECTIVES

The objective of this study was to evaluate efficacy, safety, and dose-response profiles of four dosing schemes of flutamide over 24 weeks.

METHODS

Patients were randomized to receive one of the following five treatment regimens for a period of 24 weeks: placebo capsule, flutamide capsules 125 mg twice daily, 250 mg once daily, 250 mg twice daily, and 250 mg three times daily. Patients were then evaluated at baseline (0 weeks) and at 4, 6, 12, 18, and 24 weeks after the start of treatment, and 8 weeks after the end of treatment (32 weeks). Evaluation of efficacy was performed by noting changes in urine flow rate, residual urine volume, symptom score, prostate volume, and prostate-specific antigen level. A total of 372 patients were enrolled into the study at 32 centers (14 centers in the United States and 18 international centers).

RESULTS

Baseline peak urinary flow rate and percent change from baseline in maximum flow rate showed a dose-related increase at 4 and 6 weeks; this increase was significant in the 250 mg three times daily group. At later time points, no significant differences between the flutamide and placebo groups were observed, largely because of the decreasing number of evaluable patients. At 4 and 6 weeks, 25% of patients in the 250 mg three times daily group had more than 3 cc/s increase in uroflow compared to about 10% of placebo patients (P < 0.05). All flutamide-treated groups had a significant decrease in prostate volume from baseline to the last treatment visit compared to placebo and this reduction was dose related (in comparison to placebo: P < 0.05 for 125 mg twice daily and P < 0.001 for all other treatment arms). Median decrease for the flutamide-treated groups ranged from 6% to 23% at 12 weeks and from 14% to 29% at 24 weeks. All treatment groups showed a subsequent increase in prostate volume after treatment was stopped. Furthermore, there was a significant reduction in residual urine volume at 24 weeks only in the 250 mg three times daily group. It increased following cessation of therapy. Urinary symptoms at 6, 12, 18, and 24 weeks did not show any significant difference between placebo and any flutamide dose group. The most common adverse events were nipple and breast tenderness (42% to 52%), diarrhea (29% to 34%), and gynecomastia (14% to 19%). Each of these adverse events had a significantly higher incidence in all flutamide dose groups compared with placebo, but none appeared to occur in a dose-related fashion. Sixteen percent of patients in the placebo group and 25% to 39% of patients in flutamide groups were discontinued due to diarrhea (12% to 17%) or nipple and breast tenderness (4% to 8%). A total of 1% to 3% of patients in various treatment arms discontinued due to deranged liver enzymes (1% for placebo); and 1% to 4% due to impotence (1% for placebo).

CONCLUSIONS

Flutamide reduced the prostate volume in a dose-related fashion and resulted in an increase in peak flow rate at 4 weeks (3% for 250 mg three times daily, P value < 0.05), but the early positive effects did not maintain statistical significance due to an increasing number of dropouts due to adverse events. Effect on postvoid residual volume was observed only at the highest dose and at 24 weeks (median reduction, 23 mL, P < 0.05). Despite volume reduction and early improvement in peak flow rate, there were no significant differences in urinary symptoms among the placebo and flutamide groups. Higher incidences of diarrhea, breast tenderness, and gynecomastia, however, were the main limiting factors in this study and until these problems are overcome, the role of flutamide in the management of benign prostatic hyperplasia remains investigational.

Effect of orchiectomy on the alpha adrenergic contractile response of dog prostate

PURPOSE

To investigate the effect of androgen deprivation on the alpha-adrenergic contractile response of the dog prostate using both in vitro and in vivo methods.

MATERIALS AND METHODS

In vitro muscle bath study: One month after surgery, responses to KCl (120 mM.) and norepinephrine (10(-8) to 10(-3)M.) of prostatic tissue strips (of the same size) from castrated (n = 6) and sham-operated (n = 6) adult mongrel dogs were determined. In vivo study: Before and 1 month after surgery, the intraprostatic urethral pressure response to intravenous norepinephrine administration of 6 castrated and 5 sham-operated adult dogs was examined.

RESULTS

(1) Before castration the serum level of testosterone was 1.24 +/- 0.2 ng./ml.; 1 month after castration, it had dropped to an undetectable level. (2) Histological examination of the prostates from castrated animals revealed profound atrophy of glandular tissue with a relatively increased stromal tissue component in each section. (3) In vitro study: The contractile responses to KCl and norepinephrine of individual prostate strips (same size) from castrated animals were significantly higher than control. However, if the response to norepinephrine was normalized to the response to KCl, there was no significant difference in response to norepinephrine between the 2 groups. In addition, the ED50 of the norepinephrine-stimulated contractile response was not changed by castration. (4) In vivo study: There was no significant change in intraprostatic urethral pressure response to intravenous norepinephrine administration after orchiectomy.

CONCLUSIONS

The results of this study show that the sensitivity of the alpha-adrenergic contractile response of the dog prostate is not affected by androgen deprivation, nor is alpha-adrenergic contractile activity of the dog prostate regulated by androgen.

Ageing and prostate: age-related changes in androgen receptors of epithelial cells from benign hypertrophic glands compared with cancer

Total and nuclear androgen receptors (AR) were studied from epithelial cells in internal and external prostatic zones in 51- to 86-year-old individuals with benign prostatic hyperplasia (BPH) (n = 68) and prostatic cancer (n = 9). We focussed on the role played by androgens on those processes, despite the fact that at these ages, its secretion has normally decreased. In BPH, the nuclear AR do not change, but total measured androgen receptors rise with age (r = 0.5, P < 0.01). Total or nuclear AR do not correlate with gland volume, despite its increase with age (r = 0.8, P < 0.05). In prostates less than 180 cc in volume, there is a significant correlation between size, serum total testosterone level (r = 0.53, P < 0.05) and prostatic specific antigen (PSA) (r = 0.63, P < 0.05). The amount of nuclear AR in cells from the external zone (infiltrated by cancer or healthy) is two times greater than in those from the internal region. Total receptor content of the external zone cells is also high, but the sample is too small to demonstrate an age dependence. The results suggest that ageing is accompanied by an accumulation of non-nuclear AR in the cytosol, that does not play a role in the development of BPH because the amount of nuclear receptors remains unaltered. The enrichment in nuclear receptors of the external zone cells, independently of the presence of cancer, points to a greater androgen dependence in these cells than in cells of the internal region.

Dependence of male voiding efficiency on age, bladder contractility and urethral resistance: development of a voiding efficiency nomogram

The influence of age, urethral resistance and bladder contractility on voiding efficiency was evaluated by pressure-flow studies in 138 men of a mean age of 60 years (range 18 to 86). From these studies the urethral resistance parameter was calculated and the maximum bladder contraction strength was determined. Premature fading of the bladder contraction was quantified by a bladder contraction strength decay factor. Voiding efficiency was expressed by the parameter of post-void residual urine volume as a percentage of the initial bladder volume. Multiple regression analysis showed that voiding efficiency depended significantly in descending order of importance on urethral resistance, maximum bladder contraction strength and bladder contraction strength decay factor. Patient age was not an independent factor. Maximum bladder contraction strength and bladder contraction strength decay factor were not correlated, suggesting that maximum bladder contraction strength and its decay constitute different properties of bladder contractile function. A voiding efficiency nomogram is proposed, making use of the values for maximum bladder contraction strength and urethral resistance in individual patients. Such a nomogram may have predictive value for the occurrence of acute retention but it must be tested prospectively.

Differential suppression of serum prostatic acid phosphatase and prostate-specific antigen by 5-alpha-reductase inhibitor

OBJECTIVE

To evaluate the effect of finasteride (Proscar) on the serum levels of prostatic acid phosphatase (PAP) and prostate-specific antigen (PSA) in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Thirty patients on finasteride therapy for BPH formed the study group. Serum PSA and PAP levels were monitored for 2 years while the patients were receiving finasteride.

RESULTS

During 12 months of finasteride therapy the serum PSA was suppressed but serum PAP was unaffected. The baseline mean PAP value was 1.303 ng/mL prior to finasteride therapy; this changed to 1.510 ng/mL (P = 0.195) at 6 months and 1.166 ng/mL (P = 0.383) at 12 months. The serum PSA was 2.630 ng/mL at baseline, 1.757 ng/mL (P < 0.001) at 6 months and 1.545 ng/mL (P = 0.001) at 12 months.

CONCLUSIONS

Further studies are warranted to determine if PAP has a role as a tumour marker in patients whose PSA is suppressed as a result of finasteride therapy.

Reasons for the weak correlation between prostate volume and urethral resistance parameters in patients with prostatism

In an attempt to increase our understanding of the clinical syndrome of benign prostatic hyperplasia (BPH) an analysis was made of the association between prostate volume as measured by transrectal ultrasound and several reported urodynamically determined urethral resistance parameters. Two types of obstruction can be recognized on the basis of urodynamic data: a compressive type characterized by a high urethral opening pressure and a prolonged isovolumetric contraction phase before urine flow can start, and a constrictive type characterized by a normal opening pressure and an increased slope of the urethral resistance relation. A combination of both types is often seen in BPH. In our study, parameters that selectively quantify compression correlate weakly to moderately with prostate volume, whereas parameters that mainly quantify constriction do not correlate at all with prostate volume. Parameters that combine a measure for compression and constriction correlate less well with prostate volume than parameters that mainly quantify compression. The variation in prostate volume was found to determine the variation in urethral resistance by 15% or less depending on the parameter used, which implies that the different pathophysiological mechanisms that can increase urethral resistance in the complex process of clinical BPH are mainly determined by factors other than the volume of the prostate. Thus, despite the lack of correlation between prostate volume and urethral resistance, pressure-flow studies and the determination of urethral resistance parameters provide a valuable contribution to the understanding of the pathophysiology of voiding dysfunction in men with symptoms of prostatism.

Transition zone volume and transition zone ratio: predictor of uroflow response to finasteride therapy in benign prostatic hyperplasia patients

OBJECTIVES

The aim of this study was to: (1) determine effects of finasteride on transition zone (TZ) volume, TZ ratio (TZ volume/total prostate volume), and total prostate volume; (2) analyze differences in TZ and total volume reduction among patients who improve peak urinary flow rates following finasteride therapy with those who do not; (3) investigate which parameters correlate with improvement in peak urinary flow rate and urinary symptom score; and (4) establish if there is any predictive value of these parameters for response to therapy.

METHODS

Twenty-three patients with symptomatic benign prostatic hyperplasia (BPH) were treated with finasteride (5 mg/d) for 12 months and underwent transrectal ultrasound (TRUS) evaluation of total and TZ volume of prostate and measurement of peak flow rate and modified Boyarsky symptom score at baseline and at 12 months. Statistical analysis was done by unpaired t, Mann-Whitney, and Spearman rank correlation tests among responders (more than 3 cc/s improvement in peak flow rate) and nonresponders (less than 3 cc/s improvement in peak flow rate) to therapy.

RESULTS

(1) Responders had substantial reduction in TZ volume (44.8% versus 16.05%; P < 0.03) and TZ ratio (25% versus 5% increase, P < 0.02) compared with nonresponders. (2) There was a significant correlation between reduction in TZ volume (r = 0.50; P < 0.03) and TZ ratio (r = 0.60; P < 0.006) with improvement in peak flow rates. No similar correlation was seen with total prostate volume changes. (3) Pretreatment TZ ratio helped in predicting peak flow improvement following finasteride therapy (r = 0.52; P < 0.01) and there was a 2.5-fold increased chance of improvement if baseline TZ ratio was more than 0.51. The modified Boyarsky symptom score decreased by 3.1 (mean), but there was no correlation with changes in peak urinary flow rate, total prostate volume, TZ volume, and TZ ratio. TZ ratio did not have significant predictive value for improvement in symptom score.

CONCLUSIONS

This study provides data that simple measurable parameters are available which may be used prior to therapy to predict uroflow response to finasteride and similar agents.

The effect of finasteride on prostate volume, urinary flow rate and symptom score in men with benign prostatic hyperplasia

This study was designed to determine the efficacy of the 5 alpha-reductase inhibitor finasteride (Proscar, MK-906) in men with reduced urinary flow rates and symptoms of urinary outflow obstruction secondary to benign prostatic hyperplasia. Forty-five men were randomized to one of three groups receiving either placebo, 1 mg/day or 5 mg/day finasteride for the first 12 months of the study period. At the end of this period all men received 5 mg/day finasteride for a further 2 years. Efficacy was determined by measurement of prostate volume, maximum urinary flow rate, and symptom score using a modified Boyarsky assessment. Prostate volume reduced by 20 and 27%, respectively, for those on 1 and 5 mg after the first year. At 3 years the volume had reduced by 43%. This reduction in prostate volume was associated with an improvement in maximum urinary flow rate by 50% (1 mg), and 35% (5 mg) at 1 year, and 36% at 3 years. The total, obstructive and non-obstructive symptom scores decreased (improved) for patients on 1 and 5 mg finasteride, with the total score reducing by 33% from baseline at year 3. The results demonstrate that finasteride causes a modest but significant clinical improvement in men with urinary outflow obstruction secondary to benign prostatic hyperplasia.

Turapy--transurethral ablation prostatectomy by high temperature radiofrequency--preliminary results of a multicenter study

Thermal treatment of BPH has been introduced several years ago as an alternative treatment modality for patients suffering from symptomatic BPH. The initial temperatures ranged from 44.5 to 48 degrees C. With these temperatures, about 60-70% of the patients showed significant improvement of their subjective, mainly irritative symptoms with only mild changes in their obstructive parameters. In order to improve the therapeutic effects, increase in energy delivered allowing higher temperatures in the order to 70-100 degrees C was investigated regarding the feasibility, tolerance, pathological lesions and clinical effectiveness. A new radiofrequency technique, TURAPY--TransURethral Ablation Prostatectomy, an outpatient ablative BPH treatment has been introduced recently. The treatment is applied transurethrally with a helicoidal antenna without any cooling system. Temperature delivery in the order of medium 75 degrees C was applied during a medium time of 45 minutes. An ongoing multicenter study included 38 patients. 15 patients were operated by retropubic prostatectomy after 6-30 days, for a histopathology study and 23 eligible patients were entered in a clinical study and analyzed to determine the efficacy of the TURAPY treatment. The tolerance was excellent and although patients experienced initial heating sensation at the onset of treatment, as the temperature rose to 40-50 degrees C (as with previous modalities of thermotherapy), they did not experience further pain and the procedure was never stopped. Urinary retention was observed in about 80% of the patients, due to the extensive tissular destruction. These patients had suprapubic catheter inserted one day to a maximum of one week (medium 3 days).(ABSTRACT TRUNCATED AT 250 WORDS)

Finasteride: a clinical review

Finasteride is the first of a new class of 5 alpha-reductase inhibitors which allows selective androgen deprivation affecting dihydrotestosterone (DHT) levels in target organs such as the prostate and scalp hair without effecting circulating levels of testosterone thus preserving the desired androgen mediated effects on muscle strength, bone density and sexual function. Finasteride has been demonstrated to produce significant effects in men with an enlarged prostate gland. The long-term data now emerging suggests that progression of benign prostatic hyperplasia (BPH) may be arrested providing additional long term benefits. Experimental uses in prostate cancer prevention and male pattern baldness offer new and exciting possibilities for this class of compounds.

Neodymium:YAG laser ablation of the prostate gland--acute perioperative morbidity and short-term outcome

Twenty-three patients with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were successfully treated with laser prostatectomy using the Urolase right-angle firing neodymium: Yttrium Aluminum Garnet laser fiber. Most of the patients had health problems of moderate severity. Their conditions were compared preoperatively and 3 mo postoperatively. Symptom scores decreased from an average of 23.9 to 7.0. Symptomatic relief was achieved in 95.7% of patients. Peak urinary flow rates increased from an average of 6.4 to 17.0 ml/s. The residual urine decreased from an average of 45.2 to 22.9 ml. The volume of the prostate gland measured by sonography decreased from an average of 32.8 to 25.7 ml. Virtually no blood loss was noted intraoperatively. Acute urinary retention occurred immediately following removal of the catheter in 3 out of 17 (17.6%) patients without a percutaneous cystostomy tube. Acute epididymitis developed in 5 out of 20 (25.0%) patients without bilateral vasectomy. Based on these results, laser prostatectomy may be concluded to be a safe and effective alternative to standard transurethral resection of the prostate gland, particularly in the case of high-risk patients.

5 alpha-reductase inhibitors and prostatic disease

5 alpha-Reductase inhibitors are a new class of substances with very specific effects on type I and type II 5 alpha R which may be of use in the treatment of skin disease, such as male pattern baldness, male acne and hirsutism, as well as prostatic hyperplasia and prostate cancer. At least two types of 5 alpha R inhibitors with a different pH optimum have been described. cDNA encoding for both the type I and the type II enzyme has been cloned. Most of the orally effective 5 alpha R inhibitors belong to the class of 4-azasteroids. The radical substituted in the 17 position of the steroid ring seems to be related to species specific variations and to the types of 5 alpha R enzymes in different species and organ systems. 5 alpha R inhibitors lead to a decrease of plasma DHT by about 65% while there is a slight rise in plasma testosterone. The decrease of tissue DHT in the ventral prostate of the intact rat, the dog and in humans is more pronounced and amounts to about 85%. There is a reciprocal rise of tissue T in these systems. The application of an inhibitor of 5 alpha R type II leads to a shrinkage of BPH in men by about 30%. In the rat a similar shrinkage accompanied by a significant decrease of total organ DNA occurs. This decrease, however, is not as pronounced as can be achieved with castration.(ABSTRACT TRUNCATED AT 250 WORDS)

Transdermal dihydrotestosterone treatment of 'andropause'

Male ageing coincides on average with progressive impairment of testicular function. The most striking plasma changes are an increase in sex hormone binding globulin (SHBG) and a decrease in non SHBG-bound testosterone, which is the only testosterone subfraction effectively bioavailable for target tissues. In healthy subjects the bioavailable testosterone declines by approximately 1% per year between 40 and 70 years but a more pronounced decline has been observed in non-healthy groups, especially in high cardiovascular risks groups. Relative androgen deficiency is likely to have unfavourable consequences on muscle, adipose tissue, bone, haematopoiesis, fibrinolysis, insulin sensitivity, central nervous system, mood and sexual function and might be treated by an appropriate androgen supplementation. The potential risk for prostate has been the main reason for limiting indications of such treatment. Testosterone (T) and dihydrotestosterone (DHT) are two potent androgens which have opposite effects regarding aromatase activity, an enzyme present in prostate stroma and suspected to have a pathogenic influence through local oestradiol synthesis. T is the main substrate for aromatase and oestradiol synthesis while DHT is not aromatizable and, at sufficient concentration, decreases T and oestradiol levels. A 1.8 years survey of 37 men aged 55-70 years treated with daily percutaneous DHT treatment suggested that high plasma levels of DHT (> 8.5 nmol/l) effectively induced clinical benefits while slightly but significantly reducing prostate size. Early stages of prostate hypertrophy require synergic stimulation by both DHT and oestradiol, and suppressing oestradiol instead of DHT seems easier and better adapted to the specific situation of aged hypogonadic men.(ABSTRACT TRUNCATED AT 250 WORDS)

Transurethral microwave treatment for benign prostatic hypertrophy: a randomised controlled clinical trial

OBJECTIVES

To determine whether transurethral microwave treatment for patients with benign prostatic hypertrophy provides significant symptomatic relief, a reduction in residual urine volumes, and improvements in flow rates compared with sham treatment.

DESIGN

Prospective double blind randomised study with follow up at three months.

SETTING

Department of Urology in a London teaching hospital.

PATIENTS

40 men completed the study: 22 received microwave treatment and 18 received sham treatment. Entry criteria were symptoms of prostatism of at least six months' duration, a total symptom score > 14, and a peak urine flow rate < 15 ml/s or a residual urine volume > 50 ml. Exclusion criteria were prostatic cancer, a residual urine volume > 200 ml, a very large prostate, an obstructing middle lobe, acute urinary retention, impaired renal function, coexisting urinary tract disease, and previous prostatic surgery.

INTERVENTIONS

A single 90 minute transurethral microwave treatment or sham treatment.

OUTCOME MEASURES

Patients' symptoms (including daytime frequency and nocturia) recorded in a self assessment symptom score questionnaire, peak urinary flow rates, and residual urine volumes.

RESULTS

The mean total symptom scores of the patients who received microwave treatment fell from 30 to 11 compared with a fall from 31 to 26 for patients who received sham treatment (p < 0.001). Among patients who received microwave treatment daytime frequency fell from 9.4 to 5.5 voids a day and night time frequency from 3.5 to 1.6 voids a night; residual urine volumes fell from 104 ml to 52 ml; and peak urine flow rates increased by 2.3 ml/s. In the control group there was no improvement in any of these features. Treatment preserved sexual function and antegrade ejaculation.

CONCLUSIONS

For selected patients with prostatism microwave treatment is effective and has few side effects.

Efficacy of transurethral hyperthermia in benign prostatic hyperplasia

From February 1990 through May 1991, 37 patients with benign prostatic hyperplasia were treated by transurethral hyperthermia according to two different protocols. In group I, 10 patients with an indwelling catheter underwent six one-hour sessions twice a week for three weeks, at a temperature of 43 degrees C. The 27 patients from group II (11 with indwelling catheter) had two sessions of two hours each for one week, at a temperature of 44.5 degrees C. Prostatic volume, Madsen symptom score, two estimates of peak flow, average flow, and residual urine measurements were recorded before treatment and one week, one month, six months, and one year after completing the sessions. Hyperthermia was applied through a metal ring, which was used both for heating and temperature control, mounted on a 16-F Foley-Tieman-like catheter. The follow-up period was five to fifteen months. From those who had an indwelling catheter, 5 of 10 patients (50%) from group I and 8 of 11 patients (72.7%) from group II regained spontaneous micturition and continued to void satisfactorily throughout the follow-up period. Nine of 16 patients without catheter (56.3%), showed objective and subjective improvement. Transurethral hyperthermia is a new, simple, noninvasive, and well-tolerated method for the treatment of benign prostatic hyperplasia.

Management of benign prostatic hyperplasia with particular emphasis on aromatase inhibitors

The pathogenesis of human benign prostatic hyperplasia (BPH) has not been fully elucidated. There is, however, evidence that estrogens--besides other factors--might play an important role for the growth of the prostate. Consequently, estrogen deprivation might be a new, useful principle for a conservative treatment of BPH. Atamestane, a new, highly selective steroidal aromatase inhibitor has been proven to be successful in antagonizing experimentally-induced estrogen-related stromal overgrowth of the prostate in dogs and monkeys. Double-blind placebo controlled studies are now underway in Europe and the U.S.A. It is anticipated that these studies will give us a definite answer of the clinical validity of this concept in BPH patients in the near future. However, it is very important to take into consideration that for an effective treatment of BPH, a reduction of both the glandular and stromal elements has to be achieved. In other words, both androgens and estrogens seem to be involved in the regulation of (over)growth of the prostate. Therefore, a combination of an androgen and estrogen deprivation might be a more promising approach than any single treatment.

Urodynamic effects of finasteride in the treatment of bladder outlet obstruction due to benign prostatic hyperplasia

Urodynamic effects of the 5-alpha-reductase inhibitor, finasteride, were studied in the treatment of patients with bladder outlet obstruction due to benign prostatic hyperplasia (BPH). A total of 36 patients was randomly assigned in a double-bind manner to receive either 5 mg. finasteride daily (19) or placebo (17) for 6 months. The possible relief of bladder outlet obstruction was monitored with uroflowmetry and repeated urodynamics. The mean flow rate, detrusor opening pressure, detrusor pressure at maximum flow and maximum detrusor pressure improved significantly in the patients treated with finasteride. There were no significant differences in the improvement of symptom score or peak flow rate, or in the reduction of residual urine between the finasteride and placebo groups. The treatment resulted in 30% average decrease in prostatic size and 46% decrease in prostate specific antigen concentration. The efficacy of finasteride in relief of bladder outlet obstruction caused by BPH seems to be of the same degree as that achieved by chemical castration therapy but without any significant side effects. There were wide variations among BPH patient response to finasteride treatment. Further studies are needed to define the responders who benefit from this treatment.