Impact of medical therapy on transurethral resection of the prostate: a decade of change

The decline in transurethral resection of the prostate gland in Irish public hospitals between 2005 and 2021

BACKGROUND

Lower urinary tract symptoms due to an enlarged prostate is a common condition. Transurethral resection of the prostate gland (TURP) has been the gold standard treatment. The objective of this study was to assess the trends in the prevalence of TURP procedures in Irish public hospitals within the period of 2005-2021. In addition, we explore the attitudes and practices of urologist in Ireland on this topic.

METHODS

An analysis using the Hospital In-Patient Enquiry (HIPE) system using code 37203-00 was undertaken. 16,176 discharges contained the code of interest and had undergone a TURP procedure. The data from this cohort was further analysed. In addition, members of the Irish Society of Urology undertook a bespoke questionnaire to understand the TURP surgery practices.

RESULTS

There has been a substantial decline in the prevalence of TURP procedures in Irish public hospitals from 2005 to 2021. The number of patients discharged from Irish hospitals with a TURP procedure was 66% less in 2021 compared to 2005. 75% (n = 36) of urologist surveyed felt that the declining TURP numbers were due to lack of resources, access to theatre/inpatient beds and outsourcing. 91.5% (n = 43) felt that the declining TURP numbers would result in a lack of training opportunities for trainees, 83% (39) felt this has increased morbidity for patients.

CONCLUSIONS

TURP procedures in Irish public hospitals has declined over the 16-year period studied. This decline is a concern for patient morbidity and urology training.

A Review of Aging and the Lower Urinary Tract: The Future of Urology

Lower urinary tract symptoms (LUTS) are common among elderly people, with significant effects on individuals, caregivers, and the wider health care system. As the elderly population with multiple comorbidities is increasing, the burden of LUTS will increase. This review describes the demographic trends in the aging society, changes in lower urinary tract function with aging, and deterioration of physical and cognitive function in aging, as well as what has been done regarding geriatric urology and what urologists should do to meet the health care needs of the aging population. Frailty and dementia are unmissable factors in the evaluation of elderly patients. Numerous reports have described associations between LUTS and frailty and between LUTS and dementia. Urologists must be aware of the multiplex physical, cognitive, and social characteristics of elderly people. Maintaining a geriatric viewpoint in the diagnosis, treatment, and management of elderly individuals with LUTS will fulfill the unmet needs of elderly people. It is also essential to discuss the treatment and management goals of LUTS with patients and caregivers. Active case identification, appropriate evaluations of LUTS and comorbidities, and a multidisciplinary approach with other health-care professionals are recommended for better treatment and management.

Changes in diagnosis rate and treatment trends of benign prostatic hyperplasia in Korea: A nationwide population-based cohort study

Purpose

This study aimed to evaluate benign prostatic hyperplasia (BPH) diagnosis rate and the changing landscape of medical and surgical management of BPH over the last decade using national population data of South Korea.

Methods

The present study analyzed data of patients diagnosed with BPH (N40) who underwent medical treatment or surgery in 3% of the national patient sample of the Health Insurance and Review Assessment database each year between 2012 and 2018. The primary outcome was the proportion of medical and surgical treatment for BPH. It was evaluated each year between 2012 and 2018. Secondary outcomes included total BPH diagnosis rate in each year of the study period. BPH diagnosis rate by age group was evaluated. The proportion of medical and surgical treatment for BPH according to the type of medical institution was investigated.

Results

The proportion of surgical treatment was 1.2% in 2012, 1.0% in 2013, 1.0% in 2014, 0.9% in 2015, 0.8% in 2016, 0.7% 2018, and 0.8% 2018, showing a progressive overall decrease from 2012 to 2018. The rate of surgical treatment for BPH increased with increasing age during the study period, showing a progressive overall increase (from 9,202 per 100,000 men in 2012 to 11,610 per 100 000 men in 2018). The number of patients with BPH was increased steadily from 2012 to 2018 in all age groups. The rate of surgical treatment in tertiary referral hospitals was the highest during the study period, followed by that in general hospitals, hospitals, and clinics.

Conclusions

In Korea, the diagnosis rate of BPH was steadily increasing during the study period. Overall surgical treatment gradually decreased compared with an increase in medical treatment among all treatments for BPH. Thus, a comprehensive treatment plan for BPH should be established considering this trend.

Changes in Prevalence and Treatment Pattern of Benign Prostatic Hyperplasia in Korea

Purpose

Benign prostatic hyperplasia (BPH) is associated with lower urinary tract symptoms and negatively affects the quality of life. We aimed to investigate the treatment pattern of BPH in South Korea.

Methods

Information on treatment modalities and diagnoses of BPH was obtained from the Health Insurance Review and Assessment Service-Aged Patient Sample. Data on BPH patients aged >60 years from 2012 to 2016 were obtained. We surveyed the treatment pattern of BPH, including the types of drugs used and surgeries performed, according to the type of institution.

Results

In this study, 18,260-24,657 BPH patients treated between 2012 and 2016 were included. The number of patients showed an increasing pattern, and drug therapy was the major treatment method used for BPH (98.77%). Moreover, the pattern of increased pharmacotherapy use for BPH was reinforced by the increasing number of patients. Prescription of α-blockers only was dominant in this cohort (45.7%). Transurethral resection of the prostate (TURP) was the most commonly used surgical treatment for BPH (53.6%), but it showed a decreasing pattern over time. In contrast, holmium laser enucleation of the prostate (HoLEP) showed an increase from 19.4% to 39.7%.

Conclusions

The most common treatment for BPH was drug therapy, predominantly only α-blocker therapy. The surgical treatment trend has changed from TURP to HoLEP.

Management of benign prostatic hyperplasia in the 21st century: temporal trends in Australian population-based data

OBJECTIVE

To examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018.

PATIENTS AND METHODS

Annual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000-2018. Population-adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH.

RESULTS

Overall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezūm™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply.

CONCLUSION

Despite reduced national BPH-related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted.

Surgical management of benign prostatic obstruction: 20-year population-level trends

INTRODUCTION

Benign prostatic obstruction (BPO) due to histological benign prostatic hyperplasia is highly prevalent among older men. Despite widespread use of medical therapy, surgical treatment remains a mainstay in the management of BPO. We sought to characterize trends in the surgical management of BPO in Ontario, Canada.

METHODS

We performed an interrupted time-series analysis using segmented regression among men aged 18 years and older undergoing surgical treatment for BPO between January 1, 1994 and December 31, 2014 in Ontario, Canada. The passage of time was considered the primary exposure. The primary outcome was the proportion of all BPO surgeries performed using each of the following modalities: transurethral resection of the prostate (TURP), endoscopic laser prostatectomy, open/laparoscopic prostatectomy, and others.

RESULTS

We identified 136 459 men who underwent BPO surgery between 1994 and 2014. The annual age-adjusted rate of BPO surgery declined significantly over time (24 to 10 per 10 000 population in 1994 and 2014, respectively). From 1994-2001, there were no significant changes in the distribution of BPO surgical modalities, with TURP the most common throughout (97.2% and 97% in 1994 and 2001, respectively). From 2002-2014, there was a significant decline in the use of TURP (92.1% to 76.9%; p=0.027) with a corresponding increase in the use of endoscopic laser prostatectomy (3.5% to 21.9%; p=0.0008).

CONCLUSIONS

This study demonstrates a shift in the management of BPO, with increasing use of endoscopic laser prostatectomy, beginning in 2002. However, TURP remains the most common treatment modality.

Clinical Implications for the Early Treatment of Benign Prostatic Enlargement (BPE): a Systematic Review

PURPOSE OF REVIEW

Therapeutic options for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have considerably increased in recent years. However, the ideal timing to initiate medical treatment of LUTS/BPE has not been fully established. The aim of this review was to systematically collect available evidence on the influence of early treatment on the natural history of LUTS/BPE patients.

RECENT FINDINGS

A systematic literature search from January 1996 until April 2018 was performed by combining the following MESH terms: Lower Urinary Tract Symptoms, Benign Prostatic Enlargement, male, medical treatment, surgical treatment, early treatment/intervention, and early intervention/treatment. The Medline, PubMed, and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness with regard to the topic of this review. In recent years, the medical armamentarium for the management of LUTS secondary to BPE has been extensively implemented, significantly improving treatment outcomes and markedly reducing the need for BPE surgery. Early intervention in patients at risk for disease progression may offer better clinical outcomes compared to a deferred approach. However, evidences supporting early treatment are scarce, and criteria to discriminate patients that could mostly benefit from immediate treatment remain poorly defined. Moreover, as a result of delayed surgery after prolonged medical treatment, patients undergoing surgical relief show larger prostates, older age, and comorbidities. Nevertheless, technological advancements in surgical techniques have largely counterweighed this critical scenario, and commonly, a non-pejorative trend has been reported in perioperative complications. The timeliest moment to start a medical treatment in LUTS/BPE patients is still undefined, and unexpectedly, peer-reviewed evidence remains scarce. Further studies are awaited to better discriminate patients who mostly benefit from early treatment of LUTS/BPE.

Is early benign prostatic hyperplasia (BPH) treatment worthwhile?

BACKGROUND

The medical armamentaria for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have been extensively implemented over the past decade. Nevertheless, the timeliest moment for a possible treatment has not been fully established.

EVIDENCE ACQUISITION

A systematic literature search in January 1996 until June 2016 was performed to answer the following question: in men with LUTS due to BPH, does early treatment result in better outcome? An ad hoc Population/patient Intervention/indicator Comparator/control Outcome (PICO) was developed.The Medline, PubMed and Scopus databases were searched. Each article title and abstract were reviewed for relevance and appropriateness with regard to the topic of this review.

EVIDENCE SYNTHESIS

Overtime, the introduction of novel medications and the implementation of surgical techniques have significantly improved the treatment outcomes and markedly reduced the rate of BPH surgery. Early treatments in patients at risk of disease progression may result in better clinical outcomes than a delayed approach. However, the evidence to support early intervention remains weak and criteria to identify the patient phenotype that could best benefit from immediate treatment remain ill-defined.On the contrary, the patients who ultimately undergo surgery following prolonged pharmacological treatment present with larger prostates, older age and comorbidities. At the same time, the technological progress has partly compensated this critical scenario, and commonly, a nonpejorative trend has been recorded in perioperative complications.

CONCLUSIONS

The ideal moment to begin a treatment in LUTS/BPH patients is still uncertain, and surprisingly, rare good quality studies are available on this topic.

Changing patients' profile presenting for surgical management of benign prostatic hyperplasia over the past 16 years: A single-centre perspective

INTRODUCTION

We assessed the change of patients' profile presenting for symptomatic benign prostatic hyperplasia (BPH) over 16 years and its impact on surgical outcomes over this time.

METHODS

We reviewed a prospectively maintained database of patients treated with laser for symptomatic BPH since March 1998. Patients were divided into 3 consecutive time-based groups: Group 1 for patients who underwent surgery before April 2004; Group 2, between April 2004 and March 2009; and for Group 3 from April 2009 to August 2014. We reviewed demographic and preoperative data, including prostate volume; international prostate symptoms score (IPSS), quality of life (QoL), and peak flow rate (Qmax). We also recorded any perioperative and long-term complications.

RESULTS

A total of 1835 patients were included in our study, including 542 (29.5%) in Group 1, 614 (33.5%) in Group 2, and 679 (37%) in Group 3. Preoperative prostate volume was positively correlated with age at surgery (r = 0.62, p < 0.001), total energy used (r = 0.47, p < 0.001), and total operative time (r = 0.47, p < 0.001). Patients in Group 3 were significantly older (75.28 ± 8.47 in Group 3 vs. 71.11 ± 8.9 in Group 2 vs. 65.3 ± 9.04 years in Group 1, p <0.001), were more coagulopathic (18.7% Group 3 vs. 12.3% Group 2 vs. 5.9% Group 1, p < 0.001), and had significantly larger prostates (87.96 ± 49.80 in Group 3 vs. 78.44 ± 50.84 in Group 2 vs. 74.50 ± 46.53 Group 1, p < 0.001). Preoperative prostatic medications significantly increased over time (72.6% in Group 1 vs. 85.5% in Group 2, vs. 87.4% Group 3, p < 0.001). IPSS, QoL and Qmax were significantly abnormal in patients in Group 3 (p < 0.001). After a mean follow-up of 3 years, the number of patients who did not require reoperation progressively increased (94.1% Group 1 vs. 96.1% Group 2 vs. 98.3% Group 3). Age (>72 years), prostate volume (>80 cc), operative time (>95 minutes), and preoperative PSA (>6 ng/dL) were significantly associated with postoperative urinary incontinence.

CONCLUSIONS

Patients presenting for surgery due to symptomatic BPH over the last 16 years were significantly older, more morbid, and had larger prostates and more abnormal voiding parameters. Over time, patients used prostatic medications more frequently. Despite the changes in patient profiles, perioperative safety and complication rates between groups were comparable, likely due to advancements in laser technology and techniques. Age (>72 years), prostate volume (>80 cc), operative time (>95 minutes), and preoperative PSA (>6 ng/dL) were significantly associated with reversible postoperative urinary incontinence.

Course of the type of patient who is candidate for radical prostatectomy over 2 decades (1989-2009)

OBJECTIVE

To know the changes experienced by the patient profile candidate for radical prostatectomy over the last 2 decades in our institution..

MATERIAL AND METHODS

We analyze retrospectively a series of 1.132 patients with prostate cancer stadium T1-T2, submitted to radical prostatectomy during the period 1989-2009. The series divides in five homogeneous groups as for the number of patients and arranged chronologically. There uses the free survival of biochemical progression (SLPB) as criterion principal forecast.

RESULTS

In spite of the changes in the diagnosis and treatment of the disease, from the point of view of the forecast (SLPB) we estimate two groups different from patients: the first 250 controlled ones and the rest. The point of chronological cut places in this series in 1.999. We find significant differences in the majority of the clinical-pathological variables as PSA's level to the diagnosis (P <0,001), percentage of palpable tumors (P <0,001), clinical stadium (P <0,001), Gleason in the prostate biopsy (P =0,004), groups at risk of D'Amico (P <0,001), pathological stage (P <0,001), and percentage of patients with lymph node (P <0,001). Nevertheless, there are not detected differences of statistical significance in the Gleason of the specimen of prostatectomy (P =0,06) and in the percentage of surgical margins (P =0,6).

CONCLUSIONS

This study analyzes a patients' wide proceeding sample from the whole Spanish geography and presents some important information that reflect the evolution that has suffered the cancer of prostate located, so much regarding the diagnosis as to the forecast, in our country in the last 20 years.

Impact of changing trends in medical therapy on surgery for benign prostatic hyperplasia over two decades

PURPOSE

Following the introduction of medical therapy for benign prostatic hyperplasia (BPH), we determined the effect of the change in trends in medical therapy on the indication and outcome of surgical intervention for BPH.

MATERIALS AND METHODS

We compared the basic characteristics of, weight of resected tissue of, transfusions in, and postoperative complications of patients who underwent surgery between 1985 and 1989 (before the advent of medical therapy for BPH), between 1995 and 1999 (when medical therapy was developed and became widely used as alternative treatment), and between 2005 and 2009 (when medical therapy superseded surgical intervention to become first-line treatment and when combination therapy became widely adopted).

RESULTS

At our institution, the mean age and BMI of patients increased over the past two decades (p<0.001). Hypertension, operation history, and other comorbidities also increased significantly (p<0.001, p=0.005, and p<0.001, respectively). The indications for surgery in 1985 to 1989, 1995 to 1999, and 2005 to 2009 were as follows: acute urinary retention in 34.7%, 20.2%, and 15.1% of patients and symptomatic deterioration in 61.1%, 72.3%, and 73.0% of patients, respectively. Prostate volume and the weight of resected tissue increased from 34.4±14.5 ml to 61.3±32.4 ml and from 7.2±6.4 g to 10.8±7.6 g, respectively, over two decades. Patients who underwent surgery in 2005 to 2009 had their catheters removed earlier (p<0.001). Secondary hemorrhage within four postoperative weeks and repeat transurethral resection of the prostate within 1 year decreased significantly (p=0.03 and p=0.003, respectively). No statistically significant change in impaired detrusor contractility was found (p=0.523).

CONCLUSIONS

Although patients who underwent surgery were older after widespread use of medical therapy for BPH, advancements in surgical techniques have benefitted these patients.

Changes in surgical strategy for patients with benign prostatic hyperplasia: 12-year single-center experience

Purpose

The purpose of this study was to evaluate the annual changes in prostate variables and style of surgical treatment of patients with benign prostatic hyperplasia (BPH) over the past 12 years.

Materials and Methods

The subjects were 918 patients (January 1999-November 2010) who were treated by either open prostatectomy or transurethral resection of prostate (TURP). Every year, the performance ratio between open prostatectomy and TURP was evaluated. Before surgery, total and transitional zone volumes of the prostate were measured by transrectal ultrasonography (TRUS). After surgery, resection weight and residual volume of the prostate were measured by TRUS.

Results

From 2001 through 2010, the performance ratio of TURP increased greatly from 89% to 97%. During 1999 to 2010, the total volume of the prostate increased from 40.0 cc to 55.0 cc in the TURP group and from 74.1 cc to 116.7 cc in the open prostatectomy group. During 1999 to 2010, the mean resection volume of the TURP group increased from 2.3 cc to 20.1 cc. Also, the mean resection volume of the open prostatectomy group increased from 59.3 cc to 114.3 cc. During 1999 to 2003, the resection time of the TURP group decreased from 72.9 minutes to 43.2 minutes.

Conclusions

During 1999 through 2010, the performance ratio between open prostatectomy vs TURP was high for TURP. The total volume and resection volume of the prostate increased annually, and the resection time decreased annually.

[Photoselective vaporization of the prostate with Laser Greenlight HPS: current role, technical aspects and review of the literature]

Photoselective vaporization of the prostate with 120W HPS Greenlight laser is one of the most attractive modalities of surgical treatment for benign prostatic hyperplasia at present. The specific physical characteristics of this laser provides an excellent safety and effectiveness profile, making it the ideal technique for high-risk patients or patients ongoing oral anticoagulation. Moreover, the undeniable reduction of urethral catheterization time and hospital stay compared to transurethral resection of prostate (TURP) involves a much more comfortable postoperative period for patients. We have conducted a Medline/Pubmed search, presenting in this review the outcomes and current surgical techniques described in recent studies. We have also reviewed the controversial aspects and limitations attributed to this technique.

Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results of a prospective randomized trial

PURPOSE

We report on the first randomized trial to our knowledge comparing holmium laser ablation and photoselective vaporization of the prostate in patients with a small to moderate size prostate.

MATERIALS AND METHODS

Between March 2005 and April 2007, 109 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia and prostate size 60 cc or smaller were randomized to photoselective vaporization of the prostate (52) or holmium laser ablation of the prostate (57). All patients were evaluated by preoperative and postoperative International Prostate Symptom Score, peak flow rate and post-void residual urine volume, measurement of prostate specific antigen and transrectal ultrasound prostate volume. Followup evaluations were performed during visits at 1, 3, 6 and 12 months.

RESULTS

Mean +/- SD preoperative prostate volume was 33.1 +/- 14.5 and 37.3 +/- 13.6 cc in the holmium laser ablation group and the photoselective vaporization group, respectively. Holmium laser ablation of the prostate required more operating time than photoselective vaporization (69.8 vs 55.5 minutes, p = 0.008). In the holmium laser ablation group the International Prostate Symptom Score improved from 20 +/- 6.8 to 6.2 +/- 3.9 and peak urinary flow rate increased from 6.7 +/- 3.9 to 17.2 +/- 8 ml per second. In the photoselective vaporization group the International Prostate Symptom Score improved from 18.4 +/- 6.6 to 8.2 +/- 6.2 and peak urinary flow rate increased from 6.4 +/- 3.9 to 18.4 +/- 8.4 ml per second. Urethral stricture rates were 1.7% vs 5.7%, bladder neck contractures were 3.5% vs 7.7% and revaporization rates were 3.5% vs 1.9% in the holmium laser ablation and photoselective vaporization groups, respectively.

CONCLUSIONS

Holmium laser ablation and photoselective vaporization of the prostate are safe and effective in patients with benign prostatic hyperplasia with a small to moderate size prostate. Both procedures are easy to learn but holmium laser ablation of the prostate requires a longer operating time.

High-performance system GreenLight laser: indications and outcomes

PURPOSE OF REVIEW

In this review, we present recent clinical and urodynamic data on transurethral photoselective vaporization of the prostate, and report on the recent introduction of the 120 W GreenLight laser (GLL) high-performance system.

RECENT FINDINGS

Published studies provide substantial evidence that photoselective prostate vaporization is an efficacious treatment for lower urinary tract symptoms caused by benign prostatic hyperplasia. Recent studies confirm improved urodynamic findings following GLL treatment. Moreover, it can be used safely in high-risk patients (e.g. those on anticoagulant medication and patients with cardiopulmonary diseases), and has been proposed as an alternative to prostate enucleation for larger glands. Depending on the reimbursement system in different countries, it can be a cost-effective procedure. The introduction of the 120 W high-performance system GLL does, however, place distinct demands on training and operative schemes.

SUMMARY

The clinical results of GreenLight prostate vaporization are equivalent to those following transurethral resection of the prostate, with reduced operative risks, even for the high-risk patient. These clinical benefits have been confirmed by improved urodynamic parameters. The potential advantages of the new 120 W high-performance system GLL are yet to be unequivocally proven in larger randomized trials.

An Asian multinational prospective observational registry of patients with benign prostatic hyperplasia, with a focus on comorbidities, lower urinary tract symptoms and sexual function

OBJECTIVE

To examine the characteristics, management practices and outcomes of patients presenting with symptoms of benign prostatic hyperplasia (BPH) in Asia, with a focus on comorbidities and sexuality.

PATIENTS AND METHODS

In this multinational prospective observational registry, eligible patients with BPH attending a urology clinic for the first time were enrolled. Details of comorbidities, sexuality and symptoms of BPH were collected through the International Prostate Symptom Score (IPSS), International Index of Erectile Dysfunction-5 (IIEF-5) and the Danish Prostate Symptom Score (DAN-PSS-1) questionnaires. The follow-up was scheduled at 1-3 or 3-6 months, depending on the treatment.

RESULTS

In 994 men aged 40-88 years the most common comorbidities were hypertension (38%) and obesity (36%). Nocturia was the most common symptom for consultation. A previous episode of acute urinary retention (AUR) was recorded in 12%. About 90% of the men had moderate-to-severe lower urinary tract symptoms (LUTS), and the severity increased with age. Sexual dysfunction was reported by 82%, and it correlated with the severity of LUTS. Of 918 sexually active men, only 20% had normal erectile function; 36%, 19% and 25% reported severe, moderate and mild erectile dysfunction (ED), respectively. BPH medication was started in 78%, 9% had surgery, and in 13% an approach of watchful waiting was adopted. In all, 89% of patients completed the follow-up. The symptoms of BPH resolved in 93% after surgery, in 83% on BPH medication and in 34% of those on 'watchful waiting'. Surgery, which led to a mean reduction of 17.0 IPSS points, was the most effective in improving LUTS. Improvement on the DAN-PSS-1 items of reduced erection and reduced ejaculation was higher with medication, while surgery led to better outcomes on the DAN-PSS-1 item of pain/discomfort on ejaculation. For ED, from baseline to after treatment, the mean IIEF-5 scores changed from 19.1 to 18, from 14.2 to 14.8, and from 4.5 to 5.5 for those with mild, moderate and severe ED at baseline, respectively. Only 2.3% of patients had an episode of AUR while on treatment. About 5.5% of patients on BPH medication and 6% of surgical patients reported adverse events.

CONCLUSION

Asian patients with BPH usually present with LUTS; sexual dysfunction is also very common. BPH medication is the most frequent treatment approach, followed by watchful waiting and surgery. Medication and surgery resulted in a greater reduction of LUTS and improvement in sexual dysfunction than watchful waiting. As Asian men remain sexually active even at advanced ages, sexual function should be assessed and discussed with the patient before deciding the management strategy for LUTS associated with BPH.

Greenlight Prostatectomy: A Challenge to the Gold Standard?

The use of lasers to carry out resection of the prostate gland is an ever-evolving field which has seen several different modalities of laser light used with varying success. This review looks at what makes the traditional transurethral resection of prostate the gold standard and provides the evidence on the evolution of the laser prostatectomy in trying to usurp it as the favored procedure for symptomatic benign prostatic hyperplasia. In particular, we show how the latest laser technology in the form of the Greenlight laser is challenging not only other lasers such as the holmium laser, but may form a strong contender to replace the transurethral resection of prostate.

Benign prostatic hyperplasia and subsequent risk of bladder cancer

We evaluated the risk of bladder cancer in a cohort of 79,280 Swedish men hospitalised for benign prostatic hyperplasia (BPH), identified in the Swedish Inpatient Register between 1964 and 1983 and followed until 1989 via multiple record linkages with nationwide data on cancer registry, death and emigration. Standardised incidence ratios (SIRs), the ratios of the observed to the expected numbers of incident bladder cancers, were used to calculate the risk associated with BPH. The expected number was calculated by multiplying the number of person-years by the age-specific cancer incidence rates in Sweden for each 5-year age group and calendar year of observation. Analyses were stratified by BPH treatment, latency, calendar year and presence of genitourinary (GU) comorbid conditions. After excluding the first 3 years of follow-up after the index hospitalisation, we observed 506 incident bladder cancer cases during follow-up in the cohort. No overall increased risk of bladder cancer was apparent in our main analysis involving the entire BPH cohort. However, among BPH patients with transurethral resection of the prostate (TURP), there was an increased risk in all follow-up periods; SIRs of bladder cancer during years 4-6 of follow-up was 1.22 (95% confidence interval=1.02-1.46), 1.32 for 7-9 years of follow-up, and 1.47 for 10-26 years of follow-up. SIRs of bladder cancer among TURP-treated BPH patients were particularly elevated among those with comorbid conditions of the GU tract (e.g., stone, infection, etc.); 1.72, 1.74 and 2.01 for 4-6, 7-9, 10-26 years of follow-up, respectively, and also for those whose diagnoses occurred before 1975, when TURP was more likely to be performed by a urologist than a general practitioner: 1.87, 1.90 and 1.74, respectively. These findings suggest that BPH overall is not associated with bladder cancer risk. However, among men treated with TURP, particularly those with other comorbid GU tract conditions, risk of bladder cancer was elevated.

Incidence of Primary and Recurrent Acute Urinary Retention Between 1998 and 2003 in England

PURPOSE

We report how the incidence of primary and recurrent acute urinary retention changed in England between 1998 and 2003. In addition, we present data on changes with time in the use of prostatectomy after acute urinary retention and recurrent acute urinary retention.

MATERIALS AND METHODS

Data were extracted from the Hospital Episode Statistics database of the Department of Health in England. Patients were included in the study if an International Classification of Diseases, Tenth Revision code for acute urinary retention or an operative procedure code for transurethral prostate resection was present in any diagnosis or procedure fields of the Hospital Episode Statistics database. A total of 165,527 men were identified to have been hospitalized with acute urinary retention in the study period.

RESULTS

The incidence of primary acute urinary retention was 3.06/1,000 men yearly. Acute urinary retention was spontaneous in 65.3% of cases. The incidence of acute urinary retention decreased from 3.17/1,000 men yearly in 1998 to 2.96/1,000 yearly in 2003. Surgical treatment following spontaneous acute urinary retention decreased 20% from 32% in 1998 to 26% in 2003. This trend coincided with a 20% increase in the rate of recurrent acute urinary retention.

CONCLUSIONS

The slight decrease in the incidence of primary acute urinary retention suggests that the shift away from surgical treatment for benign prostatic hyperplasia has not resulted in an increase in acute urinary retention. The increase in recurrent acute urinary retention suggests that the observed decrease in surgery after acute urinary retention may have put more men at risk for acute urinary retention recurrence.

Medical and minimally invasive therapies for the treatment of benign prostatic hyperplasia

Over the last decade, management of benign prostatic hyperplasia (BPH) has changed with a substantial decrease in the use of transurethral prostatectomy (TURP) and a simultaneous increase in the use of medical therapy and minimally invasive surgical therapy (MIST). The goal of management of this chronic progressive condition is not only to provide relief of lower urinary tract symptoms (LUTS) but also to reduce the lifetime risk of adverse outcomes. Recent clinical evidence has demonstrated a clear role for medical therapy, particularly with 5-alpha-reductase inhibitors (5ARIs) either alone or in combination with alpha-blockers, to reduce the risk of acute urinary retention and need for surgery and provide symptom relief. Clinical data on MISTs also indicate a more pronounced short-term effect; however, the long-term durability of these therapies remains uncertain. Minimally invasive surgical therapies confer treatment benefits in a single 1-h treatment session under local anesthesia. Recovery times and adverse events are improved compared with TURP, but issues such as hematuria, prolonged catheterization, urinary tract infection and retreatment remain commonly reported issues. Today, urologists are faced with the challenge of identifying the most appropriate treatment option for the long-term management of BPH. The initial choice for any given patient will depend on his presenting circumstances and the influence of treatment risks on these circumstances. Providing patients with informed treatment decisions is a key element of management.

The changing face of prostate cancer

Prostate cancer remains the most common noncutaneous human malignancy, and the second most lethal tumor among men. However, the natural history of the disease is often prolonged, and the survival benefits of local therapy for men with low-risk tumors may not be realized for a decade or more, as is increasingly well demonstrated in long-term observational cohorts in both the United States and Europe. A significant proportion of men with prostate cancer may be overdiagnosed, in the sense that diagnosis may not improve their lifespan or quality of life. However, the extent to which overdiagnosis represents a true problem relates to the consistency with which diagnosis leads invariably to active treatment. Prostate cancer is diagnosed at progressively earlier stages and with lower risk features; despite these trends, patients are less likely now than a decade ago to undergo a trial of active surveillance. Rates of brachytherapy and hormonal therapy use, in particular, have risen markedly. Important progress has been made in recent years in prostate cancer risk assessment. These advances, in combination with biomarkers in later stages of development, should be expected in the coming years to yield further improvements in clinicians' ability to diagnose prostate cancer early, and guide appropriately selected patients toward increasingly tailored treatment.

TOLTERODINE EXTENDED RELEASE ATTENUATES LOWER URINARY TRACT SYMPTOMS IN MEN WITH BENIGN PROSTATIC HYPERPLASIA

PURPOSE

In this open label, prospective study we determined the efficacy and tolerability of tolterodine extended release (ER) in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in whom previous alpha-blocker therapy had failed.

MATERIALS AND METHODS

A total of 43 consecutive men with BPH and LUTS in whom a mean of 5.7 months of alpha-blocker therapy had failed due to adverse events (11) or a lack of efficacy (32) received tolterodine ER (4 mg daily) for 6 months. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, total score on the erectile function domain of the International Index of Erectile Function and adverse events.

RESULTS

A total of 39 men (91%) with a mean age of 61 years completed the 6-month trial. Mean 24-hour micturition frequency decreased from 9.8 to 6.3 voids and nocturia decreased from 4.1 to 2.9 episodes nightly. Significant changes in mean American Urological Association symptom scores (-6.1), the peak urinary flow rate (1.9 ml per second) and post-void residual volume (-22 ml) were also observed. Of the men 27 (63%) were potent at baseline and 29 (67%) were potent after 6 months of tolterodine ER treatment. Mean International Index of Erectile Function erectile function domain scores increased (6.9). Four men (9%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention.

CONCLUSIONS

Treatment with tolterodine ER in men with BPH and LUTS may be a reasonable therapeutic option as initial therapy or after failed treatment with alpha-blockers.

The impact of medical therapy on surgery for benign prostatic hyperplasia: a study comparing changes in a decade (1992-2002)

OBJECTIVES

To compare the clinical profile (age, comorbidities, symptom severity, and incidence of acute urinary retention, AUR), the type and duration of medical treatment, and indications for surgery of patients undergoing surgery for benign prostatic hyperplasia (BPH) in 1992 and 2002 at one centre.

PATIENTS AND METHODS

In this single-centre, retrospective, cross-sectional observational study, the medical history of all patients who had surgery for BPH in the first semester of 1992 (85) and 2002 (70) was reviewed. The preoperative clinical profile was determined by assessing age, main comorbidities, prostatic volume, maximum urinary flow rate and symptom severity. The type and duration of pharmacology for BPH was evaluated from the medical history and telephone contact with the patients. Indications for surgery, the method of operation and the weight of removed tissue (open adenectomy) or the volume of the resected tissue (transurethral resection) were obtained from the patients' records and compared. Surgical complications in both groups were assessed, as was the average stay in hospital.

RESULTS

In our institution, surgery for BPH decreased by 17.6% in the decade, with patients having surgery when older, at a mean (sd) of 69.1 (8.57) vs 72.3 (7.59) years, i.e. 3.1 years older (P = 0.028), but with similar comorbidities. Reasons for surgery in 1992/2002, respectively, were AUR in 41/37%, and symptoms worsening in 48/51%. The few cases of haematuria and bladder stone were similarly distributed in both groups. Pharmacology for BPH was prescribed in 46% of patients in 1992, phytotherapy being the most common (89%), whereas in 2002, 82% (P < 0.01) were treated, most of them with alpha-adrenergic antagonists (79%). Open surgery was indicated in 18.8% of patients in 1992 (mean adenoma weight 73.8 g, sd 37.12) and in 28.6% in 2002 (79.8 g, sd 35.41; P = 0.625). The mean (sd) hospital stay was 8.9 (4.06) vs 5.0 (1.22) days in 1992 and 2002, respectively (P < 0.01) for transurethral resection, and 14.1 (5.74) vs 8.7 (4.83) for open adenectomy (P = 0.013). The complication rate was similar for both groups.

CONCLUSIONS

Compared with 1992, fewer patients with BPH have surgery, when older and after receiving medical treatment for longer. The indications for surgery are similar. Significantly more patients had open surgery, perhaps because the progressive increase in prostate volume was not affected by the medical therapy used predominantly during this decade.

Economic costs of benign prostatic hyperplasia in the private sector

PURPOSE

Several studies document the impact of benign prostatic hyperplasia (BPH) in working, aged men. Direct medical costs related to BPH treatment are largely borne by employees through higher premiums. However, indirect costs related to lost work are primarily borne by the employer. In this study we used claims data and absentee records from large employers to estimate the costs associated with BPH in working age males.

MATERIALS AND METHODS

We used 2 data sources to examine direct and indirect costs associated with BPH in a privately insured, nonelderly population. Multivariate regression models were used to predict spending for persons with and without a medical claim for BPH, controlling for relevant covariates. Data on work loss were linked to medical claims to estimate work loss related to treatment for BPH.

RESULTS

Mean annual expenditures were 4,193 dollars for men without a medical claim for BPH. In contrast, annual spending was 5,729 dollars for men with a claim for BPH. Thus, the incremental cost associated with a diagnosis of BPH was 1,536 dollars yearly. Overall the average employee with the condition missed 7.3 hours of work yearly related to BPH with approximately 10% reporting some work loss related to a health care encounter for BPH.

CONCLUSIONS

Treatment of men with BPH places a significant burden on employees and their employers through direct medical costs as well as through lost work time. Direct and indirect costs to the private sector related to BPH treatment are estimated to be 3.9 billion dollars.

Is routine post-operative haemoglobin measurement required after transurethral resection of the prostate?

The aim of this study is to evaluate the rate of blood transfusion during the post-operative period in patients undergoing transurethral resection of the prostate (TURP) and to determine the value of using post-operative haemoglobin (Hb) measurement as a guide to transfusion requirements. In a retrospective study, pre- and post-operative Hb measurements and the resected prostatic tissue weights were recorded for 106 patients. There was a statistically significant change in the Hb concentration within 48 h of the operation (P < 0.0001), although this was clinically insignificant in the majority of patients. The post-operative blood transfusion rate was 0.85% and there was a significant correlation between change in Hb concentration and the resected tissue weight (P < 0.0001). Our results show that routine post-operative Hb is not necessary in patients following a TURP.

Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician

Less than 10 years ago surgery and watchful-waiting were the only widely accepted management options for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO). There has been an enormous decline in the popularity of surgery and it is now apparent that medication is the most frequently used treatment for BPH/LUTS; this has arguably therefore been the most major change in urological clinical practice in the last decade. Currently alpha(1)-adrenoceptor antagonists are the commonest medical therapy, and are thought to act by relaxing prostatic smooth muscle, the neural or so-called 'dynamic' component of BPO. 5alpha-reductase inhibitors (finasteride, dutasteride) are another option for BPH/LUTS, which reduce prostatic mass and therefore the mechanical or 'static' component of BPO. In the last 10 years there have been four direct comparative studies between alpha(1)-adrenoceptor antagonists and finasteride, including their combination, the results of which, and their implications for therapy, are discussed. Another group of agents are the phytotherapeutic extracts, which act via various mechanisms, many as yet poorly defined. This review critically assesses existing publications relating to the medical management of BPH/LUTS.

Relationships Between American Urological Association Symptom Index, Prostate Volume, and Disease-Specific Quality of Life Question in Patients with Benign Prostatic Hyperplasia

The American Urological Association (AUA) symptom index is both valid and reliable in identifying the need to treat patients with benign prostatic hyperplasia (BPH) and in monitoring their response to therapy. We evaluated the relationships between AUA symptom index, disease-specific quality of life question, and prostate volume in patients with BPH. A total of 100 patients who came to Kaohsiung Medical University Hospital, Taiwan, for help due to lower urinary tract symptoms (LUTS) and who were diagnosed with BPH between October 2002 and June 2003 were included in the study. All patients were evaluated using transrectal ultrasonography, AUA symptom index, and disease-specific quality of life question. The disease-specific quality of life question showed good correlation with AUA symptom score (r = 0.815, p < 0.01), but weak correlation with prostate volume (r = 0.225, p < 0.05) and age (r = 0.274, p < 0.05). Prostate volume had weak correlation with AUA symptom score (r = 0.251, p < 0.05) and age (r = 0.472, p < 0.01), but good correlation with prostate specific antigen (r = 0.638, p < 0.01). In addition to AUA symptom index, we suggest using the disease-specific quality of life question to evaluate the influence on quality of life and response to treatment in clinical practice. Moreover, we should assess the impact of BPH symptoms rather than the increase in prostate volume during the management of BPH.

Short-term subjective efficacy of doxazosin in predicting probability of prostatectomy in the management of benign prostatic hyperplasia in patients with severe symptoms

BACKGROUND

The severity of symptoms still constitutes the major indication for transurethral prostatectomy, despite the extensive utilization of medical treatments. The aim of the study presented here was to investigate the impact of doxazosin on symptoms in relation to the probability of consequent surgery in severely symptomatic patients.

METHODS

Patients with an International Prostate Symptom Score (IPSS) between 18 and 35 were included in the study. The patients received 4 mg/day doxazosin, and subjective efficacy was assessed by IPSS at the first and third months. In addition, the patients were classified at the third month according to a single question regarding satisfaction with medical treatment in terms of symptom relief as 'ineffective, no change, and effective'.

RESULTS

A total of 178 patients constituted the study group. Mean total symptom scores were 24, 19 and 17 at baseline, first and third months, respectively (P < 0.05). According to results of the questionnaire, 23% of the patients claimed the treatment was ineffective, and subsequently, the majority of this group (93%) underwent prostatectomy in a year. In addition, 33% of the patients reported no change in their symptoms, while 44% reported that the medication was effective. However, after 1 year, 59% and 15% of these cases underwent surgical treatment, respectively. The probability of surgery in the 'ineffective' group was significantly higher compared to the remaining groups (P < 0.05).

CONCLUSION

The majority of patients with severe symptoms who were not satisfied with the medication at the 3rd month underwent surgery. This observation may provide a predictor for subsequent probability of prostatectomy. Therefore, reassessment of patients would be a cost-effective approach for the treatment of BPH in severely symptomatic patients.

Prostate carcinoma risk subsequent to diagnosis of benign prostatic hyperplasia: a population-based cohort study in Sweden

BACKGROUND

Pathologically, benign prostatic hyperplasia (BPH) is not considered a precursor for prostate carcinoma. However, because the two conditions share not only a similar hormonal environment within the prostate but also several common risk factors, it is possible that men with BPH may be at increased risk of prostate carcinoma due to these shared factors.

METHODS

To elucidate this further, the authors used Swedish nationwide population-based record-linkage data to assess prostate carcinoma risk up to 26 years after the diagnosis of BPH among 86,626 men.

RESULTS

Overall, relative to the general population, patients with BPH experienced little, if any, excess risk of prostate carcinoma (2% excess incidence after 10 years of follow-up). However, patients with BPH with and without surgical intervention experienced different prostate carcinoma risk patterns. Those undergoing transvesicular adenomectomy had a significant 22% lower incidence and a 23% lower mortality after the first 5 years of follow-up and those undergoing transurethral resection had a significant 10% higher incidence but a 17% lower mortality. In contrast, after the first 5 years, patients with BPH who did not receive surgical intervention experienced significant excesses of both prostate carcinoma incidence (18%) and mortality (77%).

CONCLUSIONS

The differences in prostate carcinoma incidence and mortality by BPH treatment type suggest that factors related to treatment or health reasons underlying the selection of treatment influence subsequent prostate carcinoma risk. Further studies are needed to confirm the minimal excess risk of prostate carcinoma among BPH patients overall and the possible impact of BPH treatment methods on subsequent prostate carcinoma risk.

Benign prostatic hyperplasia

In both ageing men and women, there is an increasing incidence of lower urinary tract symptoms (LUTS) which are increasing. These infections have many possible causes, including smooth muscle dysfunction, neurological factors and benign prostatic hyperplasia. Up to 15% to 25% of men aged 50-65 years have LUTS of sufficient severity to interfere with their quality of life. Although benign prostatic hyperplasia is an important cause of these symptoms, and can have serious consequences, clinicians should be aware of these other causes so that the appropriate diagnosis is made before invasive treatments are started. New medical treatments, including alpha-adrenergic blocking agents and 5 alpha-reductase inhibitors mean that many men without complications such as infection, bleeding, or chronic retention, and with mild to moderate symptoms, should be managed in primary care. Combined local protocols between primary and secondary care will help to establish which men with persistent symptoms or complications need referral for a urological opinion to determine the need for further investigation and more invasive forms of management. We review the pathophysiology of the disease, and current approaches to investigation and management of this common problem.

Current indications for transurethral resection of the prostate and associated complications

Transurethral resection of the prostate (TURP) is the most common surgical procedure for relieving symptoms of benign prostatic hyperplasia. Here, we report our experience of current indications for TURP and their associated outcomes at Kaohsiung Medical University Hospital (KMUH). A total of 111 patients who underwent TURP at KMUH between May 2000 and December 2001 were included in this retrospective review. For each patient, the surgical indication was categorized into acute urinary retention, chronic complications (including renal impairment, recurrent urinary infection, bladder stone/diverticulum, post-void residue, and recurrent hematuria), and symptomatic prostatism. Thirty-five patients (31%) had acute urinary retention, 28 (27%) had chronic complications, and 48 (42%) had symptomatic prostatism. Most patients chose TURP only when medical treatment had failed to relieve symptoms, no matter what category they belonged to. Patients with acute urinary retention and chronic complications had larger prostates (p = 0.002) and more tissue resected (p = 0.05) than those with symptomatic prostatism. Patients with acute urinary retention seemed to be at greater risk of postoperative complications such as recurrent urinary retention and urinary tract infection. We suggest that urodynamic study may be necessary to rule out concomitant bladder dysfunction before surgery and that adequate prophylactic antibiotic treatment be used to decrease the risk of urinary tract infection during or after TURP, especially when pyuria is noted preoperatively in patients with acute urinary retention.

5 alpha-reductase inhibitors: what's new?

PURPOSE OF REVIEW

Medical therapy is now the first-line treatment for most men with symptomatic benign prostatic hyperplasia. This review aims to highlight the recent contributions to our understanding of 5 alpha-reductase inhibitor usage.

RECENT FINDINGS

For the last decade, finasteride has been the only available 5 alpha-reductase inhibitor, acting upon the type 2 isoenzyme of 5-alpha reductase. Dutasteride is the first drug that can inhibit both isoenzymes and is soon to be available. Biochemically it achieves greater and more rapid dihydrotestosterone suppression compared with finasteride. Clinically, it appears to be at least as good in terms of improving symptoms and flow rates, and reducing the risk of acute urinary retention or the requirement for benign prostatic hyperplasia-related surgery. However, until these two drugs are formally compared, the true benefits of additional type 1 isoenzyme inhibition are unknown. The recently reported Medical Therapy of Prostatic Symptoms trial has convincingly demonstrated superior outcomes with combination therapy compared with monotherapy, unlike previous trials of shorter duration. The ability of 5 alpha-reductase inhibitors to prevent disease progression was also confirmed. Newer roles for 5 alpha-reductase inhibitors are also being defined. Finasteride has been shown to reduce and control benign prostatic hyperplasia-related haematuria, although its value in controlling perioperative bleeding is less clear. Their role as chemopreventive agents for prostate cancer is also under investigation.

SUMMARY

Recent studies have both clarified and extended the roles of 5 alpha-reductase inhibitors in benign prostatic hyperplasia, and these may expand further if chemopreventive abilities are proved. In addition, dual isoenzyme inhibition will soon be available.

Benign prostatic hyperplasia: solutions to an ageing problem

As the population ages, the demand for treatment of the symptoms of benign prostatic hyperplasia has never been higher. Equally the choice of treatments has never been greater. This review considers the medical and surgical options.