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

Can we predict and manage persistent storage and voiding LUTS following bladder outflow resistance reduction surgery in men? ICI-RS 2023

AIMS

Lower urinary tract symptoms (LUTS) persist in up to 50% of patients after bladder outflow resistance reduction surgery (BORRS) in men. Our think tank aims to address the predictive factors for persistent LUTS after BORRS and to propose the recommendations for future research to enable improved better patient counseling and selection by more accurate prediction of treatment outcome.

METHODS

A think tank of ICI-RS gathered in 2023, Bristol, UK, to discuss the pre and postsurgical clinical and urodynamic evaluation of men undergoing BORRS and whether it is possible to predict which men will have persistent LUTS after BORRS.

RESULTS

Our think tank agrees that due to the multifactorial, and still not fully understood, etiology of male LUTS it is not possible to precisely predict in many men who will have persistent LUTS after BORRS. However, severe storage symptoms (overactive bladder, OAB) in association with low volume and high amplitude detrusor overactivity and low bladder capacity in preoperative urodynamics, increase the likelihood of persistent OAB/storage symptoms after BORRS. Furthermore, patients who are clearly obstructed and have good bladder contractility on preoperative pressure flow studies do better postoperatively compared to their counterparts. However, the benefit of pressure flow studies is decreased in patients who do not acceptably void during the study. Poor voiding after BORRS may occur due to persistent obstruction or detrusor underactivity.

CONCLUSION

Future research is needed to increase our understanding of why male LUTS persist after surgery, and to enable better patient selection and more precise patient counseling before BORRS.

Cost-effectiveness analysis of minimally invasive surgical treatments for benign prostatic hyperplasia: implications for Japan's public healthcare system

AIMS

Benign prostatic hyperplasia (BPH) represents a significant public health issue in Japan. This study evaluated the lifetime cost-effectiveness of water vapor energy therapy (WAVE) versus prostatic urethral lift (PUL) for men with moderate-to-severe BPH from a public healthcare payer's perspective in Japan.

MATERIALS AND METHODS

A decision analytic model compared WAVE to PUL among males in Japan. Clinical effectiveness and adverse event (AE) inputs were obtained from a systematic literature review. Resource utilization and cost inputs were derived from the Medical Data Vision database and medical service fee national data in Japan. Experts reviewed and validated model input parameters. One-way and probabilistic sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affect the model results.

RESULTS

Throughout patients' lifetimes, WAVE was associated with higher quality-adjusted life years (0.920 vs. 0.911 year 1; 15.564 vs. 15.388 lifetime) and lower total costs (¥734,134 vs. ¥888,110 year 1; ¥961,595 vs. ¥1,429,458 lifetime) compared to PUL, indicating that WAVE is a more effective and less costly (i.e. dominant) treatment strategy across all time horizons. Lifetime cost-savings for the Japanese healthcare system per patient treated with WAVE instead of PUL were ¥467,863. The 32.7% cost difference between WAVE and PUL was predominantly driven by lower WAVE surgical retreatment rates (4.9% vs. 19.2% for WAVE vs PUL, respectively, at 5 years) and AE rates (hematuria 11.8% vs. 25.7%, dysuria 16.9% vs. 34.3%, pelvic pain 2.9% vs. 17.9%, and urinary incontinence 0.4% vs. 1.3% for WAVE vs PUL, respectively, at 3 months). Model findings were robust to changes in parameter input values.

LIMITATIONS

The model represents a simplification of complex factors involved in resource allocation decision-making.

CONCLUSIONS

Driven by lower retreatment and AE rates, WAVE was a cost-effective and cost-saving treatment for moderate-to-severe BPH in Japan compared to PUL, providing better outcomes at lower costs to the healthcare system.

Studies on Chromatographic Fingerprint and Fingerprinting Profile-Efficacy Relationship of Saxifraga stolonifera Meerb

This work investigated the spectrum-effect relationships between high performance liquid chromatography (HPLC) fingerprints and the anti-benign prostatic hyperplasia activities of aqueous extracts from Saxifraga stolonifera. The fingerprints of S. stolonifera from various sources were established by HPLC and evaluated by similarity analysis (SA), hierarchical clustering analysis (HCA) and principal component analysis (PCA). Nine samples were obtained from these 24 batches of different origins, according to the results of SA, HCA and the common chromatographic peaks area. A testosterone-induced mouse model of benign prostatic hyperplasia (BPH) was used to establish the anti-benign prostatic hyperplasia activities of these nine S. stolonifera samples. The model was evaluated by analyzing prostatic index (PI), serum acid phosphatase (ACP) activity, concentrations of serum dihydrotestosterone (DHT), prostatic acid phosphatase (PACP) and type II 5α-reductase (SRD5A2). The spectrum-effect relationships between HPLC fingerprints and anti-benign prostatic hyperplasia activities were investigated using Grey Correlation Analysis (GRA) and partial least squares regression (PLSR). The results showed that a close correlation existed between the fingerprints and anti-benign prostatic hyperplasia activities, and peak 14 (chlorogenic acid), peak 17 (quercetin 5-O-β-d-glucopyranoside) and peak 18 (quercetin 3-O-β-l-rhamno-pyranoside) in the HPLC fingerprints might be the main active components against anti-benign prostatic hyperplasia. This work provides a general model for the study of spectrum-effect relationships of S. stolonifera by combing HPLC fingerprints with a testosterone-induced mouse model of BPH, which can be employed to discover the principle components of anti-benign prostatic hyperplasia bioactivity.

Is there an increase in genitourinary toxicity in patients treated with transurethral resection of the prostate and radiotherapy? A systematic review

PURPOSE

Transurethral resection of the prostate (TURP) is considered by some as a risk factor for genitourinary (GU) toxicity after radiotherapy (RT). However, there are conflicting results regarding the interaction between RT and TURP with respect to GU toxicity. The purpose of this report is to review the published data concerning TURP before or after RT and its effect on urinary complication.

METHODS AND MATERIALS

A systematic literature review based on database searches in MEDLINE, EMBASE, Pubmed, Ovid, and Chochrane Library. The eligibility criteria of final review were (1) definitive RT for prostate cancer is reported; (2) comparison of GU toxicities between patients with and without TURP is reported; (3) minimum 5 patients after TURP are included.

RESULTS

Twelve articles regarding overall GU toxicity, 15 articles regarding urinary incontinence, and 13 articles regarding urinary or bladder neck stricture met eligibility criteria, and they were included in the final review. A quantitative synthesis from the data of selected articles was impossible because of variable grading systems and variable definitions in their comparisons between patients with and without TURP. However, most published articles demonstrated the increased risk of GU toxicity with TURP in patients treated with RT.

CONCLUSIONS

Our systematic review strongly suggests that TURP is one of the risk factors of GU toxicity after RT. This needs to be taken seriously when prostate cancer patients with TURP are considered for RT either external beam or brachytherapy.

Should all specimens taken during surgical treatment of patients with benign prostatic hyperplasia be assessed by a pathologist?

INTRODUCTION

In some patients submitted to transurethral resection of the prostatic (TURP) or prostatectomy (OAE) due to benign prostate hyperplasia (BPH), pathological evaluations (PE) revealed coexistence of prostate cancer (PCa) and BPH. The aim of the study is to evaluate the incidence of PCa diagnosed incidentally in prostate specimens taken during BPH surgery, to assess the need of routine PE and to define the group of patients in whom PE could be abandoned without the risk of omitting clinically significant PCa.

MATERIAL AND METHODS

968 consecutive men were subjected to surgical treatment due to BPH in Jan. 2004-Sep. 2010.

RESULTS

823 (85%) underwent TURP and 145 (15%) OAE. Incidental (Inc) PCa was diagnosed in 34(3.5%) pts. T1a and T1b stages were determined in 19 (2%) and 15 (1.5%) cases. Preoperative prostate biopsy due to abnormal prostate specific antigen (PSA) or digital rectal exam (DRE) was performed in 85 (8.8%) pts. Of PCa pts, 7 (20.58%) had undergone a cancer negative biopsy preoperatively. In BPH pts, 78 (8.35%) had undergone a prostate biopsy previously (p <0.01). Univariate and logit regression analyses had not revealed any correlations between age, Pv, serum PSA and frequency of IncPCa. The difference in rate of PCa diagnosed in patients with PSAD ≥0.15 and <0.15 was 8 pts (14.04%) and 20 pts (4.05%), respectively (p <0.001). Gls in those pts was >6 only in 4 cases.

CONCLUSIONS

Despite the fact of low PCa detection rate observed in our study, this condition was clinically relevant in 15 (1.5%) subjects. It is difficult to establish any cut off values of pts' age, Pv, serum PSA level suggestive of negligible risk for prostate cancer.

Prospective short-term evaluation of transurethral needle ablation procedure in an ambulatory setting

OBJECTIVE

To assess the results of transurethral needle ablation (TUNA) (Prostiva®, Medtronic, France) performed in an ambulatory setting in men with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A multicenter open-label study was conducted. Short-term success was defined by ability to leave the hospital on the evening of the intervention, and absence of rehospitalization due to complications during the first postoperative month. Sexual and urinary functions were evaluated by validated questionnaires.

RESULTS

The procedure was successful in 44/49 patients. Sexual and ejaculatory function was not affected or slightly improved in the majority of patients. Urinary parameters improved with a 32% decrease in the International Prostate Symptom Score. At 1 month postoperation, more than 80% of patients were satisfied, and 36/41 patients were prepared to undergo the procedure again if needed. Our study was limited by the short follow-up duration.

CONCLUSIONS

TUNA can be successfully performed in an ambulatory setting under local and/or general anesthesia with a high level of patient satisfaction and a low short-term morbidity, especially on sexual function. Thus, the procedure is a suitable mini-invasive option for patients who cannot/do not want to take medical therapy or undergo invasive surgical procedures, or want to preserve their sexual function.

An overview of prostate diseases and their characteristics specific to Asian men

In this paper, we reviewed the features of common prostate diseases, such as benign prostatic hyperplasia (BPH), prostate cancer (PCa) and chronic prostatitis (CP) that are specific to Asian men. Compared to the Westerners, Asians exhibit particular characteristics of prostate diseases. Through summarizing the epidemiology, symptomatology, diagnostics and therapeutics of these diseases, we find that Asians have a lower incidence of PCa than whites, but the incidences of BPH and CP are similar. Asian men with CP often suffer from fewer disease sites, but have a higher frequency of pain during urination rather than after sexual climax. Prostate-specific antigen (PSA) is a widely used marker for the diagnosis of PCa in both Asian and Western countries. Although the PSA level may be lower in Asians, the threshold used is based on whites. After reviewing the treatments available for these diseases, we did not find a fundamental difference between Asians and whites. Furthermore, the selection for the most appropriate treatment based on the individual needs of patients remains a challenge to urologists in Asia. After considering the traits of prostate diseases that are specific to Asian men, we hope to pave the way for the development of specific diagnostic and therapeutic strategies targeted specifically to Asian men.

Transurethral ethanol ablation of the prostate for symptomatic benign prostatic hyperplasia: long-term follow-up

BACKGROUND AND PURPOSE

Over the past decade, a variety of new minimally invasive therapies (MIT) have been developed for the treatment of patients with bladder outflow obstruction from benign prostatic hyperplasia (BPH). Transurethral ethanol ablation of the prostate (TEAP) has been introduced as a minimally invasive alternative treatment for patients with BPH. In this study, we present our experience and results of long-term follow-up of 54 months after treatment of symptomatic BPH with TEAP.

PATIENTS AND METHODS

Fifty-six men with symptomatic BPH were enrolled in our study; all patients were medically high-risk patients with multiple comorbidities. Procedures were performed under intravenous sedation combined with local urethral instillation of lidocaine jelly and a transrectal ultrasonography (TRUS)-guided periprostatic block. Dehydrated ethanol in a concentration of 95% to 98% was injected transurethrally by means of the Postaject Ethanol Injection System using a rigid cystoscope.

RESULTS

The following data were collected: International Prostate Symptom Score, prostate-specific antigen level, prostate volume using TRUS, maximum urine flow rate, and postvoid residual. There was sufficient response in 73% of our patients, while the remaining 23% showed an insufficient response and needed alternative treatment.

CONCLUSION

TEAP is an effective minimally invasive treatment option for medically high-risk symptomatic patients with BPH that can be performed as an outpatient procedure under regional anesthesia. The procedure is easy, available, inexpensive, safe, and rapid. Further larger-scale, long-term multi-institutional trials are needed.

Phase 1 and 2 studies demonstrate the safety and efficacy of intraprostatic injection of PRX302 for the targeted treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

BACKGROUND

PRX302 is a prostate specific antigen (PSA)-activated pore-forming protein toxin under development as a targeted approach for improving lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) without affecting sexual function.

OBJECTIVE

To evaluate the safety and efficacy of PRX302 in men with moderate to severe BPH.

DESIGN, SETTING, AND PARTICIPANTS

Eligible subjects were refractory, intolerant, or unwilling to undergo medical therapies for BPH and had International Prostate Symptom Score (IPSS) ≥12, a quality of life (QoL) score ≥3, and prostate volumes between 30 and 80 g. Fifteen patients were enrolled in phase 1 studies, and 18 patients entered phase 2 studies.

INTERVENTIONS

Subjects received intraprostatic injection of PRX302 into the right and left transition zone via a transperineal approach in an office-based setting. Phase 1 subjects received increasing concentrations of PRX302 at a fixed volume; phase 2 subjects received increasing volumes per deposit at a fixed concentration.

MEASUREMENTS

IPSS, QoL, prostate volume, maximum flow rate (Q(max)), International Index of Erectile Function, serum PSA levels, pharmacokinetics, and adverse events were recorded at 30, 60, 90, 180, 270, and 360 d after treatment with PRX302.

RESULTS AND LIMITATIONS

Sixty percent of men in the phase 1 study and 64% of men in the phase 2 study treated with PRX302 had ≥30% improvement compared to baseline in IPSS out to day 360. Patients also experienced improvement in QoL and reduction in prostate volume out to day 360. Patients receiving ≥1 ml of PRX302 per deposit had the best response overall. PRX302 had no deleterious effect on erectile function. Adverse events were mild to moderate and transient in nature. The major study limitation was the small sample size.

CONCLUSIONS

The promising safety profile and evidence of efficacy in the majority of treated subjects in these phase 1 and 2 studies supports further development of PRX302 as a minimally invasive, targeted treatment for BPH.

Medical therapy options for aging men with benign prostatic hyperplasia: focus on alfuzosin 10 mg once daily

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) are common in aging men and can significantly affect quality of life. Men with bothersome LUTS/BPH often present with various other age-related conditions, including sexual dysfunction, heart disease, hypertension, diabetes, and the metabolic syndrome, which can complicate management decisions. Therefore, healthcare providers should be familiar with first-line treatment options for LUTS/BPH and their differing safety profiles, particularly with respect to cardiovascular and sexual function side effects. This article presents a review of first-line medical therapy options for managing aging men with LUTS/BPH and patient considerations when evaluating and selecting these therapies, with a focus on the clinical efficacy and cardiovascular and sexual function safety profiles of the uroselective alpha1-adrenergic receptor antagonist alfuzosin 10 mg once daily. Alfuzosin improves LUTS, peak urinary flow rates, and disease-specific quality of life, reduces the long-term risk of overall BPH progression, and is well tolerated in aging men, with minimal vasodilatory and sexual function side effects, even in those with comorbidities. Alfuzosin is well tolerated when used in combination with antihypertensive medications and phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction. The long-term clinical efficacy and good cardiovascular and sexual function safety profile of alfuzosin can contribute to an improved quality of life for aging men with LUTS/BPH.

Benign prostatic hyperplasia and lower urinary tract symptoms in African Americans and Latinos: treatment in the context of common comorbidities

Benign prostatic hyperplasia (BPH), with accompanying lower urinary tract symptoms (LUTS), is a common age-related condition associated with a variety of cardiovascular, metabolic, and sexual comorbidities. While there is debate, in the United States race and ethnicity, particularly among Latinos and African American men, may confer an elevated risk for BPH and LUTS. Hypertension and deficits in sexual health are more common among African American men, while both Latino and African American men experience more metabolic-related disorders, including diabetes mellitus, insulin resistance, and end-stage renal disease. Although socioeconomic factors may play a significant role in these disparities, pathological and genetic variations between patients of different races and ethnicities are additional factors in the development of BPH. The proliferation of available treatments for BPH demands greater discernment in treatment selection, and comorbidities represent a central criterion upon which choice of appropriate BPH therapy should be based. This article reviews common comorbidities in minority populations, describes challenges to BPH management, and discusses medical, surgical, and phytotherapeutic treatment options.

Probability of finding T1a and T1b (incidental) prostate cancer during TURP has decreased in the PSA era

The purpose of this study is to assess the likelihood of detecting stage T1a and T1b cancer in transurethral prostatectomy specimens during the PSA era. Comparison was made of transurethral resection of prostate (TURP) cohorts in the pre-PSA era (1986-1987) and the PSA era (1994-2000), excluding patients with known PCa. A total of 228 men without a known history of prostate cancer underwent TURP during the pre-PSA era time frame and 501 underwent the procedure during the PSA era time frame. Malignancy diagnosed at the time of TURP decreased from 14.9 to 5.2% of patients in the pre-PSA and PSA eras, respectively. Stage T1a decreased from 4.4 to 2.4% and Stage T1b decreased from 10.5 to 2.8% of patients in the pre-PSA and PSA eras, respectively (P<0.001, Fisher's exact test). Prostate cancer newly identified during TURP has decreased significantly in the era of PSA screening in our study population, with the most significant drop being in clinically significant stage T1b. The decrease in TURP rates reduces the overall incidence of T1a/b cancer but cannot explain the lower risk of detecting previously unsuspected cancer at the time of any given TURP. Identification of many men with occult prostate cancer before TURP through screening and early detection is the most likely cause of this finding. These data suggest that men considering surgical or medical management of benign prostatic hyperplasia may be informed that it should be infrequent that men properly evaluated for prostate cancer will harbor clinically significant undetected malignancy.