Treatment of benign prostatic hyperplasia. A pharmacoeconomic perspective

Is there any effect of alpha-adrenergic blocker usage in preventing febrile urinary tract infections after prostate biopsy?

Purpose: To investigate whether the use of long term alpha-adrenergic blockers before biopsy has an effect on preventing febrile urinary tract infections (FUI) secondary to biopsy in patients undergoing prostate biopsy due to elevated prostate specific antigen (PSA). Material and Methods: The data of 2558 patients who underwent transrectal ultrasonography-guided prostate biopsy (TRUS+BX) due to elevated PSA in our clinic between January 2008 and July 2021 were analyzed retrospectively. The patients were divided into two groups as those who used alpha-blockers for a minimum of three months or longer before biopsy (Group 1) and those who did not use alpha-blockers before applying to the outpatient clinic (Group 2). Demographic data of the groups and post-biopsy FUI development rates were compared. Results: It was observed that 1340 (52.4%) of the patients were using alpha-blockers (Group 1) and 1218 (47.6%) did not (Group 2). The median age of the patients in the pre-biopsy groups was similar [Group 1=68(IQR=9) years and Group 2=68(IQR=9) years, p=0.887]. There was no significant difference between the groups in terms of median prostate volume [Group1=57(31) ml and Group2=58(34)ml, p=0.199]. The median PSA value was found to be significantly higher in Group 1 than in Group 2 [ 10.50(5.40)ng/dl vs 10.35(6.80)ng/dl, p=0.026]. Postvoid residual urine volume (PVR) was found to be significantly higher in Group 2 [Group 1=40(30) ml and Group2=60(90) ml, p

Epidemiology and treatment modalities for the management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting men. BPH can lead to a number of symptoms for patients commonly referred to as lower urinary tract symptoms (LUTS). Over the last decade, increased modifiable risk factors, such as metabolic disease and obesity, have resulted in an increased incidence of BPH. This increasing incidence has brought about a multitude of treatment modalities in the last two decades. With so many treatment modalities available, physicians are tasked with selecting the optimal therapy for their patients. Current therapies can first be divided into medical or surgical intervention. Medical therapy for BPH includes 5-alpha-reductase inhibitors and alpha-blockers, or a combination of both. Surgical interventions include a conventional transurethral resection of the prostate (TURP), as well as newer modalities such as bipolar TURP, holmium laser enucleation of the prostate (HoLEP), Greenlight and thulium laser, and prostatic urethral lift (PUL). Emerging therapies in this field must also be further investigated for safety and efficacy. This narrative review attempts to consolidate current and emerging treatment options for BPH and highlights the need for additional investigation on optimizing treatment selection.

Benign prostatic hyperplasia: An overview of existing treatment

Benign prostatic hyperplasia (BPH) is the most common condition in aging men, associated with lower urinary tract symptoms (LUTS). A better understanding of the prostate physiology, function, and pathogenesis has led to the development of promising agents, useful in the management of LUTS in men. The specific approach used to treat BPH depends upon number of factors like age, prostrate size, weight, prostate-specific antigen level, and severity of the symptoms. 5α-reductase inhibitors decrease the production of dihydrotestosterone within the prostate, which results in decreased prostate volume, increased peak urinary flow rate, improvement of symptoms, decreased risk of acute urinary retention, and need for surgical intervention. α(1)-adrenergic receptor (α(1)-AR) antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Clinical efficacy of either 5α-reductase inhibitor or α(1)-AR antagonist has been further improved by using combination therapy; however, long-term outcomes are still awaited. Many more potential new therapies are under development that may improve the treatment of BPH. This article gives a brief account of rationale and efficacy of different treatment options presently available in the management of BPH.

Benign Prostatic Hyperplasia: Cost and Effectiveness of Three Alternative Surgical Treatment Methods Used in a Turkish Hospital

The purpose of this study was to compare three alternative surgical therapies for Benign prostatic hyperplasia (BPH) in terms of their cost and effectiveness in a general hospital setting in Turkey. BPH is an important potential burden on health care resources in developing countries like Turkey, not only because of the increasing incidence of the disease, but also because of the differences in cost and effectiveness that exist among the various available treatment technologies. In this study, three alternative surgical treatments for BPH, namely open prostatectomy, transurethral resection of the prostate (TURP), and laser prostatectomy were compared in terms of their cost and effectiveness. Effectiveness was measured through the use of the International Prostate Symptom Score (IPSS) before the operation and at 3 months after. Laser prostatectomy was found to be the most costly and least effective way of treating BPH. This conclusion was valid both in terms of cost per prostate symptom score and cost per improvement of quality of life index. This study shows how a rough estimate can be made of the potential burdens that alternative treatment methods would impose on a country's health budget.

The cost of feedback microwave thermotherapy compared with transurethral resection of the prostate for treating benign prostatic hyperplasia

OBJECTIVE

To compare the efficacy of a new microwave thermotherapy for treating benign prostatic hyperplasia (BPH), the ProstaLund Feedback Treatment (PLFT, ProstaLund Operations AB, Lund, Sweden) and transurethral resection of the prostate (TURP) in a clinical trial to their effectiveness in clinical practice over 1 year, to estimate their cost over 1 year, and to evaluate the cost of re-interventions over a longer period (2-3 years).

PATIENTS AND METHODS

In a large randomized international 1-year clinical trial PLFT was as effective as TURP in improving symptoms of BPH and urinary flow. Because PLFT is an outpatient procedure it was less costly than TURP. However, the cost-effectiveness of the new procedure depends on its long-term effectiveness in clinical practice. All 146 patients in the randomized clinical trial were included in the present analysis. The outcome was based on the International Prostate Symptom Score (IPSS) and the bother score, and costs were estimated from treatment-related adverse events and hospitalization. To validate the estimates based on the clinical trial 1-year data on effectiveness and complete resource use in clinical practice were collected in a retrospective observational study from hospital charts and patient questionnaires of 88 patients who had undergone either TURP or PLFT. To assess the number of re-interventions after TURP after the first year information was obtained from hospital and surgical procedure data in the Swedish inpatient registry. The 3-year data for a total of 52,010 patients who had an index hospitalization for TURP between 1990 and 1995 were available for the analysis. The estimate of long-term consequences of PLFT was based on complication and re-intervention data for 87 patients who had undergone PLFT between 1997 and 1999.

RESULTS

The mean 1-year costs in the clinical trial were estimated at [symbol: see text] 1763 for PLFT and [symbol: see text] 3209 for TURP. When all treatment-related resource use in clinical practice for 88 patients was included the costs were estimated at [symbol: see text] 1924 and [symbol: see text] 3264 for PLFT and TURP, respectively. The IPSS and bother scores were not significantly different between the groups in both datasets. Using the registry data the cost of TURP including re-interventions (TURP and bladder neck incisions) was estimated at [symbol: see text] 3159 over 2 years and [symbol: see text] 3185 over 3 years; the respective costs for PLFT were [symbol: see text] 2121 and at [symbol: see text] 2151.

CONCLUSIONS

In the 1-year clinical trial PLFT was as effective but less costly than TURP, but long-term data are still lacking. However, the preliminary analysis over 3 years indicates that the average cost of the procedure remains lower than the total cost of TURP for the same period.

Dutasteride

Dutasteride, a potent inhibitor of type 1 and 2 5alpha-reductase, reduced dihydrotestosterone levels by >90% in 85% of patients following 1 years' administration of oral dutasteride 0.5 mg/day. A combined analysis of three placebo-controlled clinical studies conducted in patients with benign prostatic hyperplasia (BPH) found sustained improvements in American Urological Association- Symptom Index scores and urinary flow rate and a 57% decrease in the risk of acute urinary retention throughout the 2-year treatment period (all p < 0.001 vs placebo). Total prostate and transition zone volume were also reduced (both p < 0.001), as was the risk of BPH-related surgery (by 48%). A nonblind extension study found that dutasteride maintains efficacy for up to 4 years. Dutasteride monotherapy maintained symptom relief following combination treatment with dutasteride and tamsulosin in all patients but those with severe symptoms. Dutasteride was generally well tolerated. Impotence, reduced libido, gynaecomastia and ejaculation disorder occurred significantly more often in dutasteride than placebo recipients, but incidence was generally low. With the exception of gynaecomastia, incidence consistently decreased over time.

[Cost-effectiveness analysis of the treatment of moderate benign prostatic hyperplasia]

OBJECTIVES

To estimate the most cost-effective alternative of treatment of moderate benign prostatic hyperplasia and to learn whether the outcome can be varied by changing the cost or effectiveness of the alternatives.

DESIGN

The study is made by a decision tree in order to test the cost-effectiveness (CE) rate of three treatment strategies: a) watchful waiting; if there is no response a drug is administered and if there is no response transurethral resection of the prostate (TURP) is done, b) pharmacological treatment, and if there is no response TURP is done, and c) to apply TURP initially. The treatment is simulated taking 1000 patients with MBPH and testing the outcome of events and probabilities in a two-year treatment and from the point of view of the health system as services supplier.

MEASUREMENTS AND RESULTS

Effectiveness is obtained from an american experts' consensus. Only the direct fangible costs are taken into account, in constant 1998 pts. An univariant simple sensitivity analysis is made considering the cost variables of TURP and from the drugs in an acceptable range of +/- 20%, and the effectiveness of the watchful waiting and the pharmacological treatment. The lower cost alternative per improved patient (IP) is the watchful waiting (77,069 pts./IP) followed by the drug treatment (118,656 pts./IP) and lastly the TURP (456,642 pts./IP). Variations in the variable values make no difference in the relative positions of the tested alternatives.

CONCLUSIONS

From the pharmacoeconomics point of view the MBPH treatment must be iniciated by watchful waiting, proceeding to drug administration only if there is a positive response and to make use of TURP when the pharmacological procedures have not been effective.