Management of benign prostatic hyperplasia by the primary care physician in the 21st century: the new paradigm

Benign prostatic hyperplasia (BPH) is one of the commonest causes of lower urinary tract symptoms (LUTS) in men over age 50. Fifty percent of men over age 50 will require some type of management for BPH/LUTS symptoms. Until about 15 years ago, the most common management for BPH was a transurethral resection of the prostate (TURP) operation. Initially, once a diagnosis of BPH has been made, most men are treated medically. One must first rule out other serious causes of these symptoms, such as prostate cancer, bladder cancer, and other obstructions. For men with an enlarged prostate, there is a good chance that therapy with a 5-alpha-reductase inhibitor (5-ARI) can prevent disease progression and the need for surgery. There has been a lot of recent work on different combination therapies for the treatment of BPH/LUTS. If a patient's serum prostate-specific antigen (PSA) level is greater than 1.5 ng/ml and his prostate volume is greater than 30 cc and he has significant LUTS, then combination medical therapy of an alpha blocker with a 5-ARI is the most effective therapy. After a careful workup, it is quite reasonable and appropriate for the primary care physician to initiate this therapy for a patient with BPH/LUTS.     

Medical management of benign prostatic hypertrophy

Benign prostatic hyperplasia (BPH) is a common condition of the aging male. The bladder outlet obstruction caused by this condition occurs despite variations in prostate size. Symptoms of BPH include the irritative and obstructive voiding symptoms termed lower urinary tract symptoms (LUTS). While transurethral surgery has long been the gold standard for treatment of LUTS, medical treatment has emerged as the first line of treatment for those men who fail expectant or watchful waiting treatment. Medical options include: alpha blockers, 5alpha-reductase inhibitors and newly identified PDE 5 inhibitors, drugs for erectile dysfunction that have a relieving effect on the symptoms of LUTS. Newer prostate selective alpha blockers have replaced older nonselective agents as first choice in treatment of most men, especially those with smaller prostates and in whom preservation of sexual function is important. While tamsulosin has the effect of an ejaculation, alfuzosin preserves ejaculatory function. 5alpha-reductase inhibitors may decrease ejaculate volume, libido and sexual function. While this effect is frequently a self limited, it can be a compliance issue for many men. PDE 5 inhibitors, while effective in relieving LUTS symptoms, have not shown effectiveness in reducing post void residual volumes or increasing urinary flow rates.     

Prostate Artery Embolization: Current Status 2018

Purpose of Review

Prostate artery embolization (PAE) is a promising new treatment option for men with symptomatic benign prostatic hyperplasia (BPH). Our goal is to review the data on PAE with regard to outcomes, risks versus benefits, and safety.

Recent Findings

Current data suggests that PAE is safe and effective for men with symptomatic BPH. The two most robust randomized controlled trials comparing PAE with TURP both found comparable short-term results with regard to improvements in symptoms. However, the side effects of PAE were higher than those of TURP. There remain ongoing randomized controlled trials comparing the two modalities of treatment.

Summary

Though the largest randomized controlled trials comparing these two modalities of treatment of BPH are still underway, current data suggest PAE may be a promising, safe, and effective treatment option for men with symptomatic BPH. Additionally, PAE can be safely performed on larger prostates of any size and is generally performed via a single, femoral artery puncture under local anesthesia. Therefore, it is particularly appealing for patients with prostate glands >?80 g and who are poor candidates for general anesthesia.

     

超选择前列腺动脉栓塞联合经尿道前列腺切除术治疗体积>80 mL良性前列腺增生的临床疗效

目的比较超选择前列腺动脉栓塞(PAE)+经尿道前列腺切除术(TURP)与单纯TURP方案治疗前列腺体积>80 mL良性前列腺增生的疗效及安全性。方法回顾性分析我院2016年1月至2019年1月收治的84例体积>80 mL良性前列腺增生病人的临床资料,其中行单纯TURP治疗者44例为对照组,行超选择PAE+TURP治疗者40例为观察组。比较2组手术时间、切除病变组织重量和速率、膀胱持续冲洗时间、尿管留置时间、手术前后国际前列腺症状评分(IPSS)、生活质量(QOL)评分、最大尿流率(Qmax)、残余尿量(PVR)及术后并发症发生率。结果观察组手术时间、膀胱持续冲洗时间及尿管留置时间均显著少于对照组(P<0.05),切除病变组织重量和速率均显著高于对照组(P<0.05)。2组术后IPSS评分、QOL评分、Qmax及PVR水平差异均无统计学意义(P>0.05);观察组术后并发症发生率显著低于对照组(P<0.05)。结论对于体积>80 mL良性前列腺增生病人,超选择PAE+TURP方案较单纯TURP方案能够有效缩短手术时间,提高组织切除效率,加快术后康复进程,缓解临床症状,改善膀胱功能和生活质量,并有助于降低术后并发症发生风险。     

Minimally invasive techniques for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: An update

Benign prostatic hyperplasia (BPH) primarily affects middle-aged and elderly men. Consequently, medical and surgical treatments for this condition are some of the most common therapies administered in medical practice. Many minimally invasive techniques for the treatment of BPH have been introduced over the past several years to achieve comparable efficacy without the morbidity and mortality associated with transurethral resection of the prostate (TURP), the current gold standard for the surgical management of BPH. Many procedures have not sustained satisfactory results over time, whereas others have been reported as possible alternatives, in selected cases, to TURP. It may not be a simple question of comparative efficacy with TURP for these less invasive treatments, but rather a question of whether lower complication and side-effect rates are a suitable tradeoff for somewhat reduced symptom relief and possibly a need for future retreatment. This article reviews current minimally invasive therapies, addressing methods of tissue ablation, short-and long-term results, and comparisons with TURP.     

The Management of Acute Urinary Retention: Treating the Curse of the Aging Male

Acute urinary retention (AUR) is a common urological emergency usually associated with bladder outlet obstruction due to benign prostatic hyperplasia (BPH). BPH becomes increasingly prevalent in an aging population with 80 to 90 % of men in their eighth decade of life having histological evidence of BPH in post-mortem studies. A review of the literature to date has been performed to make recommendations on the best management of AUR associated with BPH. Urethral or suprapubic catheterisation followed by medical therapy with an alpha-blocker prior to a trial of voiding is currently the mainstay of treatment in men presenting with a first episode of painful retention secondary to BPH. A selective alpha 1 blocker should be started as soon as possible after catheterisation with a trial of voiding attempted after a minimum of 48 hours treatment. At presentation with AUR consideration should be given to starting a 5-alpha reductase inhibitor, in men with a prostate >40 g or PSA >1.4 ug/l to reduce the risk of disease progression. In patients unlikely to pass a trial of voiding such as those with a high retention volume (approximately >1000 ml) consideration should be given to urgent surgery. Definitive surgical treatment involves bladder outlet surgery, if necessary, in the form of a prostatectomy, with the gold standard currently being a transurethral resection of the prostate (TURP) and should best be attempted as soon as possible out with the emergency setting and preferably without a catheter.     

Contemporary Combination Therapy in the Treatment of LUTS/BPH

The primary treatment of lower urinary tract symptoms thought to be associated with histological benign prostatic hyperplasia causing bladder outflow obstruction (LUTS/BPH) has evolved from an emphasis on surgical through to medical therapies. More recently there has been an increasing trend toward developing combination pharmacotherapy utilizing agents with differing mechanism of action aimed at the various pathophysiolgies potentially underpinning voiding and storage symptoms. The focus has been on clinical benefit such as reducing disease progression, acute urinary retention and need for BPH surgery in the case of alpha-blockers (AB) and 5-alpha-reductase inhibitor combination. This effect appears to be appropriate in the subset of men with larger prostates. Anti-muscarinics with AB is safe and effective treatment in those with bothersome storage symptoms and LUTS/BPH, although only confirmed as not associated with retention based on the existing literature for men with low PVR’s </=200 ml. Further studies with longer follow up are needed to establish long-term efficacy and safety of this combination. Phosphodiesterase inhibitors with AB is an emerging combination that has demonstrated considerable improvement in IPSS and in some cases flow rates in the small number of randomized studies conducted, confirmed by a recent meta-analysis. The major challenge in the future will be determining which specific groups of men are most likely to benefit from which combination therapies whilst considering cost implications and the potential for increased side effects consequent upon using two therapeutic classes in combination.     

Management of benign prostatic hyperplasia. Alternatives to standard therapy.

Benign prostatic hyperplasia is a significant cause of morbidity in the elderly male population. The standard therapy for symptomatic prostatic obstruction has been prostatectomy by transurethral resection (TURP) or, less frequently, by open surgery. Innovative alternative treatments of benign prostatic hyperplasia, both surgical and nonsurgical, will be discussed. Additionally, an appraisal of TURP will be made.     

经尿道前列腺电切术与2μm（铥）激光前列腺汽化切除术并发症的比较

目的比较分析经尿道前列腺电切术（TURP）与2μm（铥）激光前列腺汽化切除术（TmLRP）的并发症。方法分别用TURP及TmLRP治疗良性前列腺增生症（BPH）患者114例（TURP组）和82例（TmLRP组）。两组患者年龄、前列腺体积差异无统计学意义（均P＞0.05）。比较分析采用两种术式发生术中电切综合征、包膜破裂及术后严重膀胱痉挛、急性附睾炎、尿失禁、勃起功能障碍等并发症情况。结果 TmLRP组术中发生电切综合征、包膜破裂等并发症明显少于TURP组（P＜0.05）。术后1周内,TmLRP组发生严重膀胱痉挛、急性附睾炎并发症明显少于TURP组（P＜0.05）;术后1周～1个月内,TmLRP组发生术后继发性出血、严重膀胱刺激征、腺体残留导致排尿困难并发症明显少于TURP组（P＜0.05）;术后1～3个月内,TmLRP组发生尿失禁明显少于TURP组（P＜0.05）;术后3～6个月内,TmLRP组发生勃起功能障碍明显少于TURP组（P＜0.05）。结论 TmLRP组术中及术后并发症明显少于TURP组,是一种安全有效的手术方式。     

How do transurethral needle ablation of the prostate and transurethral microwave thermotherapy compare with transurethral prostatectomy?

Throughout the past decade, several minimally invasive therapies for benign prostatic hyperplasia (BPH) have emerged to challenge transurethral prostatectomy (TURP) in efficacy and safety. This review compares high- and lowenergy transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA) of the prostate with TURP in clinical efficacy and safety. In reducing BPH symptoms, TUNA and TUMT are, at best, equal to TURP. However, the effects of TUMT and TUNA on objective measures of obstructive uropathy are minimal and less durable compared with TURP. The sole determinant of when and how to treat a patient with BPH is not solely a therapy’s clinical effectiveness. Other multiple factors must be considered, including safety, adverse effects, sexual function, and cost. The role of TUNA and TUMT lies in offering a cost-effective alternative for achieving substantial improvement in quality of life at an acceptable risk level for treatment-associated complications.     

Holmium Laser Approaches to Symptomatic Benign Prostatic Hyperplasia

The holmium laser is a well-established instrument in the treatment of a variety of urologic conditions. Treatment of benign prostatic hyperplasia (BPH) with the holmium laser has grown steadily over the past decade, with multiple studies demonstrating its role as an effective alternative to other transurethral and open surgical treatments of BPH. This review describes current surgical techniques that employ the holmium laser and surveys recent literature comparing holmium-based treatments with traditional transurethral techniques, with particular attention paid to holmium laser enucleation of the prostate. Recent studies continue to support the short- and long-term efficacy of holmium laser enucleation of the prostate and other holmium-based treatments, providing evidence for the laser’s growing use in the treatment of benign obstruction. Transurethral surgery with the holmium laser endures as an effectual treatment for BPH that offers excellent, lasting functional outcomes with favorable short- and long-term morbidity when compared with conventional transurethral techniques.     

PDE5-Is for the Treatment of Concomitant ED and LUTS/BPH

Epidemiologic data in adult men exhibit a strong relationship between erectile dysfunction (ED) and lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), indicating that men affected by ED should also be investigated for LUTS/BPH and those presenting with storage or voiding LUTS should be investigated for co-morbid ED. Common pathophysiolgical mechanisms underlying both LUTS/BPH and ED, including alteration of NO/cGMP or RhoA/Rho-kinase signaling and/or vascular or neurogenic dysfunction, are potential targets for proposed phosphodiesterase type 5 inhibitors (PDE5-Is). Several randomized controlled trials and only a few reviews including all commercially available PDE5-Is demonstrated the safety and efficacy of these drugs in the improvement of erectile function and urinary symptoms, in patients affected either by ED, LUTS, or both conditions.     

GreenLight 180W XPS photovaporization of the prostate: how I do it

Transurethral resection of the prostate (TURP) is the most common surgical intervention for benign prostatic hyperplasia (BPH), largely due to lower urinary tract symptoms refractory to medical therapy. TURP remains the gold standard for men with prostates sized 30g-80g, while open prostatectomy has been the preferred option for men with glands larger than 80g-100 g and those with other lower urinary tract anomalies such as large bladder stones or bladder diverticula. Unfortunately, these procedures have complications including bleeding (often requiring transfusion in 7%-13% of cases), electrolyte abnormalities (2% TURP syndrome), erectile dysfunction (6%-10%), and retrograde ejaculation (50%-75%). The overall incidence of a second intervention (repeat TURP, urethrotomy and bladder neck incision) has been reported in 12% and 15% of men at 5 and 10 years following TURP. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm-Greenlight). Photoselective vaporization of the prostate (PVP), initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system (American Medical Systems, Minnetonka, Minnesota, USA), has been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser's frequency, and resulting in a green light. Outcomes have demonstrated a reduced frequency and severity of clinical complications, however it was limited to smaller prostate sizes. In 2006, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced. This laser utilizes a diode pumped Nd:YAG laser light that is emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system. The HPS offered an 88% more collimated beam and smaller spot size, resulting in much higher irradiance or power density in its 2 predecessors (60W and 80W) with a beam divergence of 8 versus 15 degrees. The primary aim for this upgrade was to reduce lasing time and improve clinical outcomes while demonstrating the same degree of safety for patients. Limitations of the 120W system included treatment of large prostates greater than 80g-100g and increased cost related to fiber devitrification and fracture. In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. Internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback), better preserve the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with the opportunity to perform a more complete and rapid procedure. Published clinical data with the XPS is unfortunately lacking. The objective of this report is to detail our approach and technique for GreenLight XPS drawing on personal experience with both enucleation and vaporization techniques with various laser technologies along with having performed over 500 GreenLight HPS and 100 XPS procedures. In this regard, recommendations for training are also made, which relate to existing users of the 80W and 120W GreenLight laser as well as to new laser users.     

Surgical Treatment of BPH: Technique and Results

In the past decade, there have been significant changes in the available treatment options for lower urinary tract symptoms secondary to benign prostatic enlargement. New forms of medical and minimally invasive treatments have been introduced, while other therapies have become obsolete and well-established surgical treatments are being reassessed. Standard surgical options include: transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy (adenoma enucleation through a suprapubic transvesical or a retropubic approach) and a discussion of these treatment options is provided in this article. These techniques can still be considered the surgical standard for their respective indications to which other therapies should be compared. The rate of complication is low and the clinical outcome due to removal of the obstruction is excellent and durable over time.     

Long-term treatment outcomes of coretherm microwave feedback thermotherapy

The gold standard for definitive management of symptomatic benign prostatic hypertrophy is transurethral resection of the prostate (TURP). Despite its efficacy, TURP has significant morbidity/mortality concerns such as hemorrhage and transurethral resection syndrome. This is especially worrisome for the medically high-risk patient, but the high rates of retrograde ejaculation found with TURP also pose a problem for young patients. A minimally invasive, outpatient alternative to TURP that has long-term efficacy, low morbidity/mortality, and provides a cost-effective advantage is in high demand. This review article discusses microwave thermotherapy as such an option and reports the long-term experience with the CoreTherm (CoreTherm Operations AB, Sweden) device.     

绿激光治疗前列腺增生症并发心力衰竭患者的临床疗效

目的 评价经尿道选择性绿激光汽化术治疗前列腺增生症并发心力衰竭患者的临床疗效。方法 选择60例前列腺增生并发心衰患者随机分组,30例接受选择性绿激光前列腺汽化术(绿激光组),30例接受经尿道前列腺切除术(TURP组)。结果 两组均取得良好疗效,但绿激光组在出血情况、膀胱灌洗液用量、拔管时间、住院时间等方面均优于TURP组。结论 绿激光是治疗前列腺增生症并发心力衰竭的较好方法。     

Incidence,Predictors, and Associated Outcomes of Prostatism after Kidney Transplantation

Background and objectives: Renal transplantation is increasingly performed in elderly patients, and the incidence of benign prostatic hyperplasia (BPH) increases with age. Anuric males on dialysis may have occult BPH and not develop obstructive symptoms until urine flow is restored after transplantation. If left untreated, BPH poses a risk for numerous complications, including acute urinary retention (AUR), recurrent urinary tract infections (UTI), and renal failure. The authors hypothesized that incident BPH after renal transplantation would adversely affect allograft survival.Design, setting, participants, & measurements: Medicare claims for BPH, AUR, UTI, and prostate resection procedures (transurethral resection of the prostate; TURP) were assessed in a retrospective cohort of 23,622 adult male Medicare primary renal transplant recipients in the United States Renal Data System database who received transplants from 1 January 2000 to 31 July 2005 and followed through 31 December 2005.Results: The 3-yr incidence of BPH post-transplant was 9.7%. The incidences of AUR, UTI, and TURP after BPH diagnosis (up to 3 yr posttransplant) were 10.3%, 6.5%, and 7.3% respectively, and each was significantly associated with BPH. Cox regression analysis showed that recipient age per year, later year of transplant, and dialysis vintage were associated with incident BPH. Using Cox nonproportional hazards regression, BPH was significantly associated with renal allograft loss (including death).Conclusions: BPH is common in males after renal transplant and is independently associated with AUR, UTI, and graft loss. It is unknown whether treatment of BPH, either medical or surgical, attenuates these risks.Renal transplantation is increasingly performed in elderly patients. According to the 2006 United States Renal Data System (USRDS) Annual Report, the proportion of renal transplant recipients over age 60 increased from 10.4% in 1994 to 20.7% in 2004 (1). The incidence of benign prostatic hyperplasia (BPH) increases with age, and more than 50% of men have histologic evidence of BPH by age 60 (2). Older males on dialysis may be oliguric/anuric and not have lower urinary tract symptoms (LUTS); thus, BPH may be occult and underdiagnosed in this population. Some cases of urinary obstruction are detected by pretransplant urologic screening, but many do not develop LUTS until urine flow is restored after transplantation.There are several reports of bladder outlet obstruction from posttransplant BPH, and many of these patients eventually required surgical procedures such as transurethral resection of the prostate (TURP) to alleviate urinary obstruction (3,4,5,6,7). Because BPH may accelerate the progression of renal disease in other processes (8), we hypothesized that incident BPH diagnosed after renal transplantation would adversely affect renal allograft survival. To date, there are no studies on the epidemiology of BPH and its complications after renal transplantation.     

Statin Medications and Development and Progression of Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are common among aging men and impact quality of life. Recently, there has been an interest in alternative mechanisms of BPH and LUTS, specifically the role of chronic prostatic inflammation. Statin medications, known for their cholesterol-lowering properties, also possess certain anti-inflammatory effects, which may be of interest in the treatment and/or prevention of BPH and LUTS. Prior studies of statins have yielded conflicting results. These were limited by cross-sectional designs or limited follow-up, small sample sizes, and inability to control for confounding. One prior randomized control trial found no difference between atorvastatin vs. placebo in the treatment of BPH and LUTS after 6 months. Additional randomized trials with longer follow-up time evaluating the impact of statins on incident BPH and LUTS are required to assess the therapeutic potential of statins and develop a better understanding of alternative mechanisms for BPH and LUTS.     

Value of transurethral resection of the prostate (TURP) for treatment of symptomatic benign prostatic obstruction (BPO): an analysis of efficiency and complications in 1015 cases

1015 patients with benign prostatic hyperplasia who underwent transurethral resection (TURP) within the last seven years were analysed concerning indication, complications and results by evaluation of quality. The actual value of TURP should also be compared with that of alternative procedures of treatment. The transfusion rate (0.69 %), TUR syndrome (0.78 %) and the urinary infection rate (1.1 %) are all very low. In 4.7 % a re-operation was necessary, mostly due to significant haematuria. The mortality rate perioperatively was 0.1 %. With regard to the voiding outcome, the uroflow relatively improved in 131 % and post-void residual urine diminished in 81 %. The low rate of complications, high efficiency and satisfaction of the patients are of importance also for the evaluation of alternative procedures. At the present time these modes of treatment do not have the potential to substitute for TURP.