The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group

Serum prostate specific antigen is a strong predictor of future prostate growth in men with benign prostatic hyperplasia. PROSCAR long-term efficacy and safety study

PURPOSE

We analyze patterns of prostate growth in men diagnosed with benign prostatic hyperplasia (BPH) and treated with placebo during 4 years, and determine which baseline parameters were the strongest predictors of growth.

MATERIALS AND METHODS

A total of 3,040 men were enrolled in the 4-year randomized, placebo controlled Proscar Long-Term Efficacy and Safety study. Of these men a subgroup of 10% underwent pelvic magnetic resonance imaging prostate volume measurement at baseline and yearly thereafter. Absolute and percent volume changes during 4 years were calculated in the 164 placebo treated men in the subgroup. The ability of age, baseline prostate volume and prostate specific antigen (PSA) to predict prostate growth in placebo treated patients was assessed by multiple linear regression analyses, receiver operator characteristics curves, and evaluations of growth stratified by tertiles of baseline serum PSA and decades of life.

RESULTS

In placebo treated patients a steady increase in mean plus or minus standard deviation prostate volume from year to year was noted (2.5+/-6.1, 4.9+/-6.8, 6.4+/-8.5 and 7.2+/-8.8 ml. at years 1, 2, 3 and 4, respectively). Mean volume changes at 4 years ranged from -9 to +30 ml. Mean percent change from baseline ranged from 12.5% to 16.6% for men 50 to 59 years old to those 70 to 79 years old. Baseline serum PSA was a strong predictor of growth with 7.4% to 22.0% change at 4 years from the lowest to highest PSA tertiles. Annualized growth rates from baseline were 0.7 ml. per year for PSA 0.2 to 1.3, 2.1 for PSA 1.4 to 3.2 and 3.3 for PSA 3.3 to 9.9 ng./ml. Multiple linear regression analysis showed that serum PSA was a stronger predictor of prostate growth than age or baseline prostate volume. All but 1 man with baseline serum PSA greater than 2.0 ng./ml. had prostate growth during 4 years, and 32.6% of men with serum PSA less than 2.0 exhibited a decrease in volume.

CONCLUSIONS

Serum PSA is a stronger predictor of growth of the prostate in placebo treated patients than age or baseline prostate volume. Since prostate volume is a risk factor for acute urinary retention and the need for BPH related surgery, the ability of PSA to predict prostate growth may be an important factor when considering individual treatment options for BPH. Such use of PSA represents a shift in paradigm away from focusing solely on symptoms of BPH toward a more comprehensive approach with consideration of predicting and preventing risk factors of BPH related outcomes.

Finasteride in the treatment of benign prostatic hypertrophy: an update. New indications for finasteride therapy

A phenomenon of the prostate gland, which is also shared by hair follicles, is that it is little influenced by testosterone (T) for androgenic stimulation, but instead by its metabolite 5alpha-dihydrotestosterone (DHT). By blocking the conversion of T to DHT, the circulating level of DHT is reduced by 80%, the size of the prostate gland is reduced by about 20% and the level of prostate-specific antigen (PSA) by about 50%. Treatment of patients with obstructive benign prostatic hypertrophy (BPH) with the drug Finasteride leads to a moderately improved urinary flow, symptomatic improvement and halts the natural progress of the disease. Since DHT potentiates the effect of testosterone on erectile function, the side-effects are impotence in 3% of patients, decreased ejaculatory volume, and gynaecomastia in 0.4% of patients. The drug could be regarded as a safe way to treat moderately symptomatic BPH. The efficacy of the drug is long-lasting (more than 7 years). It has also been tried in prostate cancer, but is less effective. It reduces PSA levels by 50% and, in combination therapy, therefore, PSA levels remain low for longer when Finasteride is added. An important finding is the efficacy of Finasteride treatment in haematuria from BPH. The drug interacts with vascular endothelium growth factor and efficiently prevents new bleeding. It could be regarded as a first-line therapy for this type of haematuria. Finasteride can also be used to stop male baldness. It seems particularly effective in men aged 20-40 years; 85% of patients stopped losing hair when given Finasteride. When the treatment was stopped hair loss continued, thus therapy may have to be "lifelong".

Common urologic problems in the elderly. Prostate cancer, outlet obstruction, and incontinence require special management

Urologic problems in elderly patients often require special management that considers life expectancy, general health, and the clinical significance of the disorder. For men with prostate carcinoma or outlet obstruction, new therapies have proliferated in the last 10 years. For elderly women with incontinence, an orderly evaluation process usually results in directed and effective treatment. Finally, long-term use of Foley catheters requires careful attention to detail so that serious problems can be avoided.

[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.

A pilot study of a bioabsorbable self-reinforced poly L-lactic acid urethral stent combined with finasteride in the treatment of acute urinary retention from benign prostatic enlargement

OBJECTIVE

To assess whether patients with acute urinary retention from benign prostatic enlargement can be treated with a combined therapy comprising a bioabsorbable self-reinforced poly L-lactic acid (SR-PLLA) urethral stent and finasteride.

PATIENTS AND METHODS

Eleven men in acute urinary retention were treated as outpatients; they had a suprapubic catheter inserted and the SR-PLLA stent placed cystoscopically. The patients were allowed to attempt to void spontaneously after 2 days.

RESULTS

All patients started to void spontaneously within 2 weeks. There was a steady improvement in urinary flow rates up to 9 months, followed by a slight impairment after the bioabsorption of the stent. During the mean (range) follow-up of 24 (23-26) months only three patients required surgical treatment.

CONCLUSION

The bioabsorbable SR-PLLA stent combined with finasteride therapy provides a promising new alternative in the treatment of acute urinary retention, especially in patients unfit for surgical therapy. Larger, placebo-controlled studies are needed to establish the efficacy of this combined therapy.

Benign prostatic hyperplasia and erectile dysfunction--is there a link?

There is little evidence to support a link between benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). Any apparent relationship may reflect the fact that both are common conditions with a similar gender and age distribution. However, the surgical treatment of BPH (e.g. TURP or open prostatectomy) may cause ED as a postoperative complication in some patients. Similarly, the medical treatment of BPH with finasteride may be associated with ED (< 5% in one study). However, alpha-blockade is not associated with this side-effect.

Correlates of urinary symptom scores in men

OBJECTIVES

This study determined the prevalence of urinary symptoms and their relationship to characteristics of a cohort of men in Beaver Dam, Wis, from 1993 to 1995.

METHODS

A standardized questionnaire concerning urinary symptoms (the American Urological Association Urinary Symptom Questionnaire) was administered.

RESULTS

All outcomes were associated with age and history of enlarged prostate. Urinary frequency (57%) and nocturia (65%) were the most common individual symptoms. Diuretic usage, diabetes, history of cardiovascular disease, and smoking were related to specific symptoms.

CONCLUSIONS

While urinary symptoms are associated with age and history of enlarged prostate, symptoms may also be attributable to other diseases and exposures.

Effect of finasteride on bother and other health-related quality of life aspects associated with benign prostatic hyperplasia. PLESS Study Group. Proscar Long-term Efficacy and Safety Study

OBJECTIVES

To investigate the long-term effects of finasteride on bother and health-related quality of life (HRQOL) in men with symptomatic benign prostatic hyperplasia.

METHODS

A large prospective 4-year placebo-controlled trial (PLESS) of 3040 men with moderate to severe lower urinary tract symptoms and an enlarged prostate was performed that included self-administered questionnaires assessing HRQOL.

RESULTS

Significantly greater reductions in bother score were seen for finasteride compared with placebo at every time point after 4 months. Analysis of bother scores by baseline serum prostate-specific antigen (PSA), as it is highly correlated with prostate volume, suggested greater differences from placebo for men with PSA 1.4 ng/mL or greater, primarily due to worsening after the first-year improvement in the placebo group. An activity interference domain score was significantly improved for finasteride over placebo at each time point (P<0.01), with greater treatment differences in men with higher baseline PSA levels. Comparable results were seen for worry at each time point and embarrassment due to urinary symptoms in the last 2 years of the trial. Mean changes in sexual interest and satisfaction were somewhat better for the placebo group overall, as has been previously reported, but little difference between treatments was found in sexual satisfaction measures for men with PSA 1.4 ng/mL or greater.

CONCLUSIONS

Compared with placebo, men receiving finasteride had significantly less bother, activity interference, and worry due to urinary symptoms, with more pronounced differences for men with baseline PSA 1.4 ng/mL or greater. As expected, sexual satisfaction and sexual drive were slightly worse for finasteride overall, but little difference in sexual satisfaction measures was found for men with a higher baseline PSA. Thus, HRQOL was improved for finasteride compared with placebo, especially for men with a baseline PSA 1.4 ng/mL or greater.

Prostate disease: an overview

Diseases of the prostate remain the Cinderella of medical practice in the UK as we approach the third millennium. Despite their high prevalence, disproportionately low levels of resources are provided to investigate, treat or promote research into this important cause of morbidity and mortality in men.

Serum prostate-specific antigen and prostate volume predict long-term changes in symptoms and flow rate: results of a four-year, randomized trial comparing finasteride versus placebo. PLESS Study Group

OBJECTIVES

To determine whether baseline prostate-specific antigen (PSA), in addition to prostate volume, is associated with long-term changes in symptoms and urinary flow rate.

METHODS

Three thousand forty men with benign prostatic hyperplasia enrolled in the PLESS trial were randomly assigned to finasteride 5 mg or placebo for 4 years. Symptoms and flow rate were assessed every 4 months, and data were analyzed by dividing the patients into three groups by baseline PSA tertiles (0 to 1.3, 1.4 to 3.2, and 3.3 ng/mL or greater) and baseline prostate volume tertiles (14 to 41, 42 to 57, and 58 to 1 50 mL).

RESULTS

After the initial placebo effect, a slow deterioration in symptoms over time was observed in the placebo-treated men with a baseline PSA 1.4 ng/mL or greater. However, placebo-treated men in the lowest PSA tertile (less than 1.4 ng/mL) had sustained symptomatic improvement that was not seen in placebo-treated men in the higher tertiles (P<0.001). In all finasteride-treated groups, there was initial improvement followed by maintenance or continued symptom improvement over time (approximately 3 to 3.5 points by the end of 4 years). The differences in symptom score improvement between placebo and finasteride were marginal for men with baseline PSA levels less than 1.4 ng/mL (P = 0.128) but were highly significant for men with PSA levels 1.4 ng/mL or greater (P<0.001). Urinary flow rate results were similar to those observed for symptoms. Analysis of symptom and flow rate data by prostate volume tertiles in a 10% subset of men yielded similar results, namely a deterioration of symptoms and flow rate in the two higher tertiles treated with placebo (greater than 41 mL) and a sustained improvement in all three groups of finasteride-treated patients.

CONCLUSIONS

Baseline PSA and prostate volume are good predictors of long-term symptomatic and flow rate changes. Baseline PSA levels of 1.4 ng/mL or greater and enlarged prostate glands predict the best long-term response to finasteride compared with placebo.

Benign prostatic hyperplasia (the aging prostate)

BPH is a common phenomenon of the aging process. Clinical manifestations may range from minimally bothersome symptoms to urinary retention and renal failure. Tailoring of treatment based on the individual patient is required for successful management. For mild symptoms, watchful waiting is a valid option. For severe symptoms, surgical therapy is most appropriate. For men complaining of moderate symptoms, medical therapy has become front-line therapy, with other less invasive treatment modalities being available or in development.

Continued improvement in pressure-flow parameters in men receiving finasteride for 2 years. Finasteride Urodynamics Study Group

OBJECTIVES

To assess the long-term effects of finasteride on pressure-flow parameters in men with urodynamically documented bladder outflow obstruction (BOO).

METHODS

One hundred twenty-one men with benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS) underwent a pressure-flow study (PFS) at 1 of 11 clinical centers. The PFS technique was standardized, and all tracings were read by a single reader unaware of the treatment group. Patients who were obstructed according to a modified Abrams-Griffiths nomogram were randomized to 5 mg finasteride (n = 81) or placebo (n = 40) for 12 months; all patients continuing into an open extension received finasteride during the second 12 months of therapy. Results of the initial 12-month study demonstrated the benefit of finasteride treatment on PFS parameters. To examine the continuing effects over time, an analysis of the data from 54 patients who completed 24 months of treatment with finasteride is provided.

RESULTS

Detrusor pressure at maximum flow (PdetQmax) continued to decrease during the second 12 months of therapy (decreases of 5.3 and 11.7 cm H2O at months 12 and 24, respectively). The percentage of patients obstructed by Abrams-Griffiths classification decreased from 76.2% at baseline to 66.7% at month 12 and 59.6% at month 24. An intention-to-treat analysis yielded similar results.

CONCLUSIONS

Finasteride improves urodynamic measures of obstruction in men with BPE and LUTS, with continued improvement during the second 12 months of therapy.

beta-sitosterol for the treatment of benign prostatic hyperplasia: a systematic review

OBJECTIVES

To conduct a systematic review of the evidence for the efficacy of beta-sitosterol in men with symptomatic benign prostatic hyperplasia (BPH).

METHODS

Studies were identified through Medlinetrade mark (1966-98), EMBASEtrade mark, Phytodok, the Cochrane Library, bibliographies of identified trials and review articles, and contact with study authors and pharmaceutical companies. Randomized trials were included if: men had symptomatic BPH; plant extract preparations contained beta-sitosterols; a control group received placebo or a pharmacological therapy; and treatment duration was >/=30 days. Study characteristics, demographic information, enrolment criteria and outcomes were extracted.

RESULTS

Four trials comprising a total of 519 men met the inclusion criteria. All were double-blind and lasted 4-26 weeks. Three studies used nonglucosidic beta-sitosterols and one used a preparation that contained only beta-sitosterol-beta-d-glucoside. Compared with placebo, beta-sitosterol improved urinary symptom scores and flow measures. For the two studies reporting the International Prostate Symptom Score (IPSS), the weighted mean difference (WMD) against placebo was -4.9 IPSS points (95% confidence interval, CI,-6.3 to-3.5). The WMD for peak urinary flow rate was 3.91 mL/s (95% CI 0.91 to 6.90, four studies) and for residual volume the WMD was -28.62 mL (95% CI-41.42 to-15.83, four studies). beta-sitosterol did not reduce prostate size. The trial using pure beta-sitosterol-beta-d-glucoside (WA184) showed no improvement in urinary flow measures. Withdrawal rates for men assigned to beta-sitosterol and placebo were 7.8% and 8.0% (not significant), respectively.

CONCLUSION

beta-sitosterol improves urological symptoms and flow measures. However, the existing studies are limited by short treatment duration and lack of standardized beta-sitosterol preparations. Their long-term effectiveness, safety and ability to prevent the complications of BPH are unknown.

Medroxyprogesterone acetate and dexamethasone are competitive inhibitors of different human steroidogenic enzymes

Medroxyprogesterone acetate (MPA), a widely used progestin, can suppress the hypothalamic-pituitary-gonadal axis but can also directly inhibit gonadal steroidogenesis; the success of MPA as a treatment for gonadotropin-independent sexual precocity derives from its direct action on steroidogenic tissues. Dexamethasone, a widely used glucocorticoid, can suppress the hypothalamic-pituitary-adrenal axis, but its potential effect directly on the adrenal is unclear. Previous reports suggested that these two drugs may act on the initial steps in the rodent steroidogenic pathway; therefore, we investigated their abilities to inhibit the first three human enzymes in steroidogenesis: the cholesterol side-chain cleavage enzyme (P450scc), the 17alpha-hydroxylase/17,20-lyase (P450c17), and type II 3beta-hydroxysteroid dehydrogenase/isomerase (3betaHSDII). We found no effect of either drug on P450scc in intact human choriocarcinoma JEG-3 cells. Using microsomes from yeast expressing human P450c17 or microsomes from human adrenals, we found that dexamethasone inhibited P450c17 with a Ki of 87 micromol/L, which is about 1000 times higher than typical therapeutic concentrations, but that MPA has no detectable action on P450c17. Using microsomes from yeast expressing human 3betaHSDII, we found that this enzyme has indistinguishable apparent Km values of 5.2-5.5 micromol/L and similar maximum velocities of 0.34-0.56 pmol steroid/min x microg microsomal protein for the three principal endogenous substrates, pregnenolone, 17-hydroxypregnenolone, and dehydroepiandrosterone. In this system, MPA inhibited 3betaHSDII with a Ki of 3.0 micromol/L, which is near concentrations achieved by high therapeutic doses of 5-20 mg MPA/kg x day. These data establish the mechanism of action of MPA as an inhibitor of human steroidogenesis, and are in contrast with the results of earlier studies indicating that MPA inhibited both P450c17 and 3betaHSD in rat Leydig cells. These studies establish the "humanized yeast" system as a model for studying the actions of drugs on human steroidogenic enzymes and suggest that 3betaHSDII may be an appropriate target for pharmacological interventions in human disorders characterized by androgen excess or sex steroid dependency.

Efficacy of finasteride is maintained in patients with benign prostatic hyperplasia treated for 5 years. The North American Finasteride Study Group

OBJECTIVES

The purpose of this open-label study extension was to assess the long-term safety and efficacy of finasteride in the treatment of men with benign prostatic hyperplasia (BPH).

METHODS

A Phase III North American BPH trial originally enrolled 895 men, 297 of whom were randomized to receive finasteride 5 mg. An enlarged prostate gland by digital rectal examination, symptoms of urinary obstruction, and a maximal urinary flow rate of less than 15 mL/s were required for entry. Patients who completed the initial 12-month, double-blind, placebo-controlled study were invited to participate in an open-label extension for 4 additional years.

RESULTS

Of the 297 patients initially randomized to receive finasteride 5 mg, 259 completed 12 months in the double-blind period and 186 completed 48 months of open-label therapy. Prostate volume reached a nadir of -24.6% at month 24, and the effect was maintained through month 60. Compared with baseline values, month 60 prostate volume was decreased by 22.7% (P<0.001), the quasi-American Urological Association symptom score was decreased by 4.3 points, and maximal urinary flow was increased by 2.3 mL/s (P<0.001) on average. Finasteride was well tolerated, with no significant increase in the prevalence of sexual adverse events over time.

CONCLUSIONS

Patients treated with finasteride 5 mg maintained an initial decrease in prostate volume and improvement in symptom score and maximal urinary flow rate over 5 years.

Does long-term finasteride therapy affect the histologic features of benign prostatic tissue and prostate cancer on needle biopsy? PLESS Study Group. Proscar Long-Term Efficacy and Safety Study

OBJECTIVES

Finasteride, a common agent used to treat benign prostatic hyperplasia (BPH), inhibits 5-alpha-reductase. Testosterone is converted by 5-alpha-reductase to the more potent dihydrotestosterone, which is the primary androgen in the prostate. Leuprolide is a stronger antiandrogen that is used to downstage prostate cancer before radical prostatectomy. Leuprolide induces marked atrophy of prostate carcinoma cells, which sometimes makes pathologic diagnosis of cancer difficult, although evaluation at radical prostatectomy is easier than at biopsy. It is unknown whether finasteride produces similar changes, which would result in greater diagnostic difficulty because such changes would be seen on biopsy to rule out cancer in men with suspicious clinical findings treated for BPH. The current study investigated the histologic effects of finasteride therapy on human prostate cancer and benign prostatic tissue on needle biopsy.

METHODS

In blinded manner, we reviewed 53 needle biopsy specimens showing prostate carcinoma (35 treated with finasteride, 18 with placebo). Also reviewed in blinded manner were 50 benign needle biopsy specimens (25 treated with finasteride, 25 with placebo). The Gleason score, number of cores involved, percentage cancer involvement in a core, percentage of atrophic changes in cancer cells, presence of mitoses, blue-tinged mucinous secretions, prominent nucleoli, and high-grade prostatic intraepithelial neoplasia were documented for each case in the cancer group. The percentage of atrophy, basal cell hyperplasia, transitional metaplasia, chronic inflammation, and stromal proliferation was documented for each case in the benign group.

RESULTS

No significant histologic differences were present in either the benign or cancer group between cases treated with finasteride and placebo.

CONCLUSIONS

We conclude that finasteride treatment for BPH does not cause difficulty in the diagnosis of cancer in prostate needle specimens. It is possible that there are severely atrophic areas resulting from finasteride treatment that are undersampled. However, the conclusion that cancer seen on needle biopsy in men treated with finasteride is unaltered and readily identified as cancer remains valid.

Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia

OBJECTIVES

To assess the utility of prostate-specific antigen (PSA) as a predictor of prostate volume by characterizing the relationship between prostate volume and serum PSA in men with symptomatic benign prostatic hyperplasia (BPH) and no evidence of prostate cancer, stratified by decade of life.

METHODS

Placebo-controlled multicenter trials in patients with BPH and a safety study in normal young men provided baseline measurements of serum PSA and prostate volume. The analyses included patients with a baseline prostate volume measured by either transrectal ultrasound (TRUS) or magnetic resonance imaging and baseline serum PSA. A common central laboratory was used for all but one of the individual studies; both laboratories used the Hybritech method. Patients 80 years of age or older were excluded. Patients with a baseline serum PSA greater than 10 ng/mL were excluded to reduce the likelihood of including occult prostate cancer cases. The patients in the BPH trials were screened at baseline by digital rectal examination (DRE) and serum PSA. Those with suspicious findings underwent TRUS-guided biopsy; only patients with negative biopsies are included in these analyses.

RESULTS

The analyses included 4627 patients, 4448 from the BPH trials and 179 from the safety study. The men in the BPH trials were older (mean age+SE, 63.7+0.10 years) than the men in the safety study (mean age + SE, 30.8+/-0.43), had larger prostates (mean volume+/-SE, 43.7+/-0.38 mL versus 26.3+/-0.49 mL in the safety study), and had higher serum PSA values (mean+/-SE, 2.6+/-0.03 ng/mL versus 0.7+/-0.39 ng/mL in the safety study). The relationship between prostate volume and serum PSA was evaluated using only the BPH trial data. Prostate volume and serum PSA have an age-dependent log-linear relationship (ie, their logarithms are linearly related, and the parameters of the relationship depend on age). Older men tend to have a steeper rate of increase in prostate volume with increasing serum PSA (P < 0.00 for differences between slopes), and there was a slight tendency for PSA density to increase with age. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to predict threshold prostate sizes in men with BPH. The ROC curve analyses revealed that PSA had good predictive value for assessing prostate volume, with areas under the curve ranging from 0.76 to 0.78 for various prostate volume cutoff points (30, 40, and 50 mL). Conclusions. Prostate volume is strongly related to serum PSA in men with BPH and no evidence of prostate cancer, and the relationship depends on age. Since treatment outcome or risk of long-term complications depend on baseline prostate volume, serum PSA can estimate the degree of prostate enlargement sufficiently accurately to be useful for therapeutic decision making. To achieve a specificity of 70% while maintaining a sensitivity between 65% and 70%, approximate age-specific criteria for detecting men with prostate glands exceeding 40 mL are PSA > 1.6 ng/mL, >2.0 ng/mL, and >2.3 ng/mL for men with BPH in their 50s, 60s, and 70s, respectively.

Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia. PLESS Study Group

OBJECTIVES

Prostate-specific antigen (PSA) is produced exclusively in the prostate gland and is currently the most useful clinical marker for the detection of prostate cancer. In this report, we examine whether serum PSA is also a predictor of important benign prostatic hyperplasia (BPH)-related outcomes, acute urinary retention (AUR), and the need for BPH-related surgery.

METHODS

Three thousand forty men were treated with either placebo or finasteride in a double-blind, randomized study of 4-year duration. Serum PSA was measured at baseline, and baseline prostate volume was measured in a 10% subset of 312 men. Probabilities and cumulative incidences of AUR and BPH-related surgery, as well as reduction in risk of events with finasteride, were calculated for the entire patient population, stratified by treatment assignment, baseline serum PSA, and prostate volume.

RESULTS

The risk of either needing BPH-related surgery or developing AUR ranged from 8.9% to 22.0% during the 4 years in placebo-treated patients stratified by increasing prostate volume and from 7.8% to 19.9% when stratified by increasing serum PSA. In comparison with symptom scores, flow rates, and residual urine volume, receiver operating characteristic curve analyses showed that serum PSA and prostate volume were the most powerful predictors of spontaneous AUR in placebo-treated patients (area under the curve 0.70 and 0.81, respectively). Finasteride treatment reduced the relative risk of needing surgery or developing AUR by 50% to 74% and by 43% to 60% when stratified by increasing prostate volume and serum PSA, respectively.

CONCLUSIONS

Serum PSA and prostate volume are powerful predictors of the risk of AUR and the need for BPH-related surgery in men with BPH. Knowledge of baseline serum PSA and/or prostate volume are useful tools to aid physicians and decision makers in predicting the risk of BPH-related outcomes and choosing therapy for BPH.

Alternative methods for management of prostatic outflow obstruction

During the past year no new therapies for prostatic outflow obstruction were introduced. Instead, research focused on refinement of treatments previously available. Further reports on the efficacy and safety of alpha 1-adrenergic receptor subtype selective agents have appeared. The long-term effects of finasteride on the natural history bladder outflow obstruction have become clearer. The clinical efficacy of device therapy has evolved, and information regarding intermediate-term outcomes is now available.

Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia?

Both transurethral microwave thermotherapy (TUMT) and medical management by alpha-blockade or 5-alpha-reductase inhibition are increasingly being considered as alternatives to surgery for treatment of patients with benign prostatic hyperplasia (BPH). We review current evidence supporting the effectiveness and safety of TUMT and medical management. Factors for consideration in appropriately selecting patients for TUMT versus medical management are suggested. Available data indicate that TUMT confers greater long-term benefits than medical management as judged by symptom score and peak urinary flow rate improvements. TUMT-associated morbidity is comparatively low. Alpha-blockade affords more rapid relief than TUMT for patients with BPH; however, other strategies such as the use of temporary intraurethral endoprostheses during the acute post-TUMT recovery period may diminish or abolish the differences in time-course of symptom and flow rate improvement between TUMT and alpha-blockade. 5-Alpha-reductase inhibition with finasteride offers a favorable side-effect profile, although the magnitude of symptom and flow rate improvements is modest, and maximal effects of finasteride do not become manifest until after several months of treatment. As TUMT continues to evolve, increasing attention is being accorded the delivery of high thermal doses and precise targeting of the thermal energy delivered. The development of alpha-blockers with a more favorable side-effect profile continues to be a major focus of investigation. The potential clinical utility of combination therapy with TUMT and alpha-blockade is currently under investigation.

The medical management of lower urinary tract symptoms and benign prostatic hyperplasia

Prostatism is a widely used term assigned to the symptom complex of older men with voiding dysfunction. The cause of the syndrome has routinely been ascribed to an enlarged prostate. More recent thinking recognizes that many men with such symptoms do not, in fact, have prostate enlargement or benign prostatic hyperplasia (BPH) and that such symptoms are not a surrogate for BPH. Such recognition is essential if cost effective medical management of lower urinary tract symptoms (LUTS) is to be achieved. Prostate volume has emerged as a key factor in the selection of medical therapy of LUTS and BPH not only regarding symptom relief but also to the newer concept of the prevention of disease progression and the avoidance of future adverse events in those men with true BPH. In the United States, medical management is now first line therapy for LUTS. The proper selection of therapy based on the patient's individual pathophysiologic characteristics is now made possible by many new recent studies within the medical literature.

Treatment with finasteride preserves usefulness of prostate-specific antigen in the detection of prostate cancer: results of a randomized, double-blind, placebo-controlled clinical trial. PLESS Study Group. Proscar Long-term Efficacy and Safety Study

OBJECTIVES

To evaluate prostate cancer detection and prostate-specific antigen (PSA) among men with benign prostatic hyperplasia treated with finasteride.

METHODS

Three thousand forty men 45 to 78 years of age with PSA less than 10 ng/mL and no history of prostate cancer were randomized in a double-blind, placebo-controlled trial to finasteride (n = 1524) or placebo (n = 1516) for up to 4 years. A prerandomization biopsy negative for prostate cancer was obtained in 98% of patients with a screening PSA of 4.0 ng/mL or more, and an end-of-study biopsy was requested of all such patients without a recent second negative biopsy or a prostate cancer diagnosis.

RESULTS

Overall, 644 patients (21%) underwent biopsy and 201 (6.6%) underwent transurethral resection of the prostate. Prostate cancer was diagnosed in 4.7% of men on finasteride and 5.1% on placebo (P = 0.7). Elevated PSA prompted diagnosis in 35% of cases on finasteride and 34% on placebo. The area under the receiver operating characteristic curve for last PSA was 0.84 on finasteride and 0.79 on placebo (P = 0.07). Use of an upper limit of normal for last PSA of 2.0 ng/mL for finasteride and 4.0 ng/mL for placebo yielded similar sensitivity (66% versus 70%, P = 0.6), higher specificity (82% versus 74%, P < 0.0001), and a higher likelihood ratio (3.6 versus 2.7, P < 0.05) for finasteride than for placebo.

CONCLUSIONS

In men treated with finasteride, multiplying PSA by 2 and using normal ranges for untreated men preserves the usefulness of PSA for prostate cancer detection.

Pharmacologic therapy for prostatism

Although the general approach to management of a sufficient degree of benign prostatic hyperplasia in the past was surgical intervention (transurethral resection of the prostate), the current availability of effective pharmacologic therapy has changed the initial management strategy. At present, two types of drugs are available for treatment of prostatism: (1) selective alpha-adrenergic blocking agents (terazosin, doxazosin, and tamsulosin) and (2) an inhibitor of the 5 alpha-reductase enzyme (finasteride). Pharmacologic blockade of the alpha(1)-adrenoceptors is thought to result in relaxation of the smooth muscle in the prostate and bladder neck, which reduces urethral resistance, improves voiding function, and minimizes the symptoms of prostatism. These effects may be noted by the patient within several weeks after initiation of treatment. The mechanism of action of finasteride is a blocking of the conversion of testosterone to dihydrotestosterone and an associated volume shrinkage of the prostate. On the average, a 25% reduction in prostate volume can be achieved, but a period of 12 months or longer of finasteride therapy is needed for maximal shrinkage and maximal decrease in symptoms of prostatism. The expanding population of middle-aged and elderly men with prostatism of moderate severity will undoubtedly prompt the development of additional pharmacologic options for treatment of prostatism and benign prostatic hyperplasia.

Fundamentals of Controlled Clinical Trials and Basic Evaluation Techniques

Controlled clinical trials (CCTs) are needed to determine if a difference is present between two or more interventions (e.g, medication versus placebo). Most biomedical journals require an author to conform to a standarized format to report a CCT. The preparation of the manuscript according to this manner increases the readability and comprehension plus enables the readers to quickly locate pertinent information. Although guidelines have been developed to prepare and report CCTs, limitations are present and errors do occur; no study design and author'S description is perfect. Thus, a CCT should be critiqued using literature analysis skills to identify study strengths and limitations that should be considered in interpreting the overall meaning of the trial. Furthermore, results of more than one CCT should be analyzed before changing practice habits since no one study answers all of the questions and addresses all the issues.

Long-term implications of medical therapy on benign prostatic hyperplasia end points

There is a progression over time of relevant measurable benign prostatic hyperplasia (BPH) end points including symptoms, flow rates, prostate size, complications such as acute urinary retention (AUR), and surgical rates. Only two classes of medical therapy, the alpha-blockers and a 5-alpha-reductase inhibitor, have shown unequivocal and consistent efficacy over placebo in 1-year studies. Both of these classes of medications have demonstrated relative long-term safety. Finasteride has been shown in three large, 2-year, randomized, controlled studies to be superior to placebo, and both finasteride and the alpha-blockers have demonstrated long-term efficacy and safety in open-label studies. The efficacy of finasteride is significantly enhanced when it is used in patients with large prostates. Long-term finasteride therapy also results in a significant reduction in the incidence of AUR and the need for surgery. Long-term medical therapy for BPH is effective and safe. Data are now available that allow clinicians to analyze the long-term risks and benefits of the various medical options and subsequently rationalize long-term therapy for individual patients.