Management of Lower Urinary Tract Symptoms Related to Benign Prostatic Hyperplasia in Real-life Practice in France: A Comprehensive Population Study

Bipolar, Monopolar, Photovaporization of the Prostate, or Holmium Laser Enucleation of the Prostate: How to Choose What's Best?

Endoscopic management of benign prostatic obstruction is based on resection, vaporization, or enucleation. Enucleation provides the best efficacy and long-term outcome. Lasers have advantages in patients at high risk of bleeding. Holmium enucleation is the best evaluated technique, but has a steep learning curve. Greenlight photovaporization is a safe alternative to transurethral resection of the prostate (TURP) in prostates of less than 100 mL, especially in patients at high risk of bleeding. Bipolar devices can be used for resection, vaporization, and enucleation and provides efficacy results similar to TURP in the short term with better safety.

Using EQ-5D-3L and OAB-5D to assess changes in the health-related quality of life of men with lower urinary tract symptoms associated with benign prostatic hyperplasia

OBJECTIVES

To assess changes in the health status of men with lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) using the EQ-5D-3L and OAB-5D instruments and to evaluate the sensitivity of the instruments.

METHODS

Data were available from a large randomised phase III trial of men with moderate-to-severe storage and voiding LUTS/BPH (NEPTUNE). Men received a fixed-dose combination of solifenacin 6 mg plus oral controlled absorption system (OCAS™) formulation of tamsulosin (TOCAS, 0.4 mg), TOCAS monotherapy or placebo and completed the EQ-5D-3L and OAB-5D at baseline and weeks 4, 8 and 12. Analysis of covariance was used to estimate changes in EQ-5D-3L Index, EQ-VAS and OAB-5D. Changes in dimension level were summarised using the Paretian Classification of Health Change (PCHC).

RESULTS

Improved health-related quality of life from baseline was seen in all treatment arms on EQ-5D-3L and OAB-5D at week 12, although only OAB-5D showed statistically significant differences between active treatment and placebo, both on the index score and using the PCHC approach. Effect sizes in the active treatment groups were large (>0.8) on OAB-5D but small (≈0.2) on EQ-5D-3L. EQ-5D-3L showed a very high ceiling effect (45% of men reported full health at baseline) and a substantial proportion of these men reported improvements at week 12 in several dimensions of OAB-5D.

CONCLUSIONS

A large ceiling effect on EQ-5D-3L substantially limited its sensitivity in this population. OAB-5D proved more sensitive to changes in health status and could be considered a complement to ED-5D-3L as a source of utilities for health economic modelling.

[HoLEP learning curve: Toward a standardised formation and a team strategy]

AIM

Holmium laser enucleation of prostate (HoLEP) is renowned for the difficulty of its learning curve. Our aim was to evaluate the interest of a three-step tutorial in the HoLEP learning curve, in a university center.

METHODS

It is a retrospective, monocentric study of the 82 first procedures done consecutively by the same operator with a proctoring in early experience and after 40 procedures. For all patients were noted: enucleation efficiency (g/min), morcellation efficiency (g/min), percentage of enucleated tissue (enucleated tissue/adenome weigth evaluated by ultrasonography. g/g), perioperative morbidity (Clavien), length of hospital stay, length of urinary drainage, functional outcomes at short and middle term (Qmax, post-void residual volume [PVR], QOL scores and IPSS at 3 and 6months).

RESULTS

Enucleation and morcellation efficiency were significantly higher after the second proctoring (0.87 vs 0.44g/min; P<0.0001 and 4.2 vs 3.37g/min, P=0.038, respectively) so as the prostatic volume (43.5 vs 68.1mL, P=0.0001). Percentage of enucleated tissue was higher in the second group, however, the difference was not significant (69.5% vs 80.4%, P=0.03). Per- and postoperative complications, hospital length of stay, urinary drainage length and functional results at 3 and 6months were not significantly different.

CONCLUSION

The learning curve did not interfere with functional results. The second proctoring was essential to us in order to grasp the technique. These data underlined the necessity of a pedagogic reflexion in order to built a standardized formation technique to the HoLEP.

LEVEL OF EVIDENCE

4.

Positive Response to Thermobalancing Therapy Enabled by Therapeutic Device in Men with Non-Malignant Prostate Diseases: BPH and Chronic Prostatitis

Background: The most common types of non-malignant prostate diseases are benign prostatic hyperplasia (BPH) and chronic prostatitis (CP). The aim of this study was to find out whether thermobalancing therapy with a physiotherapeutic device is effective for BPH and CP. Methods: During a 2.5-year period, 124 men with BPH over the age of 55 were investigated. Clinical parameters were tested twice: via the International Prostate Symptom Score (IPSS) and via ultrasound measurement of prostate volume (PV) and uroflowmetry maximum flow rate (Q_max), before and after six months of therapy. In 45 men with CP under the age of 55, the dynamics of the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) were studied. Results: The results of the investigated index tests in men with BPH confirmed a decrease in IPSS (p < 0.001), a reduction in PV (p < 0.001), an increase in Q_max (p < 0.001), and an improvement of quality of life (QoL) (p < 0.001). NIH-CPSI scores in men with CP indicated positive dynamics. Conclusions: The observed positive changes in IPSS, PV, and Q_max in men with BPH and the improvement in NIH-CPSI-QoL in patients with CP after using a physiotherapeutic device for six months as mono-therapy, support the view that thermobalancing therapy with the device can be recommended for these patients. Furthermore, the therapeutic device is free of side effects.

Medical management of benign prostatic hyperplasia: Results from a population-based study

INTRODUCTION

In men with bothersome lower urinary tract symptoms (LUTS), medical treatment usually represents the first line. We examined the patterns of medical management of benign prostatic hyperplasia (BPH) in the Montreal metropolitan area, within the context of a case control study focusing on incident prostate cancer.

METHODS

Cases were 1933 men with incident prostate cancer. Population controls included 1994 age-matched men. In-person interviews collected sociodemographic characteristics and medical history, including BPH diagnosis, its duration, and type of medical treatment received. Baseline characteristics were compared by the chi-square likelihood test for categorical variables and by the students t-test for continuously coded variables.

RESULTS

Overall, 1120 participants had history of BPH; of those 53.7% received medical treatment for BPH. Individuals with medically treated BPH, compared to individuals with medically untreated BPH, were older at index date [mean: 66.9 vs. 64.9 years, p<0.001)] and at diagnosis of BPH [mean: 62.3 vs. 60.3 years, p<0.001]. They also had a longer duration of BPH-history [mean: 4.7 vs. 4.0 years, p=0.02]. Regarding medical treatment, mono-therapy was more often used than combination therapy [87.6% vs. 12.4%, p<0.001]. Alpha-blockers (69.9%) were most commonly used as monotherapy, followed by 5alpha-reductase inhibitors (5ARIs) (26.6%). Alpha-blockers plus 5ARIs were the most common combination therapy (97.3%).

CONCLUSIONS

Despite evidence from randomized, controlled trials for better efficacy with use of combination therapy, monotherapy consisting of alpha-blockers or 5ARI, in that order, is most frequently used. Additionally, 5ARI use was more common than previously reported (27% vs. 15%).

Quality of life in patients with lower urinary tract symptoms associated with BPH: change over time in real-life practice according to treatment--the QUALIPROST study

Purpose

To evaluate change in quality of life (QoL) and symptoms in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) in conditions of current clinical practice.

Methods

Prospective, longitudinal, multicenter open-label study was carried out in urology outpatient clinics. Patients were ≥40 years of age with an International Prostate Symptom Score (IPSS) score ≥8. QoL and symptoms were measured at baseline and 6 months using the Benign Prostatic Hyperplasia Impact Index (BII) and the IPSS.

Results

1713 patients were included for analysis. Mean (SD) IPSS and BII scores at baseline were 16.8 (5.4) and 6.8 (2.6), respectively. 8.9 % (n = 153) of study participants did not receive treatment (watchful waiting, WW), 70.3 % (n = 1204) were prescribed monotherapy (alpha-adrenergic blockers [AB]; phytotherapy [PT, of which 95.2 % was the hexanic extract of Serenoa repens, HESr]; or 5-alpha-reductase inhibitors [5ARI]), and 20.8 % (n = 356) received combined treatment (AB + 5ARI; AB + HESr; others). At 6 months, improvements in QoL were similar across the different medical treatment (MT) groups, both for monotherapy (AB: mean improvement [SD] of 2.4 points [2.4]; PT: 1.9 [2.4]; 5ARI: 2.5 [2.3]) and combined therapy (AB + 5ARI: 3.1 [2.9]; AB + PT: 3.1 [2.5]). There were no clinically significant differences between MT groups and all showed significant improvement over WW (p < 0.05). HESr showed similar efficacy to AB and 5ARI both as monotherapy and in combination with AB. Results on the IPSS were similar.

Conclusions

Improvements in QoL and symptoms were equivalent across the medical treatments most widely used in real-life practice to manage patients with moderate or severe LUTS. HESr showed an equivalent efficacy to AB and 5ARI with fewer side effects.

[Evaluation of postoperative symptoms after Greenlight™ photovaporization of the prostate through a dedicated questionnaire]

AIMS

To evaluate postoperative symptoms after Greenlight™ photovaporisation of the prostate (PVP), through a dedicated questionnaire.

METHODS

A retrospective study has been conducted between 2008 and 2014. The questionnaire had 5 sections about pain while voiding, hematuria, urgency, incontinence and urinary stream, and was filled at one-month postoperative. The main outcome criterion was pain while voiding. Descriptive statistical analyses were done to identify predictive factors for pain while voiding.

RESULTS

Out of 169 patients, 22% had no pain while voiding, 37% had moderate pain, 30% acceptable pain and 11% intense pain. Patients with pain were significantly older, (P=0.012), had more urgency (P=0.01) and more often hematuria (P=0.0001). Only 7% of patients had no symptoms of urgency, and urgency was painful or bothering in 57% of cases. Hematuria was frequent, with clots in 21% of cases. Ninety three percent felt improvement of urinary stream.

CONCLUSIONS

Systematic evaluation of symptoms through a dedicated questionnaire one month after PVP has shown that 41% of patients felt pain while voiding, 57% had urgency and 39% significant hematuria. These results should encourage a more accurate patient information and further studies to better understand postoperative healing after PVP.

Patient's adherence on pharmacological therapy for benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS) is different: is combination therapy better than monotherapy?

BACKGROUND

Recent studies showed that the non-adherence to the pharmacological therapy of patients affected by BPH-associated LUTS increased the risk of clinical progression of BPH. We examined the patients adherence to pharmacological therapy and its clinical consequences in men with BPH-associated LUTS looking at the differences between drug classes comparing mono vs combination therapy.

METHODS

A retrospective, population-based cohort study, using prescription administrative database and hospital discharge codes from a total of 1.5 million Italian men. Patients ≥ 40 years, administered alpha-blockers (AB) and 5alpha-reductase inhibitors (5ARIs), alone or in combination (CT), for BPH-associated LUTS were analyzed. The 1-year and long term adherence together with the analyses of hospitalization rates for BPH and BPH-related surgery were examined using multivariable Cox proportional hazards regression model and Pearson chi square test.

RESULTS

Patients exposed to at least 6 months of therapy had a 1-year overall adherence of 29 % (monotherapy AB 35 %, monotherapy 5ARI 18 %, CT 9 %). Patient adherence progressively declined to 15 %, 8 % and 3 % for AB, 5ARI, and CT, respectively at the fifth year of follow up. Patients on CT had a higher discontinuation rate along all the follow-up compared to those under monotherapy with ABs or 5ARIs (all p < 0.0001). Moreover, CT was associated with a reduced risk of hospitalization for BPH-related surgery (HR 0.94; p < 0.0001) compared to AB monotherapy.

CONCLUSIONS

Adherence to pharmacological therapy of BPH-associated LUTS is low and varies depending on drugs class. Patients under CT have a higher likelihood of discontinuing treatment for a number of reasons that should be better investigated. Our study suggests that new strategies aiming to increase patient's adherence to the prescribed treatment are necessary in order to prevent BPH progression.

[Serious and unexpected complications of benign prostatic obstruction surgery: Results of the LUTS Committee survey from urologists of the French Urological Association]

PURPOSE

Rare and severe complications of benign prostatic hyperplasia (BPH) surgery are poorly documented in the literature. Our purpose was to make an inventory of severe and unexpected complications of BPH faced by urologists of the French Association of Urology (AFU).

MATERIAL AND METHODS

A declarative 13-question survey was sent by e-mail 2 months before the 108th French Congress of Urology to the urologist's members of the AFU. Complications were split in complications due to material and complications directly related to the surgery.

RESULTS

Overall, 216 (16.2%) urologists surveyed but only 85 forms were usable. Complications related to the material was divided into: excessive temperature of the serum irrigation leading to urethral and bladder burns (n=5), material default leading to interruption of the procedure (n=1) or incomplete hemostasis (n=2) and endoscope rupture (n=1). Peroperative complications related to surgery were divided into surgical complications: haemorrhage (n=7), urethral wounds (n=6), perforation and/or explosion (n=16), rectal wounds (n=11), obstructive renal failure (n=1); and medical complications: TURP syndrome (n=2), cardiovascular (n=5) and septic shock (n=6).

CONCLUSION

This is the first French declarative study having allowed the identification of severe and unexpected complications of BPH surgery. The recorded occurred complications were very eclectic and secondary to all types of techniques used.

[Evaluation of the impact of CTMH guidelines on the management of benign prostatic hyperplasia]

INTRODUCTION

The French guidelines on the management of benign prostatic hyperplasia (BPH) have been published in 2012 by the LUTS committee of the French Urological Association. The aim of this study was to evaluate the impact of these guidelines on the BPH management by French urologists.

MATERIAL AND METHODS

A questionnaire has been distributed by email to 1141 urologists members of the French Association of Urologists in November 2013.

RESULTS

We collected 222 responses (response rate: 19%). The guidelines have been read by 73% of the urologists. The guidelines were followed most of the time by 76% of them, 11% followed them systematically and 4.5% did not follow them. The new terminology was used by 28 to 52% according to the items. The symptoms were evaluated by the IPSS score (33%), by interrogatory alone (64%) or by neither of them (3%). Prostate volume was not systematically taken for account in the treatment strategy by 57% of the urologists. Sexual function was assessed systematically by 28% of the urologists, 11% used a questionnaire (IIEF: 92%). PSA was tested respectively by 70 and 51% of the urologists at the initial evaluation and the follow-up. After introduction of a monotherapy, 56% of the urologists evaluated the efficacy at 3 months.

CONCLUSION

The French guidelines for the management of benign prostatic hyperplasia (BPH) by the LUTS committee of the French Urological Association were well known and used by French urologists. Some improvements can be expected for the use of the IPSS score, the evaluation of the sexual function, and the use of the new terminology.

LEVEL OF EVIDENCE

4.

Honokiol, a constituent of Magnolia species, inhibits adrenergic contraction of human prostate strips and induces stromal cell death

Purpose

Smooth muscle contraction and prostate growth are important targets for medical therapy of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia. Honokiol and Magnolol are lignan constituents of Magnolia species, which are used in traditional Asian medicine. Here, we examined effects of honokiol and magnolol on contraction of human prostate tissue and on growth of stromal cells.

Methods

Prostate tissues were obtained from radical prostatectomy. Contraction of prostate strips was examined in organ bath studies. Effects in stromal cells were assessed in cultured immortalized human prostate stromal cells (WPMY-1). Ki-67 mRNA was assessed by reverse transcription-polymerase chain reaction, and proliferation by a fluorescence 5-ethynyl-2′-deoxyuridine assay.

Results

Honokiol (100μM) reduced noradrenaline-induced contractions, which was significant at 10 to 100μM noradrenaline. Honokiol reduced phenylephrine-induced contractions, which was significant at 3 to 100μM phenylephrine. Honokiol reduced electric field stimulation-induced contractions very slightly. In WPMY-1 cells, honokiol (24 hours) induced cell death. Magnolol (100μM) was without effects on contraction, and cellular viability.

Conclusions

Honokiol inhibits smooth muscle contraction in the human prostate, and induces cell death in cultured stromal cells. Because prostate smooth muscle tone and prostate growth may cause LUTS, it appears possible that honokiol improves voiding symptoms.

[Evolution of lower urinary tract symptoms under silodosin: factors influencing patients' satisfaction]

The objective of this study was to analyze the efficacy and safety of silodosin in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) in current urologic practice.

METHOD

This was a prospective observational study conducted by 272 urologists on patients treated by silodosin for BPH. The parameters evaluated were the weighted IPSS score, the IPSS question 8 related to quality of life, the USP score and the Athens Insomnia Scale (AIS) measured at treatment initiation and after 3 months.

RESULTS

Nine hundred and fourteen patients whose average age was 66 years with LUTS for 3.3 years were analyzed. After 3 months of treatment, a significant decrease in IPSS (from 16.2 ± 6.1 to 9.7 ± 5.5, P<0.0001) and USP score (from 10.6 ± 5.1 to 6 0 ± 4.6, P<0.0001) were observed, quality of life (from 67.1% to 14.4% of unsatisfied patients, P<0.0001) and sleep were significantly improved (from 49.2% to 28.9% patients with insomnia, P<0.0001). Among the patients, 21.2% experienced at least one adverse event. The most frequent were abnormal ejaculation (17.2%). And 7.1% discontinued the treatment for this reason. After 3 months of treatment silodosin was continued in 86.9% of patients.

CONCLUSION

This large study confirmed the efficacy of silodosin in LUTS associated with BPH with a safety profile that does not affect patient satisfaction.

Is metabolic syndrome truly a risk factor for male lower urinary tract symptoms or just an epiphenomenon?

To define whether the association of male lower urinary tract symptoms (LUTS) and metabolic syndrome (MS) is real or simply an epiphenomenon, 490 male adults (mean age 58 ± 9 years) underwent International Prostate Symptom Score (IPSS), physical and prostate digital examinations, blood analysis, and urinary tract transabdominal ultrasound with prostate volume measurement. Mild, moderate, and severe LUTS were found in 350 (71.4%), 116 (23.7%), and 24 (4.9%) patients, respectively. MS was present in 198 (40.4%) patients, representing 37.4% (131 of 350) of those with mild LUTS, 46.5% (54 of 116) of those with moderate, and 54.1% (13 of 24) of those with severe. The odds ratio of MS having moderate or severe LUTS was 2.1. MS was more common in older age, higher body mass index, and larger prostate size. Moderate and severe LUTS were more frequent in older age, lower levels of high density cholesterol, and higher blood pressure. Older age and body mass index had significant relative risk for lower urinary tract symptoms and only age remained independent factor for LUTS on multivariate analysis. Our results suggest that the association of male LUTS, prostate volume, and MS might be coincidental and related to older age.