What are the predicting factors for the therapeutic effects of dutasteride in male patients with lower urinary tract symptoms? Investigation using a urodynamic study

Recent developments in diagnostic ultrasound for lower urinary tract function

Ultrasonography (US) is an essential tool in the clinical management of lower urinary tract dysfunction (LUTD), including lower urinary tract symptoms, overactive bladder, and benign prostatic hyperplasia, in which prostatic volume and post-void residual volume are routinely used to evaluate the pathophysiological characteristics of afflicted patients. US can also be employed to diagnose hydronephrosis and bladder calculus as complications of severe LUTD. Moreover, US is essential for identifying pathophysiological characteristics and surgical indications, predicting disease development and drug efficacy, and monitoring bladder function improvement by means of such parameters as bladder wall thickness, prostatic urethral length, intravesical prostatic protrusion, and prostatic urethral angulation/angle. Herein, I narratively review the recent advances in US approaches for the management of LUTD, especially in adult males.

Risk factors for failure of long-term dutasteride add-on treatment to alpha-adrenergic antagonist for patients with lower urinary tract symptoms and benign prostatic enlargement

PURPOSE

To identify the clinical factors resulting in the failure of dutasteride add-on treatment to alpha-adrenergic antagonist for patients with lower urinary tract symptoms and benign prostatic enlargement (BPE).

METHODS

We retrospectively surveyed the patient cohort who had been enrolled in the study of dutasteride add-on treatment to alpha-adrenergic antagonist from December 2009 to November 2011. Treatment failure was defined as receiving surgery for BPE or requiring intermittent catheterization or permanent bladder catheter for urinary retention or huge postvoid residual urine. Clinical parameters before dutasteride treatment were compared between the successful and failed group.

RESULTS

Of 92 patients, 23 (25%) were defined as treatment failure at 7-109 months (mean: 38 months) after dutasteride add-on treatment. In the failed group, the patient' age was younger (71.6  ±  6.8 vs 75.4  ±  8.4, p = 0.033), prostatic volume (PV) was larger (76  ±  41 vs 49  ±  26 ml, p = 0.005), voiding efficiency was lower (54  ±  27 vs 68  ±  24%, p = 0.045) and bladder outlet obstruction index was higher (73  ±  30 vs 48  ±  30, p = 0.015). The cox proportional-hazards model indicated that only intravesical prostatic protrusion (IPP) was associated with treatment failure. Non-failure rate at 3 years after dutasteride add-on treatment was 89% with patients of IPP < 13 mm versus 51% with those of IPP ≥ 13 mm (p < 0.001).

CONCLUSION

IPP ≥ 13 mm is the risk factor resulting in the failure of dutasteride add-on treatment to alpha-adrenergic antagonist. This kind of information should be provided to the patients early in the clinical practice so that they could consider the necessity of BPE surgery in the long run.

Pre-treatment serum testosterone level can be a useful factor to predict the improvement in bladder outlet obstruction by tadalafil for male patients with lower urinary tract symptoms induced by benign prostatic obstruction

INTRODUCTION

To investigate possible pre-treatment factors related to the therapeutic effect of tadalafil on bladder outlet obstruction (BOO).

MATERIALS AND METHODS

Eighty untreated outpatients with lower urinary tract symptoms (LUTS) due to BOO received 5 mg tadalafil daily for 12 months. Subjective symptoms and objective findings were evaluated before and 12 months after treatment. At 12 months, the patients were divided into two groups according to an improvement grade in BOO index (BOOI). Patient characteristics including age, serum total testosterone level (TT), PSA, and prostate volume, and subjective and objective parameters on LUTS were set as candidates of pre-treatment factors, and the parameters that influenced the improvement of BOO were statistically analysed.

RESULTS

A total of 69 patients with mean age of 69.8 years and mean prostate volume of 48.8 mL were included. Subjective symptoms and BOOI were significantly ameliorated after 12 months. In terms of an improvement of BOOI, 30 patients (43.5%) showed insignificant improvement in BOO, whereas 39 patients (56.5%) exhibited excellent improvement. Comparison of pre-treatment factors between the groups showed that TT was the only independent predictor related to the improvement in BOO. The improvement of BOO was significantly better in patients with higher TT.

CONCLUSIONS

Pre-treatment TT was considered to be a useful predictor of therapeutic effects of tadalafil for BOO.

Clinical characteristics and useful signs to differentiate detrusor underactivity from bladder outlet obstruction in men with non-neurogenic lower urinary tract symptoms

OBJECTIVE

To investigate the clinical characteristics and useful signs to differentiate detrusor underactivity from bladder outlet obstruction in men with non-neurogenic lower urinary tract symptoms.

METHODS

A total of 638 treatment-naive men with non-neurogenic lower urinary tract symptoms who underwent subjective and objective evaluations were reviewed retrospectively. We divided the patients into detrusor underactivity and bladder outlet obstruction groups based on urodynamic findings, and compared parameters obtained from questionnaires and non-invasive tests. Detrusor underactivity was defined as bladder contractility index ≤100 and bladder outlet obstruction index ≤40, whereas bladder outlet obstruction was defined as bladder contractility index >100 and bladder outlet obstruction index >40.

RESULTS

Of 638 patients, 145 (22.7%) had detrusor underactivity and 273 (42.8%) had bladder outlet obstruction. Total international prostate symptom score and international prostate symptom score-voiding subscore were significantly higher in the detrusor underactivity group. There were significant differences in prostate volume, intravesical prostatic protrusion, and all uroflowmetry parameters between the two groups. In multivariate logistic regression analysis, lower intravesical prostatic protrusion (cut-off value 8.2 mm), lower bladder voiding efficiency (cut-off value 70%), and the presence of sawtooth and interrupted waveform on uroflowmetry were significant predictive factors for detrusor underactivity. In particular, the incidence of sawtooth and interrupted waveform was significantly higher in the detrusor underactivity group (80%) than in the bladder outlet obstruction group (12.8%), which showed both high sensitivity (80%) and specificity (87.2%) in differentiating detrusor underactivity from bladder outlet obstruction.

CONCLUSIONS

Sawtooth and interrupted waveform on uroflowmetry can be a useful predictive factor for detrusor underactivity. In addition, lower intravesical prostatic protrusion and bladder voiding efficiency can be of supplementary use.

Symptom improvement and predictors associated with improvement after 6 weeks of alpha-blocker therapy: An exploratory, single-arm, open-label cohort study

Objectives

Clinicians should not only know how many patients will benefit from alpha-blocker therapy but should also be able to identify who will benefit. We studied the changes in patient symptoms following alpha-blocker therapy and the predictors of symptom improvement in clinical practice.

Design

This was a single-arm, open-label observational cohort study with a 6-week follow-up.

Setting

Twenty-two pharmacies in the Netherlands.

Participants

Patients were eligible for inclusion if they attended a pharmacy with a new prescription for an alpha-blocker from a general practitioner or urologist.

Primary and secondary outcomes

Outcomes were assessed using the International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire Short Form (OAB-q SF), and Patient Global Impression of Improvement (PGI-I). Demographic, disease-related, and drug-related information were collected to identify predictors of symptom improvement. These predictors were then assessed by logistic and linear regression analyses of both the original data set and an imputed data set that accounted for the missing variables.

Results

During the study, 37% of patients with lower urinary tract symptoms perceived clear symptomatic improvement based on the results of the PGI-I. Improvement was more likely in those who still used alpha-blockers at the end of the 6-week study period and in those who used multiple medications. Although symptom scores decreased significantly on the IPSS and OAB-q SF, the only predictor of change was the pretreatment symptom severity.

Conclusions

Approximately one-third of our cohort perceived symptom improvement on alpha-blocker therapy. However, we identified no clear predictors of who might benefit from alpha-blocker treatment, indicating that alpha-blockers should still be prescribed on a trial basis.

Intravesical prostatic protrusion is not always the same shape: Evaluation by preoperative cystoscopy and outcome in HoLEP

AIMS

To examine how morphological differences in intravesical prostatic protrusion (IPP) predict outcome of Holmium laser enucleation of prostate (HoLEP) treatment.

METHODS

We analyzed 173 patients who had undergone HoLEP in our hospital. The protrusion shape was evaluated by outpatient preoperative flexible cystoscopy and classified into five groups: A, no protrusion; B, middle lobe only; C, unilateral lobe only; D, bilateral lobes; and E, B + C or B + D. Paired-match analysis that adjusted for preoperative International Prostate Symptom Score (IPSS) voiding/storage subscores and IPP was performed between the group with middle lobe protrusion (B + E) and the group without it (C + D).

RESULTS

Type A prostate shape was found in 23 patients, type B in 14, type C in 31, type D in 71, and type E in 34. Groups with middle lobe protrusion (B and E) had better changes in the total IPSS (P < 0.05) and the IPSS storage subscore (P < 0.01). Pair matching identified 37 patients each with or without middle lobe protrusion. The group with middle lobe protrusion had significantly more improved total IPSS (-17.5 ± 7.5 vs -13.5 ± 8.3, P < 0.05) and IPSS storage subscore (-6.9 ± 3.4 vs -4.8 ± 3.3, P < 0.05) than did those without middle lobe protrusion.

CONCLUSIONS

Patients with middle lobe protrusion had greater IPSS improvement after HoLEP than those having comparable-length IPP but without middle lobe protrusion. IPP is not always the same shape and should be clinically divided into at least two groups.

Patterns of Benign Prostate Hyperplasia Based on Magnetic Resonance Imaging Are Correlated With Lower Urinary Tract Symptoms and Continence in Men Undergoing a Robot-assisted Radical Prostatectomy for Prostate Cancer

OBJECTIVE

To investigate the association between benign prostatic hyperplasia (BPH) patterns, classified by magnetic resonance imaging (MRI), with lower urinary tract symptoms (LUTS) or continence, preoperatively and after robot-assisted laparoscopic radical prostatectomy (RARP).

MATERIALS AND METHODS

This retrospective study included 49 prostate cancer patients, with prostate size >47 cm³, who underwent an endorectal MRI followed by RARP. Five BPH patterns were identified according to Wasserman, and additional prostate measurements were recorded. LUTS were assessed using the International Prostate Symptom Score and the PR25-LUTS-Questionnaire score. Continence was assessed using the International Consultation of Incontinence Questionnaire-Short Form.

RESULTS

BPH pattern 3 (44.9%) was identified most common, followed by pattern 5 (26.6%), 1 (24.5%), and 2 and 4 (both 2%). BPH patterns were significant predictors of preoperative LUTS, with pedunculated with bilateral transition zone (TZ) and retrourethral enlargement (pattern 5) causing more severe symptoms compared with bilateral TZ and retrourethral enlargement (pattern 3) and bilateral TZ enlargement (pattern 1), whereas pattern 3 was additionally associated with more voiding symptoms compared with pattern 1. None of the BPH patterns was predictive of postoperative LUTS and continence. Independent predictors of continence at 12 months were lower preoperative PR25-LUTS score (P = .022) and longer membranous urethral length (P = .025).

CONCLUSION

MRI is useful for classifying patients in BPH patterns which are strongly associated with preoperative LUTS. However, BPH patterns did not predict remnant LUTS or postoperative incontinence. Postoperative continence status was only associated with preoperative LUTS and membranous urethra length.