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Gharbieh S, Reeves F, Challacombe B. The prostatic middle lobe: clinical significance, presentation and management. Nat Rev Urol 2023; 20:645-653. [PMID: 37188789 DOI: 10.1038/s41585-023-00774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.
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Oelke M, Abt SD, Becher KF, Dreikorn K, Madersbacher S, Magistro G, Michel MC, Muschter R, Reich O, Rieken M, Salem J, Schönburg S, Höfner K, Bschleipfer T. [Diagnostic work-up of benign prostatic hyperplasia : The German S2e-guideline 2023 part 1]. UROLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00120-023-02142-0. [PMID: 37401972 DOI: 10.1007/s00120-023-02142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH; in German guidelines: benign prostatic syndrome [BPS]) is the most frequent urological disease in men and can result in a considerable deterioration of quality-of-life. BPS can be associated with LUTS, benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO) or benign prostatic obstruction (BPO), respectively. The expert group on BPS of the German Society of Urology has re-evaluated the tests for the assessment of BPH and provides evidence-based recommendations. OBJECTIVES Presentation and evidence-based rating of tests for the assessment of patients with BPS. MATERIALS AND METHODS Summary and overview of chapters 5, 6, and 8 of the latest long version of the German S2e guideline on BPS. RESULTS The diagnostic work-up should clarify (1) whether the complaints of the patient are caused by BPS, (2) how relevant the complaints are and whether treatment is necessary, (3) whether complications of the lower or upper urinary tract already exist, and (4) which treatment will be most suitable. Baseline assessment should be done in all BPS patients and include history, measurement of LUTS and quality-of-life, urinalysis, serum prostate-specific antigen, post-void residual, ultrasound of the lower urinary tract, including measurements of prostate volume, intravesical prostatic protrusion and detrusor wall thickness, and ultrasound of the upper urinary tract. Additional tests can follow when questions remain unanswered after baseline assessment. These optional tests include bladder diaries, uroflowmetry, serum creatinine, urethrocystoscopy, other noninvasive tests for the determination of BOO/BPO such as penile cuff test, condom catheter method and near-infrared spectroscopy, and other imagining tests such as X‑ray and MRI investigations. CONCLUSIONS The updated German S2e guideline summarizes evidence-based recommendations on the diagnostic work-up, including the assessment of the BPS components BPE, LUTS, and BOO/BPO.
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Affiliation(s)
- Matthias Oelke
- Klinik für Urologie, Urologische Onkologie und Roboter-assistierte Chirurgie, St. Antonius-Hospital GmbH, Möllenweg 22, 48599, Gronau, Deutschland.
| | - S Dominik Abt
- Klinik für Urologie, Spitalzentrum Biel, Biel, Schweiz
| | - Klaus F Becher
- Klinik für Rehabilitation, Klinik Wartenberg Professor Dr. Selmair GmbH & Co. KG, Wartenberg, Deutschland
| | | | | | - Giuseppe Magistro
- Klinik für Urologie, Asklepios Westklinikum GmbH, Hamburg, Deutschland
| | - Martin C Michel
- Abteilung Pharmakologie, Johannes Gutenberg Universität, Mainz, Deutschland
| | - Rolf Muschter
- Urologische Abteilung, ALTA Klinik, Bielefeld, Deutschland
| | - Oliver Reich
- Urologische Privatpraxis Prof. Dr. Oliver Reich, München, Deutschland
| | | | - Johannes Salem
- CUROS urologisches Zentrum, Klinik LINKS VOM RHEIN, Köln, Deutschland
- Klinik für Urologie und Kinderurologie, Universitätsklinikum, Medizinische Hochschule Brandenburg Theodor Fontane, Brandenburg a.d. Havel, Deutschland
| | - Sandra Schönburg
- Universitätsklinik und Poliklinik für Urologie, Martin-Luther Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Klaus Höfner
- Klinik für Urologie, Evangelisches Krankenhaus, Oberhausen, Deutschland
| | - Thomas Bschleipfer
- Klinik für Urologie und Kinderurologie, Regiomed Klinikum, Coburg, Deutschland
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Madersbacher S, Oelke M, Häcker A, Bschleipfer T. [Sophisticated surgical management of distinctive patients with benign prostatic hyperplasia (BPH)]. Urologe A 2020; 59:1168-1176. [PMID: 32845346 DOI: 10.1007/s00120-020-01310-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Herein we describe four clinical scenarios. For the standard patient (prostate volume 30-80 ml, life expectancy >10 years) transurethral resection of the prostate (TURP) remains the standard of care, while endoscopic enucleation is a valuable alternative. Patients with a relevant middle lobe profit most from TURP, endourological enucleation procedures, or laser vaporization. In the case of the absence or a moderate-sized middle lobe and the absence of severe bladder outlet obstruction (BOO), minimally invasive procedures such as Rezūm®, UroLift® or prostate artery embolization (PAE) can be offered. Patients have to be informed that long-term data on this specific indication are lacking. Particularly younger men requiring BPH surgery are interested in preserving ejaculatory function. In the presence of severe BOO, ejaculatory-protective TURP or endoscopic enucleation by preserving the pericollicular region or aquablation are the methods of choice providing an antegrade ejaculation in 60-90% of cases. Rezūm®, AquaBeam®, and UroLift® enable preservation of ejaculation in almost 100%; data on PAE with this respect are more controversial. For patients with a small prostate and significant post void residual, a thorough preoperative work-up, including urodynamics and bladder/detrusor wall thickness measurement, is of great importance. Desobstructive surgery provides satisfactory short- and midterm outcome, yet the long-term outcome is disappointing and remains to be determined in greater detail. The broad spectrum of therapeutic options enables today an individualized minimally invasive or surgical management of BPH considering patient wishes, anatomical factors or urodynamic factors. The time of a "one therapy fits all" strategy is definitely history.
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Affiliation(s)
- S Madersbacher
- Abteilung für Urologie, Klinikum Favoriten, Kundratstraße 3, 1100, Wien, Österreich. .,Sigmund Freud Privatuniversität, Wien, Österreich.
| | - M Oelke
- Klinik für Urologie, St. Antonius-Hospital, Gronau, Deutschland
| | - A Häcker
- Marienhaus Klinikum Hetzelstift, Akademisches Lehrkrankenhaus der Johannes, Gutenberg-Universität Mainz, Stiftstraße 10, 67434, Neustadt a.d. Weinstraße, Deutschland
| | - T Bschleipfer
- Klinik für Urologie, Klinikum Weiden/Kliniken Nordoberpfalz, Weiden, Deutschland
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Maron SZ, Sher A, Kim J, Lookstein RA, Rastinehad AR, Fischman A. Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes. J Vasc Interv Radiol 2020; 31:370-377. [PMID: 31956004 DOI: 10.1016/j.jvir.2019.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP). MATERIALS AND METHODS This was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm3 (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10-656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes. RESULTS No significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R2 = .5, P < .0001; IPP: P = .702; QOL: R2 = .5, P = .0003; IPP: P = .108). CONCLUSIONS There were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.
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Affiliation(s)
- Samuel Z Maron
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1234, New York, New York 10029. https://twitter.com/MaronSamuel
| | - Alex Sher
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1234, New York, New York 10029
| | - Jeremy Kim
- Charlotte Radiology, Charlotte, North Carolina
| | - Robert A Lookstein
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1234, New York, New York 10029
| | - Ardeshir R Rastinehad
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1234, New York, New York 10029
| | - Aaron Fischman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1234, New York, New York 10029.
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The role of prostatic apex shape in voiding symptoms and urine flow: an exploratory and confirmatory study. World J Urol 2019; 38:1275-1282. [PMID: 31456018 DOI: 10.1007/s00345-019-02925-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Lower urinary tract symptoms in men have previously been attributed to obstruction from an enlarged prostate. However, several factors in addition to prostate volume have been identified as impacting urine flow. Prostatic apex shape is one factor that has not been evaluated. This study evaluates the relationship between prostatic apex shape and voiding symptoms and urine flow. METHODS A retrospective, exploratory data review was conducted for 806 healthy men who underwent routine transrectal ultrasonography at our hospital, and data for 329 patients with uroflowmetric measurements were reviewed for the confirmatory study. Patients were categorized into four groups according to the prostatic apex shape on midsagittal ultrasonography. The association between prostatic apex shape and voiding symptoms was investigated. International Prostate Symptom Score (IPSS) and uroflowmetry were measured, and the associations between IPSS, uroflowmetry, and prostatic apex shape were analyzed. RESULTS Patients in group 4 (356/806, 44.2%), whose prostatic apex did not overlap the membranous urethra anteriorly or posteriorly, had a significantly lower incidence of moderate and severe lower urinary tract symptoms compared to other groups. There was a significant relationship between prostatic apex shape and total International Prostate Symptom Score. Patients in group 3, whose prostatic apex overlapped posteriorly with the membranous urethra, had lower maximum flow rates on uroflowmetry. There were significant correlations between the maximum flow rate and independent factors including age, intravesicle prostatic protrusion, and prostatic apex shape. CONCLUSIONS Prostatic apex shape is an independent risk factor for voiding symptom severity and low maximum flow rate.
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