Evaluation and results of treatments for prostatism

Development and validation of a new treatment outcome score for men with LUTS

AIMS

To develop, validate, and test elements of a new outcome score for men with lower urinary tract symptoms (LUTS).

METHODS

Elements of well-established questions from the International Prostate Symptom Score (IPSS) assessment were combined with both established noninvasive objective determinants of voiding function including maximum uroflow (Qmax), postvoid residual urine volume (PVR), total number voids, maximum voided volume (MVV) as well as a subjective patient assessment parameter, to create a new LUTS treatment outcome instrument which we have termed the "LUTS outcome score" (LOS). The LOS is comprised of eight items; each assigned a score of 0, 1, or 2. Thus, the score ranges from 0 (best) to 16 (worst). Patients were divided into surgical/non- surgical (pharmacologic or behavior modification) treatment groups. Content validity and cutoff values for cure/improve/fail were established by an expert panel. Criterion validity was established by comparison to the IPSS. Internal reliability analysis was performed to obtain information about the relationships between individual items in the scale. Individual LOS items were correlated with the subjective outcome score. We also calculated the correlations between the LOS, IPSS, subjective post-treatment response, and age. Internal consistency, based on the average inter-item correlation was calculated using Cronbach's alpha statistic. Associations between continuous variables were examined by calculating the Pearson correlation coefficient, and between ordinal variables, using Spearman's rho. Test-retest analysis was recorded to determine reproducibility of the patient subjective outcome score. Seventy-seven men who underwent treatment for LUTS for at least 6 months participated in the study. All completed a detailed pretreatment and post-treatment clinical evaluation consisting of history/physical, questionnaire, voiding diary, urinalysis, Q, PVR, and videourodynamic study. Subjective responses of cured/improved/failed status following treatment were assessed by independent investigators.

RESULTS

A high level of internal consistency was observed among the LOS symptom questions, Cronbach's alpha = 0.81 for the total cohort. The LOS correlated directly and significantly with the patient's subjective post-treatment response (r = 0.75, P < 0.001), age (r = 0.27, P = 0.02), and with the total IPSS (r = 0.62, P < 0.001). The IPSS also correlated directly and significantly with the patient's subjective post-treatment response (r = 0.48, P < 0.001) but did not correlate with the patient's age (r = 0.10, P = 0.41). When the subjective parameter for post-treatment response was subtracted from the LOS, the resulting correlation (r = 0.52, P < 0.001) approximated that obtained using the IPSS.

CONCLUSIONS

The LOS is valid and internally consistent. Unlike the IPSS, it combines subjective, semisubjective, and objective parameters. Because of the objective components, it diminishes the possibility of overestimating cure and underestimating improvement relying only on patient's symptoms. Further, we believe it will prove to be useful for post hoc analysis in patients who have not had pre-treatment assessment.

Ex-vivo comparison of the haemostatic properties of standard transurethral resection and transurethral vaporization resection of the prostate

OBJECTIVE

To compare the haemostatic properties of standard transurethral resection of the prostate (TURP) and transurethral vaporization resection of the prostate (TUVRP), as perioperative bleeding is still regarded as the major complication of prostate resection.

MATERIALS AND METHODS

Isolated blood-perfused porcine kidneys were used to determine the haemostatic efficacy of TURP and TUVRP (using two different electrodes). Bleeding was quantified precisely in relation to tissue ablation for the two techniques, and specimens were evaluated histologically.

RESULTS

Both TUVRP groups had significantly less bleeding (P = 0.005) than the TURP group for a standardized ablation volume of perfused kidney tissue (18.9, 19.5 and 24.1 mL/min, respectively). The different TUVRP electrodes had no significant haemostatic differences. The histology showed significantly (P = 0.03) larger coagulation zones for the TUVRP groups than for standard TURP.

CONCLUSIONS

TUVRP ex-vivo was associated with significantly better haemostasis than TURP. The haemostatic properties of different active electrodes for TUVRP seem to be equivalent.

Combination of interstitial laser coagulation and transurethral resection of the prostate: ex vivo evaluations

OBJECTIVES

To evaluate the combination of interstitial laser coagulation (ILC) and transurethral resection of the prostate (TURP) in an ex vivo model. Perioperative bleeding is still regarded as the main complication of conventional TURP. The minimally invasive procedure ILC and the highly effective TURP seem to be a promising concept to improve hemostasis.

METHODS

Isolated blood-perfused porcine kidneys were used to determine hemostatic efficacy of different interstitial laser procedures (neodymium:yttrium-aluminum-garnet [Nd:YAG], 1064 nm; and holmium:YAG [Ho:YAG], 2100 nm) in combination with conventional TURP. Bleeding could thus be quantified in relation to tissue ablation for the different techniques. Additionally, the specimens were evaluated histologically.

RESULTS

A combination of Nd:YAG ILC, followed by TURP, resulted in significantly (P <0.001) reduced bleeding compared with TURP alone for a standardized ablation volume of 16 cm(3) of perfused kidney tissue (5.1 mL/min versus 24.1 mL/min). Similarly, significantly (P <0.001) better hemostasis was demonstrated with the combination of Ho:YAG ILC compared with TURP alone (4.8 mL/min versus 24.1 mL/min). The differences between the two laser procedures were not significant. The histologic examinations revealed significantly larger coagulation zones for the groups pretreated with Nd:YAG ILC or Ho:YAG ILC compared with TURP alone.

CONCLUSIONS

ILC before conventional TURP leads, ex vivo, to a significantly superior hemostasis compared with TURP alone. The hemostatic effects of Nd:YAG and Ho:YAG laser treatments seem comparable.

The 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy vs transurethral resection of the prostate

OBJECTIVE

To assess the 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy of the prostate (IRFT) vs transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Patients with lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outlet obstruction (BOO) were randomized to undergo IRFT or TURP and were followed up using the International Prostate Symptom Score (IPSS) and urodynamic assessment for 2 years.

RESULTS

At 2 years there was a clinically relevant reduction in the IPSS in the IRFT (20 to 9) and TURP groups (22 to 4). There was also a statistically significant reduction in the detrusor pressure at maximum urinary flow in both groups, but the reduction in the IRFT group was probably not sufficient to explain the observed symptomatic improvements solely from a reduction in BOO.

CONCLUSION

IRFT can produce a sustained improvement in LUTS for at least 2 years. However, such improvements are unlikely to be entirely the result of a reduction in BOO. The effects of radiofrequency energy may, at least partly, be independent of any thermal effect and depend instead on neuromodulation of lower urinary tract nerves.

The use of lasers in benign prostatic enlargement

This article reviews the laser techniques available for the treatment of lower urinary tract symptoms. Early data on short-term mortality, morbidity, complication rates, and outcome are available, but information on cost-effectiveness, long-term outcome, and patient preference are as yet unavailable. In the 8 years since laser methods became popular it has become clear that substantial and variably durable flow and symptomatic responses are achieved that do not quite match transurethral resection of the prostate (TURP). Less immediate physiologic stress is balanced by a delay before full response. Same-day surgery may be possible, but an extended period of catheterization may be necessary. Laser methods remain an option for treatment and are particularly applicable to the less fit man. Whether men will choose a less effective but less invasive treatment option for symptom relief is not yet obvious. Limited early data suggest the holmium laser technique most closely approaches the gold standard.

Bladder mucosal cell abnormalities and symptomatic outcome after transurethral resection of the prostate

OBJECTIVES

To identify predictors of poor symptomatic improvement after transurethral resection of the prostate (TURP), we investigated mucosal cell abnormalities in men about to undergo this procedure, and any association between these abnormalities and pre- and postoperative urinary tract symptoms.

METHODS

Bladder lavages were obtained from patients undergoing TURP for outflow obstruction during 1995 to 1996 at the Repatriation General Hospital. Pressure flow studies were obtained preoperatively, and International Prostate Symptom Scores and flow rates were obtained preoperatively and 3 months and 2 years postoperatively. Cells from bladder washings were examined flow-cytometrically for Tn antigen expression and DNA cell cycle parameters.

RESULTS

Of 192 patients recruited, 145 met the inclusion criteria. The frequency of Tn antigen expression, aneuploidy, and tetraploid aneuploidy in bladder mucosal cell washings in this group was comparable to a previous study. Weak, statistically significant associations were found between S-phase fraction and the initial International Prostate Symptom Score irrespective of whether total S-phase fraction cell numbers or categories were used. The trend of each of these associations was consistent (ie, patients with higher S-phase fraction values had more severe symptoms, poorer quality of life, and lower flow rates). The association was maintained at 3 months postoperatively but not at 2 years. Potential confounding factors did not explain the association.

CONCLUSIONS

Bladder mucosal cell abnormalities can be found in men selected to undergo TURP to relieve obstruction and are associated with poor short-term symptomatic outcome. Further studies are needed to confirm these findings, in particular any association between higher mucosal cell proliferation rates and the presence of lower urinary tract symptoms.

Atherosclerosis-induced chronic ischemia causes bladder fibrosis and non-compliance in the rabbit

PURPOSE

The overall goal was to determine whether chronic ischemia and hypercholesterolemia interfere with bladder function and structure. The roles of atherosclerosis-induced chronic ischemia and hypercholesterolemia in bladder fibrosis and non-compliance were studied in the rabbit. The relationship between ischemia-induced changes in the expression of transforming growth factor-beta1 (TGF-beta1) and basic fibroblast growth factor (bFGF) and the severity of bladder fibrosis was also investigated.

MATERIALS AND METHODS

Male New Zealand White rabbits were divided into chronic bladder ischemia (CBI, n = 11), hypercholesterolemia (Hch, n = 8) and control (n = 8) groups. The CBI group underwent balloon endothelial injury of the iliac arteries and received a 0.5% cholesterol diet. The Hch group received a 0.5% cholesterol diet alone. The control group was placed on a regular diet. After 16 weeks, iliac artery and bladder wall blood flow measurements, cystometrograms (CMG) and aorto-iliac arteriograms were obtained in all animals. Iliac arteries and bladder tissues were processed for histological staining and computer-assisted histomorphometric image analysis. The expressions of TGF-beta1 and bFGF in bladder tissue were determined by immunohistochemical staining utilizing monoclonal antibodies.

RESULTS

At 16 weeks, arteriography and histology showed significant diffuse atherosclerotic occlusive disease of the aorto-iliac arteries in the CBI group. Iliac artery and bladder wall blood flows were significantly decreased in the CBI group compared with the Hch and control groups. Atherosclerosis-induced CBI shifted the volume-pressure curve to the left and caused severe bladder fibrosis. Hypercholesterolemia also caused fibrosis and non-compliance but to a much lesser extent compared with those caused by CBI. In histomorphometry, the percentage of detrusor smooth muscle was moderately decreased in the Hch group and severely decreased in the CBI group compared with the control group. In immunohistochemical stains of bladder tissues, bFGF expression was similar in the three groups of animals. TGF-beta1 expression was significantly greater in bladder tissues from the CBI group compared with the Hch and control groups.

CONCLUSIONS

Our studies show that atherosclerosis-induced chronic ischemia increases TGF-beta1 expression in the bladder leading to fibrosis, smooth muscle atrophy and non-compliance. Hypercholesterolemia also interferes with bladder structure and compliance but to a significantly lesser extent compared with CBI. Our studies suggest that arterial insufficiency and hypercholesterolemia, common aging-associated disorders, may play important roles in the pathophysiology of voiding dysfunction in the elderly.

Elettrovaporizzazione transuretrale della prostata: Risultati a un anno di distanza

Transurethral vaporisation of the prostate plays a leading role among the techniques for BPH treatment. Between April and December 1995 the authors treated 49 patients with BPH, all of whom benefited immediately. Assessment at the 12-month follow-up highlighted a reduction in IPSS to 7 and an increase in mean PFR to 23 ml/s. Complications were minimal. The immediate advantages of EVAP are widely acknowledged: little bleeding, absence of TUR syndrome, short catheter drainage, shorter hospitalisation and lower costs. The good PFR and IPSS values at 12 months confirm the effectiveness and safety of this technique, making it, in our opinion, even more interesting and less invasive for the surgical management of BPH.

The economics of benign prostatic hyperplasia treatment: a literature review

Benign prostatic hyperplasia (BPH) is one of the most common benign neoplasms in elderly men in the United States; it has been estimated that the annual costs of caring for these men exceed $4 billion. This condition is rarely life threatening, but often affects the individual's quality of life in varying degrees. There are several treatments for this condition, including surgery, with the most common procedure being transurethral resection of the prostate. Other treatment options include medication (such as finasteride and terazosin), balloon dilation, and watchful waiting. The cost associated with BPH depends on the severity of the disease and the appropriate course of treatment. The objective of this paper is to identify and evaluate the economic research papers that have considered either the economic burden or costs associated with alternative BPH therapy options and to identify key areas for future economic research. This review indicates that the economic studies of BPH are diverse in nature and greater attention needs to be placed on the societal appraisal of competing BPH therapies. Other research areas include the economic analysis of both short- and long-run BPH treatment options, increased cost-utility analysis, and the use of retrospective claims database analysis using regression techniques.

Initial human clinical experience with diode laser interstitial treatment of benign prostatic hyperplasia

OBJECTIVES

To report the initial results of treatment of outlet obstruction induced by benign prostatic hyperplasia (BPH) using interstitial laser coagulation performed with the Indigo 830 nm diode laser system.

METHODS

A group of 112 men with lower urinary tract symptoms caused by BPH underwent treatment with the Indigo 830 nm laser system between October 1994 and November 1995. Patients were assessed prior to treatment and at specified post-treatment intervals for symptom score, uroflow, postvoid residual, and prostate volume. Adverse events and changes in laboratory parameters were monitored at each post-treatment visit to investigate safety of the procedure.

RESULTS

Symptom score decreased from 20.9 at initial measurement to 9.6 at 3 months after procedure and 7.9 at 6 months. Uroflow rate increased from 8.0 mL/s initially to 15.2 and 14.2 mL/s at 3 and 6 months, respectively. Residual bladder volumes decreased from 105 mL initially to 59 and 38 mL at 3 and 6 months, respectively. There were no major complications (impotence, sustained incontinence, significant blood loss). Minor complications occurred in a small number of patients but were generally associated with urinary tract infection in patients with catheters. Three patients (2.7%) required retreatment and underwent transurethral resection of the prostate.

CONCLUSIONS

Interstitial laser coagulation using an 830-nm diode laser system appears to be a promising new treatment, with substantial improvements in objective and subjective parameters of obstruction and a favorable side-effect profile.

An estimate of the life-time cost of surgical treatment of patients with benign prostatic hyperplasia in Sweden

Two clinical series (n = 96 + 90) and one record-linkage study (n = 492) were used for estimation of the health care utilization for the treatment of BPH patients, mainly by TURP, in Sweden during one year before and 5-7 years after surgery. The total cost for a single patient amounted to ca. 33000 SEK in 1900 prices (5850 USD). Costs for surgery dominated and for a TURP amounted to about 70% of the Total. The costs during one year preoperatively and 5 years postoperatively each amounted to 15% of the total costs. In the present study the outcome of surgery was similar to other reports from the same period. The surgical mortality was 0.4% and the readmission rate because of complications of surgery or manifestations of BPH was 25% after 7 years of observation. Of the patients 11% were reoperated on within 7 years. When transurethral resection of the prostate (TURP) replaced open surgery in Sweden during the 1970's it had several of the attributes of the new methods introduced for treatment of benign prostate hyperplasia (BPH) currently in use. However, the spread of TURP resulted in wider indications for surgery and an increase in the total number of surgical procedures. An important argument for the adoption of the new, less invasive methods for treatment of BPH is the lower cost. To make a fair comparison of the costs of different methods for treatment of BPH the long-term costs have to be included in the calculation.