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Boruah P, Daoud RMEH, Walsh DV, Kharytaniuk N, Fredericks S, Ryan J, Abdelatif A, Birido N, Walsh TN. Patient's Perception of the Role of Gym Activity in Abdominal Wall Herniation in Adults: A Prospective Study. SPORTS MEDICINE - OPEN 2024; 10:88. [PMID: 39134817 PMCID: PMC11319541 DOI: 10.1186/s40798-024-00749-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/02/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Despite significant changes in healthcare, work practices, and leisure activity, the proposed precipitating factors for abdominal wall hernias have remained largely unchanged for almost two centuries. We aimed to investigate if there have been shifts in these factors over time by examining patients' perception of precipitating factors for abdominal wall hernia development. This study was conducted in the Royal College of Surgeons In Ireland Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, where patients with abdominal wall hernias completed a questionnaire . RESULTS A total of 277 patients (mean age 55.7; 85.6% male) with abdominal wall hernia completed the questionnaire (66.1% inguinal; 10.8% umbilical; 6.9% paraumbilical; 10.5% epigastric; 3.2% incisional; 1.4% femoral, and 1.1% port-site). One hundred and twenty patients (43.3%) believed their hernia was due to lifting, 71 (25.6%) cited gym activity and 17 (6.1%) cited other sporting activities as the precipitating factor. Traditional factors - chronic cough and constipation - were cumulatively cited only by 11 patients (4.0%), while prostatic obstruction was not cited by any. CONCLUSION This study suggests that fitness pursuits may be an increasing contributor to the development of abdominal wall hernia. Greater attention should be paid to the proper use of gym equipment to minimise the risk of hernia development.
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Affiliation(s)
- Prabir Boruah
- Department of Surgery, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
| | - Rabbani Mahmoud ElSayed Hassan Daoud
- Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain.
- Department of Surgery, Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain.
| | - Dylan Viani Walsh
- Department of Surgery, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
| | - Natallia Kharytaniuk
- Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain
- Academic Department of Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland
| | - Salim Fredericks
- Department of Biochemistry, Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain
| | - James Ryan
- Department of Surgery, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
| | - Asila Abdelatif
- Department of Surgery, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
| | - Nuha Birido
- Department of Surgery, Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain
| | - Thomas Noel Walsh
- Department of Surgery, Royal College of Surgeons in Ireland, Connolly Hospital, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland - Medical University Bahrain, Busaiteen, Bahrain
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Benign Prostatic Hyperplasia and Kidney Stone Disease Thermobalancing Therapy with Dr Allen’s Device: Key to Successful Ageing Without Medications, Surgery, and Risky Exposure to Coronavirus Infection. Nephrourol Mon 2021. [DOI: 10.5812/numonthly.110771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The choice of treatment for benign prostatic hyperplasia (BPH) and kidney stone disease (KSD) impacts the attainment of successful ageing and the level of patient care required in the long-term. Medications and surgeries typically used for these conditions have serious side effects and can interfere with healthy aging. Objectives: This study assesses the impact of Dr Allen’s Therapeutic devices (DATD) and thermobalancing therapy® (TT) on the ageing process of people with BPH and KSD. Methods: This study evaluated the outcomes of a clinical trial investigating the dynamics of symptoms and parameters in 124 male patients with BPH who used DATD as a monotherapy for six months at home and compared the results with a control group comprising 124 BPH patients who did not receive treatment with DATD. Furthermore, five case studies were randomly selected for assessment from 10-year empirical observations of patients with KSD treated with DATD. Results: DATD with TT reduced prostate volume (PV) from 45 mL to 31 mL (P < 0.001) and reduced urinary symptoms score from 14.2 to 4.9 (P < 0.001). It also improved quality of life (QoL) as measured by the reduction in the International Prostate Symptom score (I-PSS) from 3.9 to 1.3 (P < 0.001), while the control group showed no positive changes. DATD with TT dissolved kidney stones without renal colic in all patients. No side effects were observed. Conclusions: Using DATD and TT to treat BPH and KSD demonstrated high efficacy, safety, and easy disease management at home. In contrast, medications and surgeries for BPH and KSD often lead to sexual dysfunction, depression, hypertension, chronic kidney failure, and other morbidities, requiring an increased care level in the long-term. Thus, DATD and TT generate high treatment efficacy with lower exposure to coronavirus, reduce long-term care needs, and are vital to attaining successful ageing and longevity.
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Changes in Prevalence and Treatment Pattern of Benign Prostatic Hyperplasia in Korea. Int Neurourol J 2021; 25:347-354. [PMID: 33504124 PMCID: PMC8748302 DOI: 10.5213/inj.2040412.206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022] Open
Abstract
Purpose Benign prostatic hyperplasia (BPH) is associated with lower urinary tract symptoms and negatively affects the quality of life. We aimed to investigate the treatment pattern of BPH in South Korea. Methods Information on treatment modalities and diagnoses of BPH was obtained from the Health Insurance Review and Assessment Service-Aged Patient Sample. Data on BPH patients aged >60 years from 2012 to 2016 were obtained. We surveyed the treatment pattern of BPH, including the types of drugs used and surgeries performed, according to the type of institution. Results In this study, 18,260-24,657 BPH patients treated between 2012 and 2016 were included. The number of patients showed an increasing pattern, and drug therapy was the major treatment method used for BPH (98.77%). Moreover, the pattern of increased pharmacotherapy use for BPH was reinforced by the increasing number of patients. Prescription of α-blockers only was dominant in this cohort (45.7%). Transurethral resection of the prostate (TURP) was the most commonly used surgical treatment for BPH (53.6%), but it showed a decreasing pattern over time. In contrast, holmium laser enucleation of the prostate (HoLEP) showed an increase from 19.4% to 39.7%. Conclusions The most common treatment for BPH was drug therapy, predominantly only α-blocker therapy. The surgical treatment trend has changed from TURP to HoLEP.
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Valladales-Restrepo LF, Machado-Alba JE. Potentially inappropriate prescriptions of anticholinergic drugs in patients with benign prostatic hyperplasia. Aging Male 2020; 23:785-792. [PMID: 30955405 DOI: 10.1080/13685538.2019.1595572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prostatic hyperplasia is frequent in the elderly, and it can be associated with urinary retention in patients who use cholinergic antagonists. The objective was to estimate the anticholinergic burden of drugs prescribed to patients diagnosed with benign prostatic hyperplasia. METHODS A cross-sectional study using a population database to identify prescriptions of cholinergic antagonists drugs used in the management of benign prostatic hyperplasia. The anticholinergic burden was evaluated using the Anticholinergic Drug Scale. RESULTS Three thousand seven hundred and sixty patients with benign prostatic hyperplasia were identified, with a mean age of 68.26 ± 10.46 years. Of these patients, 2961 (78.8%) received pharmacological treatment mainly with tamsulosin monotherapy (34.7%, n = 1026). Overall, 34.7% (n = 1303) of all patients were taking cholinergic antagonists. Patients aged 75-84 years (OR: 1.985, 95%CI: 1.063-3.709) and those 85 or older (OR: 2.52, 95%CI: 1.287-4.948) had a greater probability of having an anticholinergic burden score ≥3 points. Of the patients not receiving pharmacological treatment for benign prostatic hyperplasia, 35% (n = 280) were taking medications with anticholinergic properties. CONCLUSIONS A high proportion of patients with benign prostatic hyperplasia were receiving medical management for the relief of symptoms, mostly via monotherapy. However, one-third of patients received some type of medication with anticholinergic properties, being much more frequent after 75 years.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira-Audifarma S.A, Pereira, Colombia
- Fundación Universitaria Autónoma de las Américas, Avenida de las Américas Calle, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira-Audifarma S.A, Pereira, Colombia
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Sung SY, Le TTH, Chen JH, Hsieh TF, Hsieh CL. Alpha-1 blocker use increased risk of subsequent renal cell carcinoma: A nationwide population-based study in Taiwan. PLoS One 2020; 15:e0242429. [PMID: 33211759 PMCID: PMC7676733 DOI: 10.1371/journal.pone.0242429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Elevated Renal cell carcinoma (RCC) risk has been associated with the use of several antihypertensive medications but has not yet been elucidated in the populations prescribed alpha-1 blockers that are commonly used in the treatment of hypertension and lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS-BPH). The aim of the present study was to investigate the association between alpha-1 blocker use and the risk of developing RCC using a nationwide population-based database in Taiwan. Patients who were treated with alpha-1 blockers for at least 28 days were identified through the Taiwan National Health Insurance Research Database from 2000 to 2010. The unexposed participants were matched with the exposed cases according to age, sex, and index year at a ratio of 3:1. Cox proportional hazards regression, stratified by sex and comorbidities and adjusted for age, was performed to estimate hazard ratios (HRs) for the risk of subsequent RCC. Among 2,232,092 subjects, patients who received alpha-1 blocker treatment had a higher risk of RCC than the unexposed group. Taking into account hypertension and BPH, the adjusted HR was significantly higher in male alpha-1 blocker users who had no BPH and either the presence (HR: 1.63, 95% confidence interval [CI] = 1.22–2.18) or absence (HR: 2.31, 95% CI = 1.40–3.81) of hypertension than in men not receiving these drugs. Taken together, male alpha-1 blocker users who had no comorbidity of BPH exhibited an increased risk for developing RCC independent of hypertension. Further study is warranted to elucidate the underlying mechanisms of this association.
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Affiliation(s)
- Shian-Ying Sung
- The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Ph.D. Program for Translational Science, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, Taiwan
- Office of Human Research, Taipei Medical University, Taipei, Taiwan
| | - Trang Thi Huynh Le
- International Master/Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jin- Hua Chen
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Research Center of Biostatistics, College of Management, Taipei Medical University, Taipei, Taiwan
- Biostatistics Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Teng-Fu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Chia-Ling Hsieh
- The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Ph.D. Program for Translational Science, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Morton A, Williams M, Perera M, Teloken PE, Donato P, Ranasinghe S, Chung E, Bolton D, Yaxley J, Roberts MJ. Management of benign prostatic hyperplasia in the 21st century: temporal trends in Australian population-based data. BJU Int 2020; 126 Suppl 1:18-26. [PMID: 32558340 DOI: 10.1111/bju.15098] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018. PATIENTS AND METHODS Annual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000-2018. Population-adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH. RESULTS Overall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezūm™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply. CONCLUSION Despite reduced national BPH-related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted.
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Affiliation(s)
- Andrew Morton
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Michael Williams
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Marlon Perera
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Patrick E Teloken
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Peter Donato
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sachinka Ranasinghe
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Eric Chung
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Andro Urology Centre, Brisbane, Queensland, Australia
| | - Damien Bolton
- Department of Surgery, Austin Health, The University of Melbourne, Parkville, Victoria, Australia
| | - John Yaxley
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Nepean Urology Research Group, Nepean Hospital, Kingswood, New South Wales, Australia.,Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia
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Kričković Z, Simatović M, Lukić D, Stanojević A, Škrbić V, Janjić G. Frequency of common complications during treatment of patients with benign prostate hyperplasia. SCRIPTA MEDICA 2020. [DOI: 10.5937/scriptamed51-25726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Moon HW, Yang JH, Choi JB, Bae WJ, Cho HJ, Hong SH, Lee JY, Kim SW, Park SH, Han K, Ha US. Prescription pattern of alpha-blockers for management of lower urinary tract symptoms/benign prostatic hyperplasia. Sci Rep 2018; 8:13223. [PMID: 30185936 PMCID: PMC6125595 DOI: 10.1038/s41598-018-31617-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/17/2018] [Indexed: 11/09/2022] Open
Abstract
This study investigated trends in the prescription of α-blockers for patients with BPH, focusing on changing patterns of prescriptions during 2002–2013 using National Health Insurance Service-National Sample Cohort data. A total of 65,596 Korean males over 50 years old diagnosed with BPH were identified from the NHIS-NSC database between 2002–2013. Patterns of each α -blocker prescription were analyzed and persistence rate, switch rate, and return rate during a follow-up period of 3 years after the first prescription were calculated. A total of 28,318 men over 50 years old (64.95 ± 9.12), changed medication within six months following the first prescription of α -blocker. (1) Tamsulosin showed the highest persistence rate when compared with other α-blockers (2) Among patients who switched to a second α-blocker, tamsulosin showed the highest return rate when compared with other α-blockers. Tamsulosin has been the most commonly prescribed α1-blocker since the mid-2000s, in line with its demonstrated highest persistence and return rates. These data probably reflect patient satisfaction with α1-blockers in the management of BPH, in which the decision to stop and switch pharmacological treatments is primarily based on changes in symptoms or side effects.
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Affiliation(s)
- Hyong Woo Moon
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Hyup Yang
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Bong Choi
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woong Jin Bae
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyuk Jin Cho
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hoo Hong
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Youl Lee
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sae Woong Kim
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Hyun Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - U-Syn Ha
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Clinical Implications for the Early Treatment of Benign Prostatic Enlargement (BPE): a Systematic Review. Curr Urol Rep 2018; 19:70. [PMID: 29987480 DOI: 10.1007/s11934-018-0823-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW Therapeutic options for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have considerably increased in recent years. However, the ideal timing to initiate medical treatment of LUTS/BPE has not been fully established. The aim of this review was to systematically collect available evidence on the influence of early treatment on the natural history of LUTS/BPE patients. RECENT FINDINGS A systematic literature search from January 1996 until April 2018 was performed by combining the following MESH terms: Lower Urinary Tract Symptoms, Benign Prostatic Enlargement, male, medical treatment, surgical treatment, early treatment/intervention, and early intervention/treatment. The Medline, PubMed, and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness with regard to the topic of this review. In recent years, the medical armamentarium for the management of LUTS secondary to BPE has been extensively implemented, significantly improving treatment outcomes and markedly reducing the need for BPE surgery. Early intervention in patients at risk for disease progression may offer better clinical outcomes compared to a deferred approach. However, evidences supporting early treatment are scarce, and criteria to discriminate patients that could mostly benefit from immediate treatment remain poorly defined. Moreover, as a result of delayed surgery after prolonged medical treatment, patients undergoing surgical relief show larger prostates, older age, and comorbidities. Nevertheless, technological advancements in surgical techniques have largely counterweighed this critical scenario, and commonly, a non-pejorative trend has been reported in perioperative complications. The timeliest moment to start a medical treatment in LUTS/BPE patients is still undefined, and unexpectedly, peer-reviewed evidence remains scarce. Further studies are awaited to better discriminate patients who mostly benefit from early treatment of LUTS/BPE.
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Is early benign prostatic hyperplasia (BPH) treatment worthwhile? Urologia 2017; 84:142-147. [PMID: 28665456 DOI: 10.5301/uj.5000251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND The medical armamentaria for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have been extensively implemented over the past decade. Nevertheless, the timeliest moment for a possible treatment has not been fully established. EVIDENCE ACQUISITION A systematic literature search in January 1996 until June 2016 was performed to answer the following question: in men with LUTS due to BPH, does early treatment result in better outcome? An ad hoc Population/patient Intervention/indicator Comparator/control Outcome (PICO) was developed.The Medline, PubMed and Scopus databases were searched. Each article title and abstract were reviewed for relevance and appropriateness with regard to the topic of this review. EVIDENCE SYNTHESIS Overtime, the introduction of novel medications and the implementation of surgical techniques have significantly improved the treatment outcomes and markedly reduced the rate of BPH surgery. Early treatments in patients at risk of disease progression may result in better clinical outcomes than a delayed approach. However, the evidence to support early intervention remains weak and criteria to identify the patient phenotype that could best benefit from immediate treatment remain ill-defined.On the contrary, the patients who ultimately undergo surgery following prolonged pharmacological treatment present with larger prostates, older age and comorbidities. At the same time, the technological progress has partly compensated this critical scenario, and commonly, a nonpejorative trend has been recorded in perioperative complications. CONCLUSIONS The ideal moment to begin a treatment in LUTS/BPH patients is still uncertain, and surprisingly, rare good quality studies are available on this topic.
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Presicce F, De Nunzio C, Tubaro A. Can Long-term LUTS/BPH Pharmacological Treatment Alter the Outcomes of Surgical Intervention? Curr Urol Rep 2017; 18:72. [DOI: 10.1007/s11934-017-0721-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Drake MJ, Bowditch S, Arbe E, Hakimi Z, Guelfucci F, Amri I, Nazir J. A retrospective study of treatment persistence and adherence to α-blocker plus antimuscarinic combination therapies, in men with LUTS/BPH in the Netherlands. BMC Urol 2017; 17:36. [PMID: 28532455 PMCID: PMC5440896 DOI: 10.1186/s12894-017-0226-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/02/2017] [Indexed: 12/04/2022] Open
Abstract
Background To assess treatment persistence and adherence in men ≥45 years of age with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH), using prescription records from the Netherlands IMS Lifelink™ LRx database. Methods In this retrospective, observational cohort study, we identified men who received combination therapy with an α-blocker plus an antimuscarinic (e.g. solifenacin or tolterodine) between 1 November 2013 and 31 October 2014. Treatment could be received as a fixed-dose combination (FDC) tablet or as two drugs administered together (concomitant therapy), if both combination drugs were prescribed within 30 days. The primary objective was to assess treatment persistence, defined as the time from initiation of combination therapy until first discontinuation of the FDC or at least one of the drugs given concomitantly (i.e. ≥30 days without prescription renewal). Subgroup and sensitivity analyses were conducted to assess persistence by antimuscarinic agent, and with different gap lengths used to define discontinuation (45, 60 and 90 days), respectively. Results A total of 1891 men received an α-blocker plus an antimuscarinic (FDC, N = 665; concomitant therapy, N = 1226). Median time to discontinuation was significantly longer with FDC versus concomitant therapy (414 vs. 112 days; adjusted hazard ratio [HR] 2.04, 95% confidence interval 1.77, 2.35; p < 0.0001). Persistence at 12 months (51.3% vs. 29.9%) was also significantly greater with FDC compared with concomitant therapy. Assessment of antimuscarinic subgroups showed that median time to discontinuation was longest with solifenacin combinations (214 days) compared with other antimuscarinic combinations (range, 47–164 days; adjusted HR range, 1.27–1.77, p = 0.037). No observable impact on treatment persistence was found by adjusting the gaps used to define discontinuation. Discussion This study of real-world evidence of men with LUTS/BPH treated with α-blocker plus antimuscarinic combination therapy in the Netherlands showed that treatment persistence was significantly greater in those who received a FDC tablet compared with combination therapy given concomitantly. The study also shows that treatment persistence was extended in men who received combination therapy containing solifenacin compared with other antimuscarinics. Conclusions Overall, these findings may be useful for prescribers, as improved persistence on-treatment may translate into improved outcomes for men with LUTS/BPH. Further study is warranted to establish the key drivers of persistence in men receiving combination therapy for LUTS/BPH. Electronic supplementary material The online version of this article (doi:10.1186/s12894-017-0226-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marcus J Drake
- Bristol Urological Institute and the School of Clinical Sciences, University of Bristol, Bristol, UK.
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Lin W, Lee S, Wu J, Kuo Y, Hsieh T. 5-alpha-reductase inhibitor therapy postpones urine retention and prostate surgery in patients with prostate enlargement and a maximum uroflow rate of less than 15 ml/sec. PLoS One 2017; 12:e0175356. [PMID: 28394903 PMCID: PMC5386275 DOI: 10.1371/journal.pone.0175356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/26/2017] [Indexed: 11/19/2022] Open
Abstract
Background This study investigated the risk of transurethral resection of prostate (TURP) and acute urine retention (AUR) in relation to 5-alpha-reductase inhibitor (5ARI) therapy. Methods We identified 22,687 patients who were newly diagnosed with PE and low urinary tract symptoms (LUTS) between January 1, 2002 and December 31, 2011. We further classified study subjects who had moderate to severe LUTS and a maximum uroflow rate of less than 15ml/sec into three groups by their defined daily dose (DDD) of 5ARI used. The control group consisted of 7–28 cumulative DDD (cDDD) 5ARI users, while the short-term treatment group was 29-179cDDD 5ARI users, and the long-term treatment group was users of more than 180cDDD 5ARI. Each patient was monitored to identify those who subsequently developed TURP and AUR. Results TURP and AUR are detected in 5.6% of control group, 7.6% of short-term treatment group and 5.5% of long-term treatment group during 10-year follow up. Compared with the control group, there was no difference in the risk of TURP and AUR in the short-term and long-term treatment groups (HR = 1.41, 95% CI 0.76 to 2.62 and HR = 0.81, 95% CI 0.42 to 1.56, respectively). Conclusion 5ARI therapy did not change the risk of TURP and AUR events in patients with PE, moderate to severe LUTS and a maximum uroflow rate of less than 15 ml/sec in 10 years of follow-up. But long-term 5ARI used can postpone AUR and TURP for 8.16 months.
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Affiliation(s)
- Wenhsu Lin
- Department of Urology, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan
| | - Shangsen Lee
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Jengyuan Wu
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Yuhung Kuo
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Tengfu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- * E-mail:
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Tratamiento a largo plazo de los síntomas del tracto urinario inferior en personas mayores. Semergen 2016; 42:e167-e168. [DOI: 10.1016/j.semerg.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 12/01/2015] [Indexed: 11/20/2022]
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15
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Alcántara-Montero A, Brenes-Bermúdez F. Finasteride or dutasteride for the pharmacological treatment for male lower urinary tract symptoms due to benign prostatic hyperplasia? Actas Urol Esp 2016; 40:268-9. [PMID: 26774534 DOI: 10.1016/j.acuro.2015.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
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Bishr M, Boehm K, Trudeau V, Tian Z, Dell'Oglio P, Schiffmann J, Jeldres C, Sun M, Shariat SF, Graefen M, Saad F, Karakiewicz PI. Medical management of benign prostatic hyperplasia: Results from a population-based study. Can Urol Assoc J 2016; 10:55-9. [PMID: 26977208 DOI: 10.5489/cuaj.3058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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%).
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Affiliation(s)
- Mohamed Bishr
- Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada;; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada
| | - Katharina Boehm
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada;; Martini-Klinik am Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Trudeau
- Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada;; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada;; McGill University, Department of Epidemiology, Biostatistics and Occupational Health, Montreal, QC, Canada
| | - Paolo Dell'Oglio
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada;; Division of Oncology, Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jonas Schiffmann
- Martini-Klinik am Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Claudio Jeldres
- Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada
| | - Sharokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Markus Graefen
- Martini-Klinik am Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fred Saad
- Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada
| | - Pierre I Karakiewicz
- Department of Urology, University of Montreal Health Centre, Montreal, QC, Canada;; Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, QC, Canada
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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. Int Urol Nephrol 2016; 48:645-56. [PMID: 26810324 PMCID: PMC4839045 DOI: 10.1007/s11255-015-1206-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/28/2015] [Indexed: 12/04/2022]
Abstract
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.
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Actualización en el tratamiento médico de los síntomas del tracto urinario inferior en el varón. Semergen 2016; 42:31-7. [DOI: 10.1016/j.semerg.2015.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 11/21/2022]
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Staszewsky L, Cortesi L, Baviera M, Tettamanti M, Marzona I, Nobili A, Fortino I, Bortolotti A, Merlino L, Disertori M, Latini R, Roncaglioni MC. Diabetes mellitus as risk factor for atrial fibrillation hospitalization: Incidence and outcomes over nine years in a region of Northern Italy. Diabetes Res Clin Pract 2015. [PMID: 26220013 DOI: 10.1016/j.diabres.2015.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIMS Diabetes mellitus (DM) and atrial fibrillation (AF) are worldwide public health challenges and major causes of death and cardiovascular events. The association between DM and AF is controversial in literature and data on outcomes of individuals with both diseases have not been evaluated in population studies. We tested the hypothesis that DM is independently associated to AF hospitalization and assessed the risk of stroke and mortality in people with both conditions. METHODS We conducted a population-based cohort-study of DM patients and their corresponding controls identified in a administrative health database of the Lombardy Region. Both cohorts were followed for nine years. A multivariable Cox proportional-hazards-regression model was used to estimate the hazard ratio (HR) for first hospitalization for AF and for clinical outcomes. RESULTS Out of 9,061,258 residents, 285,428 (3.14%) DM subjects were identified, mean age 65.8±15 years, 49% were women. The cumulative incidence of AF in DM was 10.4% vs. 7.4% in non-DM. DM was a risk factor for AF (HR 1.32, 95% CI 1.30-1.34; p<0.0001). Oral anticoagulants were prescribed in 34.8% of DM patients with AF. DM associated with AF, presented the highest HR for stroke: 2.63; 95% CI 2.47-2.80 and for total death, HR 2.41; 95% CI 2.36-2.47. CONCLUSIONS In this population study, DM was an independent risk factor for AF hospitalization. DM patients with AF had the highest risk of stroke and total mortality. Early identification of AF and a structured plan to optimize the comprehensive management of DM and AF patients is mandatory.
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Affiliation(s)
- Lidia Staszewsky
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Cardiovascular Clinical Pharmacology, Milan, Italy.
| | - Laura Cortesi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Marta Baviera
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Mauro Tettamanti
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Geriatric Neuropsychiatry, Milan, Italy
| | - Irene Marzona
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Alessandro Nobili
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory for Quality Assessment of Geriatric Therapies and Services, Milan, Italy
| | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | | | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | | | - Roberto Latini
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Cardiovascular Clinical Pharmacology, Milan, Italy
| | - Maria Carla Roncaglioni
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
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Hsieh TF, Yang YW, Lee SS, Lin TH, Liu HH, Tsai TH, Chen CC, Huang YS, Lee CC. Use of 5-alpha-reductase inhibitors did not increase the risk of cardiovascular diseases in patients with benign prostate hyperplasia: a five-year follow-up study. PLoS One 2015; 10:e0119694. [PMID: 25803433 PMCID: PMC4372445 DOI: 10.1371/journal.pone.0119694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 01/15/2015] [Indexed: 01/14/2023] Open
Abstract
Background This nationwide population-based study investigated the risk of cardiovascular diseases after 5-alpha-reductase inhibitor therapy for benign prostate hyperplasia (BPH) using the National Health Insurance Research Database (NHIRD) in Taiwan. Methods In total, 1,486 adult patients newly diagnosed with BPH and who used 5-alpha-reductase inhibitors were recruited as the study cohort, along with 9,995 subjects who did not use 5-alpha-reductase inhibitors as a comparison cohort from 2003 to 2008. Each patient was monitored for 5 years, and those who subsequently had cardiovascular diseases were identified. A Cox proportional hazards model was used to compare the risk of cardiovascular diseases between the study and comparison cohorts after adjusting for possible confounding risk factors. Results The patients who received 5-alpha-reductase inhibitor therapy had a lower cumulative rate of cardiovascular diseases than those who did not receive 5-alpha-reductase inhibitor therapy during the 5-year follow-up period (8.4% vs. 11.2%, P=0.003). In subgroup analysis, the 5-year cardiovascular event hazard ratio (HR) was lower among the patients older than 65 years with 91 to 365 cumulative defined daily dose (cDDD) 5-alpha-reductase inhibitor use (HR=0.63, 95% confidence interval (CI) 0.42 to 0.92; P=0.018), however there was no difference among the patients with 28 to 90 and more than 365 cDDD 5-alpha-reductase inhibitor use (HR=1.14, 95% CI 0.77 to 1.68; P=0.518 and HR=0.83, 95% CI 0.57 to 1.20; P=0.310, respectively). Conclusions 5-alpha-reductase inhibitor therapy did not increase the risk of cardiovascular events in the BPH patients in 5 years of follow-up. Further mechanistic research is needed.
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Affiliation(s)
- Teng-Fu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Yu-Wan Yang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Shang-Sen Lee
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Tien-Huang Lin
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Hsin-Ho Liu
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Tsung-Hsun Tsai
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Chi-Cheng Chen
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Yung-Sung Huang
- Division of Neurology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- * E-mail: (YSH); (CCL)
| | - Ching-Chih Lee
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- Department of Education, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- Center for Clinical Epidemiology and Biostatistics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- * E-mail: (YSH); (CCL)
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