Patients With Prostatic Inflammation Undergoing Transurethral Prostatic Resection Have a Larger Early Improvement of Storage Symptoms

Development and validation of a clinical nomogram to predict prostatic inflammation in men with lower urinary tract symptoms

BACKGROUND

Prostatic inflammation is an important etiological component of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). The Prostatic Inflammation Nomogram Study (PINS) aimed to develop and validate a nomogram for predicting the presence of prostatic inflammation in men with LUTS.

METHODS

This non-interventional, cross-sectional, prospective study was conducted in six secondary/tertiary centers across Cyprus, Greece, Italy, Portugal, and Spain. Men (≥40 years) with BPH/LUTS scheduled to undergo prostatic surgery or transrectal ultrasound-guided (TRUS) prostate biopsy were included. Fifteen demographic and clinical participant characteristics were selected as possible predictors of prostatic inflammation. The presence of inflammation (according to Irani score) in the prostatic tissue samples obtained from surgery/TRUS biopsy was determined. The effect of each characteristic on the likelihood a prostate specimen demonstrated inflammation (classified by Irani score into two categories, 0-2 [no/minimal inflammation] or 3-6 [moderate/severe inflammation]) was assessed using multiple logistic regression. A nomogram was developed and its discriminatory ability and validity were assessed.

RESULTS

In total, 423 patients (mean age 68.9 years) were recruited. Prostate volume ultrasound (PVUS) > 50 mL, history of urinary tract infection (UTI) treatment, presence of diabetes, and International Prostate Symptom Score (IPPS) Storage score were statistically significant predictors of Irani classification. Logistic regression demonstrated a statistically significant effect for leucocytes detected via urine dipstick, presence of diabetes, PVUS > 50 mL, history of UTIs, and higher IPSS Storage score for the odds of an inflammatory score category of 3-6 versus 0-2. The nomogram had a concordance index of 0.71, and good internal validity.

CONCLUSIONS

The nomogram developed from PINS had good predictive ability and identified various characteristics to be predictors of prostatic inflammation. Use of the nomogram may aid in individualizing treatment for LUTS, by identifying individuals who are candidates for therapies targeting prostatic inflammation.

Unveiling prostatic inflammation to optimize management of lower urinary tract symptoms: a discussion with experts

Benign prostatic obstruction (BPO) and associated lower urinary tract symptoms (LUTS) are common conditions in men, which increase in frequency and severity with age, and have a significant impact on quality of life. Chronic prostatic inflammation is increasingly being recognized as a key component of BPO. This may lead to new targets for the management of BPO/LUTS. This podcast is based on presentations from a symposium titled 'Unveiling prostatic inflammation to optimize LUTS management' held at the European Association of Urology 2023 Congress. The presenters outline evidence of a role for prostatic inflammation in the development and progression of BPO/LUTS, approaches to the identification of biomarkers of inflammation, and the implications of prostatic inflammation for the optimal management of BPO/LUTS.

Prostatic resection cavity large stone post transurethral resection of the prostate (TURP). A rare case scenario

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Prostatic cavity stone post TURP should be highlighted in the surgeon mind in patient with persistent storage LUTS post TURP.

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CT adequately burden the stone suspected.

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Persistent storage symptoms post TURP was the main complaint.

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Incidental stone occupying the prostatic fossa post TURP is a remote possibility but it should by highlighted to raise urologist awareness for its possibility.

Introduction

Transurethral resection of the prostate (TURP) compromise the mainstay surgical treatment of LUTS due to benign prostatic hyperplasia (BPH). The storage symptoms post TURP may be attributed to urinary tract infection (UTI), preoperative detrusor over-activities, and residual prostatic adenoma causing voiding symptoms.

Presentation of case

A 56 year old male presented storage LUTS (mainly frequency and urgency) since two years. Two years earlier, he underwent uncomplicated monopolar TURP. The patient has occasional straining and intermittent urine. No history of hematuria. No notable medical history was present. Digital rectal examination showed small prostate. Anal tone and Bulbocavernosal reflex were intact. CT showed a large vesical stone extending into the prostatic fossa measuring 51.5 mm × 67.0 mm. The patient was managed by suprapubic cystolitholapaxy.

Discussion

Post TURP LUTS necessitates evaluation with a thorough history and physical, including International Prostate Symptom Score, and urine culture to rule out infection. In a rare case report, delayed occurrence of storage and obstructive voiding symptoms after TURP can be caused by dystrophic calcification of the prostatic resection cavity. The stone could have been due to a metal or plastic piece of the resectoscope embedded in the prostatic cavity, but, this postulation was deferred based on the non-attached stone to the mucosa as confirmed by cystoscope. In such case, based on the large stone burden, more cost would be a potential burden, and longer operative time, the open cystolitholapaxy is the modality of choice.

Conclusion

Prostatic cavity stone is a rare pathology. Incidental stone occupying the prostatic fossa post TURP is a remote possibility but it should by highlighted to raise urologist awareness for its possibility.

Phamacological treatment of persistant lower urinary tract symptoms after a transurethral resection of the prostate is predictive of a new surgical treatment: 10 years follow-up study

AIM

To evaluate possible risk factors of re intervention in patients with benign prostatic enlargement (BPE) undergoing transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

A consecutive series of patients with LUTS and BPE underwent TURP in our center in 2004 and 2005 and they were then followed up to September 2016. Patients were assessed at baseline, 3-, 6-month postoperatively and yearly thereafter with medical history, international prostate symptom score, prostate specific antigen, maximal urinary flow rate, post void residual urine. Reoperation was defined as the requirement of a new TURP to relieve bothersome LUTS. Cox regression was used to determine covariates associated with reoperation rate and the Kaplan-Meier curve assessed the time to reoperation.

RESULTS

Overall, 92 patients were enrolled. Median follow up was 142 months. 13 patients underwent a second TURP during the follow-up period (reoperation rate was 14%); out of them 9/13 (69%) received medical treatment for persistent LUTS (p = .001). The need of LUTS/BPE pharmacological treatment after TURP is an independent risk factor for a second surgical procedure (odds ratio 9,3; p = .001). Out of the 13 patients treated with a re-TURP, 12 (92%) underwent surgery within 5 years of follow-up.

CONCLUSION

In our single center study, the need of LUTS/BPE pharmacological treatment was a predictive factor of a re-TURP. Considering that more than 90% of re-TURP were performed during the first 5 years of follow-up, it is assumable that a follow-up longer than 5 years is not needed in these patients.

The relation between the storage symptoms before and after transurethral resection of the prostate, analysis of the risk factors and the prevention of the symptoms with solifenacin

OBJECTIVE AND HYPOTHESIS

We aimed to investigate the reasons of storage symptoms ( SS) after transurethral resection of the prostate (TURP). The hypothesis was that a positive correlation would be identified between preoperative and postoperative SS in patients with undergoing TURP and starting early solifenacin treatment in patients with high preoperative SS would be reasonable. In addition, we aimed to analyze multiple other risk factors for post-TURP SS.

MATERIALS AND METHODS

A total of 160 patients undergoing TURP were prospectively evaluated and divided into two groups according to their OABS. Those with a score of ≥10 points were Group 1 (G1), and those with < 10 points Group 2 (G2). In addition, patients in each group were randomly further divided into two subgroups: those who were started on 5 mg solifenacin succinate in the early postoperative period (G1/G2 A) and those who were not (G1/G2 B). In additions to SS Preop, perop and at the 3rd-month of postoperatively 14 variable were evaluated. The effects of these factors, surgery and the efficacy of an early medical treatment on the postoperative SS were investigated. LUTS were assessed by International Prostate Symptom Score (IPSS) and SS were assessed by sum of IPSS 2, 4 and 7 questionnaires (Storage, S- IPSS).

RESULTS

Preoperative IPSS and S-IPSS were significantly higher in G1 (p< 0.001); there was a significant improvement at IPSS, S-IPSS, QoL score, Qmax, and PVR for all groups after surgery. Only preoperative S-IPSS was found to have significant effect on postoperative SS (p< 0.001). There was a significant difference between G1A and G1B but no significant difference between G2A and G2B in terms of SS at postoperatively. In addition to this, prostatic volume was found smaller than non-symptomatic patients in de novo SS patients.

CONCLUSION

TURP provides significant improvement in both storage and voiding symptoms. The predictive value of the preoperative S-IPSS on postop SS is significant. These results suggest that 5 mg solifenacin succinate treatment in the early postoperative period may be beneficial for patients with high preoperative SS and may not be beneficial in others. Small prostatic volume may bode ill for postoperative SS in the patients with de novo SS.

Impairment of autophagy may represent the molecular mechanism behind the relationship between obesity and inflammation in patients with BPH and LUTS

BACKGROUND

Aim of this study was to evaluate the roles of inflammation and autophagy in obese patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS).

METHODS

We analyzed 150 surgical specimens from patients underwent transurethral resection of the prostate (TURP) for LUTS/BPH (Median age 70.3±8.1 years, median BMI 25.7±4.0 kg/m² and median PSA 6.0±5.4 ng/mL). All surgical specimens were investigated for the presence inflammatory infiltrates, according to the standardized classification of chronic prostatitis of the National Institute of Health. The inflammatory score (IS Score) was calculated. High IS score was defined as ≥7. Each sample was stained for anti-LC3B (cell signaling) and for anti-P62/SQSTM1 (MBL) according to manufacturer's suggestions and scored as follow: 0 (no dots); 1 (detectable dots in 5-25% of cells); 2 (readily detectable dots in 25-75% of cells); 3 (dots in >75% of cells). High percentage of p62 or LC3B was defined as >25%, whereas low percentage of p62 or LC3B was defined as <25% of cells with dots.

RESULTS

Overall 74/150 (49.3%) patients were overweight or obese (BMI >25 kg/m²). Obese patients presented a higher inflammatory score. Obese/overweight patients presented a lower percentage of LC3B (58/74; 78.4%) and higher of p62 (49/74; 66.2%) compared to those of normal weight, which it means a deactivated autophagy (P<0.05). At multivariate analysis LC3B (OR=0.22; CI: 0.069-0.70; P=0.01) percentage and BMI (OR=1.118; CI: 1.001-1.250; P=0.04) were independent risk factors of prostatic inflammation (IS≥7).

CONCLUSIONS

Here we confirm the association between obesity and prostatic inflammatory infiltrates and present the first evidence of autophagy deregulation in obese patients with LUTS/BPH. Further studies should better investigate this relationship and provide new possible therapeutic targets.

Chronic prostatitis effectively managed by transurethral prostatectomy (TURP) in a spinal cord injury male

Introduction

Spinal cord injury (SCI), specifically suprasacral SCI, results in high intravesical pressures, elevated post-void residual and urinary incontinence which are all risk factors for urinary tract infections (UTIs). The management of UTIs usually is conservative medical antibiotic treatment. However, recurrent UTIs in the SCI patient population warrant further investigation. The method of urinary drainage (intermittent or indwelling urinary catheters, urinary diversion) and untreated complications of NLUTD (vesicoureteral reflux, stone formation, chronic incomplete emptying of the bladder) are risk factors for recurrent UTIs (rUTIs). Removal of these UTI risk factors and improving urinary drainage are goals of urologic management; however, when conservative interventions do not succeed, surgery may be a viable solution in select cases of rUTIs.

Case presentation

We present a case of complicated persisting rUTIs and associated urethral discharge in a middle-aged SCI male who manages his bladder with intermittent catheterization (IC). We detail the evaluation and management approach that leads to an eventual transurethral prostatectomy (TURP) as a final solution for his rUTIs. Fortunately, the surgical intervention was successful, and the patient is free of UTIs after 4 years of follow-up.

Discussion

In SCI male patients with rUTIs and suspected chronic prostatitis, TURP may be a valuable treatment option once all predisposing factors have been remediated.

Physical Activity as a Protective Factor for Lower Urinary Tract Symptoms in Male Patients: A Prospective Cohort Analysis

OBJECTIVE

To assess the association between physical activity, evaluated by the Physical Activity Scale for Elderly (PASE) questionnaire and lower urinary tract symptoms (LUTS) in male patients.

METHODS

From 2009 onward, a consecutive series of patients with LUTS-benign prostatic enlargement were enrolled. Symptoms were evaluated using the International Prostate Symptom Score (IPSS) with its subscores and prostate volume using transrectal ultrasound. Physical activity was evaluated with the PASE questionnaire, consisting of 12 questions regarding frequency and duration of leisure activity and recently used to evaluate physical activity in patients with prostatic disorders. The risk of detecting LUTS (IPSS ≥8), voiding LUTS (vIPSS≥5), and storage LUTS (sLUTS) (sIPSS ≥4) was evaluated using binary logistic regression analysis.

RESULTS

Six hundred and seventeen patients were enrolled in 2 centers (Rome, Vasto, Italy). Median PASE score was 118 (IQR 73/169), and median IPSS was 9 (IQR 5/15). Overall 189 of 617 (30%) patients presented moderate/severe LUTS. These patients presented a lower PASE score (111 IQR 69/160 vs 125 IQR 83/180; P = .016) when compared to patients with total IPSS ≤7. On multivariate analysis, PASE score (OR = 0.997 per unit, 95%CI: 0.994-1.000; P = .023), and prostate volume (OR = 1.008 per mL, 1.000-1.016; P = .045) were independent predictors of LUTS severity. As well PASE score was an independent predictor of moderate/severe sLUTS (OR = 0.996, 95%CI:0.993-0.999; P = .015).

CONCLUSION

In our study a reduced physical activity, assessed using the PASE questionnaire, is associated with an increased risk of moderate severe LUTS, more specifically of moderate/severe sLUTS.

Inflammatory mediators in the development and progression of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common urological disease in elderly men. Epidemiological data suggest a causal link between this condition and prostatic inflammation. The prostate is an immune-competent organ characterized by the presence of a complex immune system. Several stimuli, including infectious agents, urinary reflux, metabolic syndrome, the ageing process, and autoimmune response, have been described as triggers for the dysregulation of the prostatic immune system via different molecular pathways involving the development of inflammatory infiltrates. From a pathophysiological standpoint, subsequent tissue damage and chronic tissue healing could result in the development of BPH nodules.

Prostatic inflammation: a potential treatment target for male LUTS due to benign prostatic obstruction

BACKGROUND

The purpose of this narrative review is to evaluate the role of prostatic inflammation as a treatment target for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and provide an update on the available therapies.

METHODS

An extensive literature search was conducted for studies on established and investigational treatments with anti-inflammatory mechanism of action that has been assessed for the management of male LUTS due to BPO.

RESULTS

Data on phosphodiesterase 5 inhibitors, nonsteroidal anti-inflammatory drugs, vitamin D3 receptor analogs, phytotherapy, statins, and lifestyle changes have been reviewed and analyzed. Preclinical evidence has shown the anti-inflammatory effect of these treatments on prostate. However, there is a wide variation in the degree of mature of each therapy. In addition, there are significant differences between the studies in terms of design, number of patients, and duration of follow-up.

CONCLUSIONS

Several drugs classes have been investigated for their impact on prostatic inflammation and improvement of male LUTS. The reviewed data support the rationale for use of agents that may alter and improve the inflammatory environment in the prostate in men with LUTS, but further high-quality long-term studies are required for the exact positioning of the new drugs in daily practice.

Metabolic syndrome and smoking are associated with an increased risk of nocturia in male patients with benign prostatic enlargement

BACKGROUND

To evaluate the relationship between cigarette smoking, metabolic syndrome (MetS) and nocturia in patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE).

METHODS

From 2009 onward, a consecutive series of patients with LUTS/BPE were enrolled. Symptoms were assessed using the International Prostate Symptom Score (IPSS). Age, body mass index (BMI), smoker status, prostate volume (PV), prostate-specific antigen (PSA) levels, fasting glucose levels, triglyceride levels, and high-density lipoprotein levels were recorded. MetS was defined according to Adult Treatment Panel III criteria. Moderate/severe nocturia was defined as nocturnal micturition episodes ≥2.

RESULTS

Overall 492 patients were enrolled with median age and BMI of 68 years (IQR 61/74) and 26.5 kg/m² (IQR: 24/29), respectively. Moderate/severe nocturia was reported in 212 (43.1%) patients. MetS was diagnosed in 147 (29.9%) patients and out of them 89 (60.5%) complained moderate/severe nocturia (p = 0.001). Overall 187 (38%) patients were current smokers and out of them 99 (52%) presented moderate/severe nocturia(p = 0.034). Patients with moderate/severe nocturia were older (p = 0.001) and with larger prostate volume (p = 0.003). On multivariate analysis, age (OR: 1.067 per year, 95% CI: 1.036-1.098; p = 0.001), PV (OR: 1.011 per ml, 95% CI: 1.003-1.019; p = 0.006), MetS (OR: 2.509, 95% CI: 1.571-4.007; p = 0.001) and smoking (OR: 1.690, 95% CI: 1.061-2.693; p = 0.027) were associated with nocturia severity.

CONCLUSIONS

MetS and smoking doubled the risk of moderate/severe nocturia in patients with LUTS and BPE. Assessing smoking and metabolic status in LUTS/ BPE patients is suggested.

Predictors of Improvement in Storage Symptoms at Three Years After 120W GreenLight High Performance System Laser Treatment for Benign Prostate Hyperplasia

PURPOSE

This study was conducted to investigate the indicators of recovery in storage symptoms after GreenLight High Performance System photoselective vaporization of the prostate (HPS-PVP) in men with benign prostate hyperplasia.

METHODS

A total of 155 men with a baseline subtotal storage symptom score of international prostate symptom score (sIPSS) greater than or equal to six, who underwent HPS-PVP and were followed up on for as much as 3 years, were included in this retrospective study. Surgical outcomes were evaluated at 1, 3, 6, 12, 24, and 36 months after surgery. Improvement of storage symptoms was defined as a reduction greater than or equal to 30% of sIPSS after surgery compared to the baseline.

RESULTS

The mean age was 67.5 ± 7.8 years and the preoperative median prostate-specific antigen, mean total prostate volume, and sIPSS were 1.95 (0.97-5.27) ng/mL, 52.1 ± 32.5 mL, and 9.6 ± 2.6, respectively. The mean improvement rate of sIPSS after 3 years was 34.4%. Age was only associated with an improvement of sIPSS in the multivariate analysis (odds ratio = 0.889, p = 0.008). The mean improvement rates of sIPSS according to age group (<65 vs ≥65) were 44.7% and 26.0%, respectively.

CONCLUSIONS

Age can serve as an independent predictor of storage symptom improvement for as much as 3 years. Therefore, we suggest that older patients who are being considered candidates for surgical treatment should be further evaluated.

Autophagy deactivation is associated with severe prostatic inflammation in patients with lower urinary tract symptoms and benign prostatic hyperplasia

Autophagy is a conserved evolutionary process that allows cells to maintain macromolecular synthesis and energy homeostasis during starvation and stressful conditions. We prospectively evaluated the relationship between autophagy and prostatic inflammation in a series of transurethral prostatic resection samples. Inflammatory infiltrates were defined according to the standardized classification of chronic prostatitis of the National Institute of Health. The inflammatory score (IS score) was calculated. High IS score was defined as ≥7. Each sample was stained for anti-LC3B and for anti-P62/SQSTM1 and scored. High p62 or LC3B percentage was defined as >25%, whereas low was defined as <25% of cells with dots. We analyzed 94 specimens. Overall, 18/94 (19%) showed no sign of prostatic inflammation, whereas 76/94 (81%) presented inflammatory infiltrates. Inflammation was mild in 61/76 (80%), moderate/severe in 15/76 (20%). Patients with high p62 percentage were 62/94 (66%) while 32 (34%) showed low p62 percentage. Patients with high LC3B percentage were 37/94 (39%) while 57(61%) showed low LC3B percentage. Overall 42/94 (44%) patients presented a high p62 percentage and concomitant a low LC3B percentage. IS score was significantly higher in patients with a with high p62 percentage (median IS 7 (6/8) vs 5 (3/7); p= 0.04) and in patients with a low LC3B percentage (median IS 7 (6/8) vs 5 (3/7); p= 0.004) when compared to patients with a low p62 percentage or a high LC3B percentage respectively. On multivariate analysis, p62 (OR: 10.1, 95%CI: 2.6-38.6; p= 0,001) and LC3B expression (OR: 0.319; 95%CI: 0.112-0.907; p= 0.032) were independent predictors of a high IS. Here we present the first evidence of autophagy deregulation in prostatic inflammation. These results raise many questions about the mechanisms mediating the autophagy dysfunction and the links to prostatic inflammation that need to be addressed.

Effect of Tripterygium Wilfordii Polyglycoside on Experimental Prostatitis Caused by Ureaplasma Urealyticum in Rats

Background

Prostatitis is a common and refractory urological disease with complicated etiology. Ureaplasma urealyticum (UU) has a close relationship with human urinary tract infection that can induce nonbacterial prostatitis. Tripterygium wilfordii polyglycoside (TWP) is a non-steroidal immune inhibitor that causes significant immune suppression and anti-inflammatory effects. Its role in prostatitis caused by UU has not yet been established. The aim of this study was to investigate the effect of TWP on UU-infected prostatitis in a rat model.

Material/Methods

UU-infected prostatitis SD model rats were randomly divided into 2 groups: the prostatitis group (model group) and the TWP treatment group (treatment group). At 7 days after treatment, prostate weight, leucocyte count, lecithin corpuscles, UU infection rate, and UU microbe count were compared between the 2 groups. Serum inflammatory cytokines TNF-α was determined by ELISA, and ICAM-1 and NF-κB expression were detected.

Results

UU infection rate was 80% after modeling. The rat prostate weight and leucocyte count in the model group increased significantly, while lecithin corpuscles decreased. Compared with controls, inflammatory factor TNF-α, ICAM-1, and NF-κB expression were obviously higher (P<0.05). TWP markedly reduced prostate weight and leucocyte count, increased lecithin corpuscles, and decreased UU microbe count and TNF-α, ICAM-1, and NF-κB expression (P<0.05).

Conclusions

TWP can inhibit expression of inflammatory factors and may be useful in treating UU-infected prostatitis through reducing UU infection rate.