Evaluation of Intravesical Prostatic Protrusion as a Predictor of Dutasteride-Resistant Lower Urinary Tract Symptoms/Benign Prostatic Enlargement With a High Likelihood of Surgical Intervention

Recent developments in diagnostic ultrasound for lower urinary tract function

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

Exploring the Enigma of 5-ARIs Resistance in Benign Prostatic Hyperplasia: Paving the Path for Personalized Medicine

PURPOSE OF REVIEW

Despite the widespread utilization of 5-alpha reductase inhibitors (5-ARIs) for managing benign prostatic hyperplasia (BPH), certain BPH patients exhibit unresponsiveness to 5-ARIs therapy. This paper provides a comprehensive overview of the current perspectives on the mechanisms of 5-ARIs resistance in BPH patients and integrates potential biomarkers and underlying therapeutic options for 5-ARIs resistance. These findings may facilitate the development of novel or optimize more effective treatment options, and promote personalized medicine for BPH.

RECENT FINDINGS

The pathways contributing to resistance against 5-ARIs in certain BPH patients encompass epigenetic modifications, shifts in hormone levels, autophagic processes, and variations in androgen receptor structures, and these pathways may ultimately be attributed to inflammation. Promisingly, novel biomarkers, including intravesical prostatic protrusion, inflammatory factors, and single nucleotide polymorphisms, may offer predictive insights into the responsiveness to 5-ARIs therapy, empowering physicians to fine-tune treatment strategies. Additionally, on the horizon, GV1001 and mTOR inhibitors have emerged as potential alternative therapeutic modalities for addressing BPH in the future. After extensive investigation into BPH's pathological processes and molecular landscape, it is now recognized that diverse pathophysiological mechanisms may contribute to different BPH subtypes among individuals. This insight necessitates the adoption of personalized treatment strategies, moving beyond the prevailing one-size-fits-all paradigm centered around 5-ARIs. The imperative for early identification of individuals prone to treatment resistance will drive physicians to proactively stratify risk and adapt treatment tactics in future practice. This personalized medicine approach marks a progression from the current standard treatment model, emerging as the future trajectory in BPH management.

The prostatic middle lobe: clinical significance, presentation and management

The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.

[Diagnostic work-up of benign prostatic hyperplasia : The German S2e-guideline 2023 part 1]

BACKGROUND

Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH; in German guidelines: benign prostatic syndrome [BPS]) is the most frequent urological disease in men and can result in a considerable deterioration of quality-of-life. BPS can be associated with LUTS, benign prostatic enlargement (BPE), and bladder outlet obstruction (BOO) or benign prostatic obstruction (BPO), respectively. The expert group on BPS of the German Society of Urology has re-evaluated the tests for the assessment of BPH and provides evidence-based recommendations.

OBJECTIVES

Presentation and evidence-based rating of tests for the assessment of patients with BPS.

MATERIALS AND METHODS

Summary and overview of chapters 5, 6, and 8 of the latest long version of the German S2e guideline on BPS.

RESULTS

The diagnostic work-up should clarify (1) whether the complaints of the patient are caused by BPS, (2) how relevant the complaints are and whether treatment is necessary, (3) whether complications of the lower or upper urinary tract already exist, and (4) which treatment will be most suitable. Baseline assessment should be done in all BPS patients and include history, measurement of LUTS and quality-of-life, urinalysis, serum prostate-specific antigen, post-void residual, ultrasound of the lower urinary tract, including measurements of prostate volume, intravesical prostatic protrusion and detrusor wall thickness, and ultrasound of the upper urinary tract. Additional tests can follow when questions remain unanswered after baseline assessment. These optional tests include bladder diaries, uroflowmetry, serum creatinine, urethrocystoscopy, other noninvasive tests for the determination of BOO/BPO such as penile cuff test, condom catheter method and near-infrared spectroscopy, and other imagining tests such as X‑ray and MRI investigations.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations on the diagnostic work-up, including the assessment of the BPS components BPE, LUTS, and BOO/BPO.

Prostatic Urethral Lift for Obstructive Median Lobes: Consistent Results Across Controlled Trial and Real-World Settings

Introduction: The evidence for prostatic urethral lift (PUL), in treating lower urinary tract symptoms/benign prostatic hyperplasia (BPH) in men with obstructive median lobes (OMLs), has grown. In this study, we present the first detailed comparison of outcomes between OML patients treated with PUL in controlled and real-world settings to relevant comparators (subjects treated with transurethral resection of the prostate [TURP] and sham in randomized controlled trials [RCTs]) to demonstrate similar symptom, safety, and patient experience outcomes. Materials and Methods: Symptom and safety outcomes and patient satisfaction were compared through 12 months among controlled PUL studies: BPH6 RCT (35 men randomized to TURP); L.I.F.T. pivotal RCT in subjects with lateral lobe obstruction (66 subjects randomized to sham) and MedLift, an U.S. Food and Drug Administration-approved Investigational Device Exemption (IDE) extension of the L.I.F.T. trial (45 men with OML). Symptom improvement, catheterization, and adverse event rates were compared between MedLift subjects and OML patients (n = 187) from the large real-world retrospective (RWR) study of PUL filtered on baseline characteristics to approximate the MedLift population. Results: Posttreatment, International Prostate Symptoms Score (IPSS) improvement for MedLift subjects was 170% greater compared with sham at 3 months with significantly better quality of life (QoL), Qmax, and benign prostatic hyperplasia impact index (BPHII). Compared with TURP, MedLift IPSS and QoL improved significantly better at 1 and 3 months and with superior ejaculatory function scores at all time points after PUL. IPSS, QoL, postvoid residual (PVR), and Qmax outcomes were equivalent between MedLift and RWR OML groups at 3, 6, and 12 months. RWR OML patients did not experience higher rates of overall adverse events compared with MedLift. Conclusion: Controlled and real-world outcomes confirm PUL is a safe and effective treatment for BPH patients with and without OML.

Clinical Significance of Intravesical Prostatic Protrusion Index in Patients with Clinical Diagnosis of Benign Prostatic Hyperplasia

Background: To investigate the clinical significance of the intravesical prostatic protrusion (IPP) index in benign prostatic hyperplasia (BPH) patients to clarify its diagnostic value in predicting the clinical and structural abnormalities of the prostate. Methods: In this descriptive and analytical cross-sectional study, every man older than 50 years with lower urinary tract symptoms (LUTS), predominantly voiding or obstructive, suggestive of BPH were included. The patients were evaluated to determine the following indices: International Prostate Symptom Score (IPSS) index, quality of life (QoL), prostate volume (PV) and postvoid residual urine (PVR), serum PSA level, and the maximum urinary flow rate (Qmax) obtained by uroflowmetry. Subsequently, the assessment of the IPP index was conducted by transabdominal ultrasonography. The categorization of the IPP index was done into 3 grades: grade one (below 5 mm), grade two (between 5 and 10 mm), and grade three (greater than 10 mm). Results: A significant direct correlation between the IPP and IPSS, QoL, PV, PVR, and serum PSA, as well as inversely with the Qmax, was detected before and after medical treatment. Also, the need for surgical intervention increased significantly with the IPP index. Conclusions: The IPP can be used to evaluate and predict the severity of symptoms and outcomes in patients with clinical BPH.

Dutasteride add-on treatment to tadalafil for patients with benign prostatic enlargement is similarly effective as dutasteride add-on treatment to alpha blocker: a propensity-score matching analysis

PURPOSE

To investigate the efficacy of dutasteride add-on treatment to tadalafil in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic enlargement (BPE).

METHODS

A prospective study was conducted in patients with BPE who had not been satisfied with tadalafil monotherapy for more than 3 months. Inclusion criteria were prostate volume (PV) ≥ 30 ml and IPSS ≥ 8 or QOL index ≥ 3 under administration of tadalafil without anticholinergic agent. Before and 24 weeks after dutasteride add-on treatment to tadalafil, we assessed IPSS, overactive bladder symptom score (OABSS), serum PSA and testosterone, and uroflowmetry (UFM) to compare these parameters before and after dutasteride add-on treatment. Using a propensity-score matching analysis, the efficacy of dutasteride add-on treatment to tadalafil was compared with the previous study of dutasteride add-on treatment to alpha blocker.

RESULTS

Of 52 patients who were enrolled in this study, 48 patients completed the study (mean age: 72 ± 5 years old). Dutasteride add-on treatment to tadalafil significantly improved IPSS (from 16.4 ± 5.2 to 13.3 ± 6.4) and IPSS-QOL (from 4.0 ± 1.2 to 3.3 ± 1.1), and reduced PV from 55 ± 26 to 39 ± 22 ml. Propensity-score matching identified 42 matched pairs of patients. The improvement rate of IPSS and reduction rate of PV were similar between patients treated with dutasteride add-on treatment to tadalafil and dutasteride add-on treatment to alpha blocker. The logistic regression analysis showed that PV at baseline and reduction rate of PV after treatment were associated with the effective symptomatic outcome.

CONCLUSIONS

The dutasteride add-on is a reasonable treatment option for male patients with LUTS who are not satisfied with tadalafil monotherapy.

The cutoff value of transitional zone index predicting the efficacy of dutasteride on subjective symptoms in patients with benign prostate hyperplasia

OBJECTIVES

We investigated the efficacy of dutasteride add-on therapy to α-1 adrenoceptor antagonists in patients with benign prostate hyperplasia (BPH) in relation to the transitional zone index (TZI) and evaluated the cutoff value of TZI that predicted improvements of subjective symptoms at 6 months.

METHODS

Male BPH patients with prostate volume (PV) ≥ 30 mL receiving dutasteride 0.5 mg/d for 6 months as add-on therapy along with α-1 adrenoceptor antagonists were enrolled. PV, transitional zone volume (TZV), TZI, International Prostate Symptom Score (IPSS), and uroflowmetry parameters before and at 6 months with dutasteride add-on treatment were evaluated.

RESULTS

Eighty-three patients were included. The changes of total IPSS, IPSS voiding subscore, IPSS quality of life score, and voided volume were significantly correlated with TZI. Among baseline parameters, TZV and TZI were significantly associated with the changes of total IPSS in univariate analysis, and only TZI remained as an independent predictive factor for improving total IPSS in multivariate analysis (odds ratio -8.3, P = .048). The cutoff point of TZI for predicting an improvement of the total IPSS by 6 points or more was 0.67 (area under the curve 0.71, sensitivity 0.62, specificity 0.79).

CONCLUSIONS

A higher TZI was significantly associated with improvement of subjective symptoms but not uroflowmetric findings for BPH patients with 6 months of dutasteride add-on therapy along with α-1 adrenoceptor antagonists, and the predictive value of TZI for effective dutasteride add-on therapy was higher than 0.67. BPH patients using α-1 adrenoceptor antagonists with a TZI higher than 0.67 can be good candidates for add-on dutasteride therapy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review

Prostatic artery embolization (PAE) has been established as a routine treatment for symptomatic benign prostatic hyperplasia (BPH) all over the world. With increasing clinical experience in the last decade, investigators have sufficient data to assess predictive factors with the purpose to guide patient selection and counseling for PAE or to individualize therapeutic plans after PAE. This paper is a comprehensive review to introduce the concept of clinical predictors and give a systemic classification of various predictive factors in PAE. The authors review each individual factor and its predictive capability and discuss the possible reasons for the inconsistent or conflicting findings in the literature. Based on current evidence, the baseline prostate volume, in particular the transition zone volume and transition zone index; 24 h post-PAE prostate-specific antigen (PSA) level; and prostate infarction and prostate volume reduction at 1–3 months have potential in prediction of treatment outcomes. Patients with Adenomatous-dominant BPH or with indwelling bladder catheter before PAE may have more benefits from PAE. Baseline intravesical prostatic protrusion (IPP), C-reactive protein (CRP) level at 48 h and early detection of prostate infarct at 1 day and 1 week after PAE need further investigating.

Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes

PURPOSE

To evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP).

MATERIALS AND METHODS

This was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm³ (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10-656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes.

RESULTS

No significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R² = .5, P < .0001; IPP: P = .702; QOL: R² = .5, P = .0003; IPP: P = .108).

CONCLUSIONS

There were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.

Correlation between prostatic urethral angulation and symptomatic improvement after surgery in patients with lower urinary tract symptoms according to prostate size

PURPOSE

To investigate the effect of prostate anatomical factors on the changes in lower urinary tract symptoms (LUTS) and uroflowmetric values after surgery.

METHODS

The medical records of 448 patients who underwent transurethral resection of the prostate (TURP) from January 2006 to December 2018 were analyzed retrospectively. Changes in the International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual urine volume (PVR) at 3 months after TURP were evaluated. Prostate volume, intravesical prostatic protrusion (IPP), and prostatic urethral angulation (PUA) were measured using transrectal ultrasonography, and their effect on the changes in LUTS after TURP was analyzed using multivariable linear regression.

RESULTS

Among patients with prostate volume < 50 mL, preoperative IPSS total score (IPSS-t), voiding symptom score (IPSS-vs), and storage symptom score (IPSS-ss) were significantly better in patients with a smaller PUA (< 51°) than in those with a larger PUA (≥ 51°) (p = 0.001, < 0.001, and 0.020, respectively). Changes in IPSS-t, IPSS-vs, IPSS-ss, and PVR at 3 months after TURP were significantly correlated with PUA (p ≤ 0.001, < 0.001, 0.048, and 0.012, respectively). Multivariable linear regression revealed PUA to be independently associated with changes in IPPS-t and IPSS-vs (p = 0.025 and < 0.001, respectively) only in patients with prostate volume < 50 mL.

CONCLUSION

Prostatic urethral angulation was significantly associated with postoperative changes in LUTS only in patients with small prostate, and had no clinical significance in patients with large prostate. In patients with small prostate and large PUA, surgery should actively be considered.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Considerations for Intravesical Prostatic Protrusion in the Evaluation and Management of Bladder Outlet Obstruction Secondary to Benign Prostatic Hyperplasia

Background

Intravesical prostatic protrusion (IPP) is a manifestation of benign prostatic hyperplasia marked by overgrowth of the prostatic median lobe into the bladder, producing bladder outlet obstruction and related storage and voiding symptoms.

Methods

A MEDLINE® database search of the current literature was guided using combination of "prostate" with the following terms: intravesical prostatic protrusion, bladder trabeculation, bladder outlet obstruction, lower urinary tract symptoms, alpha blockers, transrectal ultrasonography, and prostatectomy.

Results

Although IPP can be identified via a variety of imaging modalities, it is easily detected via transrectal ultrasonography (TRUS). Failing to detect IPP promptly by TRUS may result in refractory symptoms of benign prostatic hyperplasia, as the condition may not respond to typical α₁-adrenoceptor antagonist therapy. In addition, depending on grade, IPP can influence outcomes and complications of prostatectomies.

Conclusion

Upon report of lower urinary tract symptoms, initial performance of TRUS along with digital rectal examination prevents delay in the appropriate evaluation and management of prostatic diseases.

Intravescical prostatic protrusion is a predictor of alpha blockers response: results from an observational study

BACKGROUND

To investigate the efficacy of tamsulosin in patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) with intravesical prostatic protrusion (IPP). Ultrasound measurement of the IPP has been previously described as an effective instrument for the evaluation of benign prostatic obstruction (BPO) and could help in clarifying the role of alpha-blockers in patients with (BPE).

METHODS

Patients with BPE and LUTS were enrolled in this observational study. Intravesical prostatic protrusion was graded as grade 1 (< 5 ml), 2 (5 < IPP < 10 ml) and 3 (> 10 ml). Patients were treated with tamsulosin for twelve weeks. Evaluation was performed before and at the end of treatment by means of International Prostate Symptom Score (IPSS) and uroflowmetry. Patients were considered responders if a reduction of IPSS > 3 points was reported.

RESULTS

One hundred forty-two patients were enrolled. Twelve patients were excluded because of incomplete data. Fifty patients showed an IPP grade 1 (group A), 52 a grade 2 (group B) and 28 a grade 3 (group C). Treatment success was obtained in 82%, 38,5% and 7,1% of patients respectively; these differences (group A vs B-C and group B vs C) were highly significant. The odd ratio to obtain a treatment success was of 59 and 8.1 in group A and group B respectively, in comparison to group C. After a multivariate regression, the relationship between IPP grade and treatment success remained significant. Improvement of uroflowmetry parameters has been reported in all the groups especially in patients with a low grade IPP (p value = 0,016 group A vs group B; p value = 0,005 group A vs group C). Prostate volume seems not to influence this relationship.

CONCLUSIONS

Intravesical prostatic protrusion has found to be significantly and inversely correlated with treatment success in patients with LUTS and BPE under alpha-blockers therapy. Alpha blockers odd ratio of success is 59 times higher in patients with a low grade IPP in comparison to patients with a high grade.

Benign prostatic hyperplasia surgical scoring (BPHSS): an novel scoring system for the perioperative outcomes of holmium laser enucleation of the prostate

To develop a standardized scoring system, the BPH surgical scoring (BPHSS) system, to quantify the ability to predict the perioperative outcomes resulting from an enlarged prostate. There are two parts included in this study: the retrospective observational study (875 patients treated with holmium laser enucleation of the prostate, HoLEP) and the prospective observational study (111 patient underwent HoLEP). All the outcome data included the following: the basic patient preoperative characteristics, operation time (OT), pre- and post- surgery hemoglobin decrease, Na⁺ variation, hospital stay duration, duration of bladder irrigation, catheterization time, and hospitalization time. The BPHSS, consisting of prostatic volume (PV), prostate-specific antigen (PSA), bladder stones, intravesical prostatic protrusion (IPP), and metabolic syndrome (MetS), was observed regarding the perioperative outcomes. In the retrospective study, patients in high BPHSS group (6-8 points) showed significant increase in the OT (74.61, 95%CI = 16.98-327.84, P < 0.001), hemochrome reduction (416.50, 95%CI = 35.48-4889.88, P < 0.001), hospital stay (1.80, 95%CI = 1.35-2.41, P < 0.001), and bladder irrigation duration (4.04, 95%CI = 1.35-12.10, P = 0.013) compared with the low BPHSS group (0-2 points). In the prospective study, there also existed significant differences between the three scoring grades (P < 0.01) in OT, hemochrome decrease, and the hospital stay. The BPHSS is suitable to predict the perioperative outcomes in patients undergoing HoLEP. It may help urologist to prepare more before surgery to treat the enlarged prostates. Further studies are needed to validate this scoring system in BPH patients in multiple centers.

Dutasteride add-on therapy reduces detrusor mass in patients with benign prostatic enlargement not satisfied with alpha-adrenergic antagonist monotherapy: A single center prospective study

AIMS

The ultrasound assessment of bladder wall thickness (BWT) and intravesical prostatic protrusion (IPP) have emerged as a non-invasive, inexpensive, time-saving alternatives to pressure-flow studies to assess benign prostatic obstruction (BPO). Aim of our study was to evaluate the effect on detrusor mass of dutasteride add-on therapy in men with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE).

METHODS

A consecutive series of BPE patients with a prostate volume (PV) ≥30 mL and an international prostate symptoms score (IPSS) ≥8 not satisfied with Tamsulosin monotherapy were enrolled. Free maximum flow (Qmax), PV, BWT, and IPP were recorded at baseline and at 24 weeks follow-up.

RESULTS

Overall, 27 men were enrolled. Dutasteride significantly improved LUTS (-46.7%; P = 0.001) and Qmax (+18.7%; P = 0.001) and reduced PV (-13%; P = 0.002), BWT (-40.3%; P = 0.001), and IPP (-14.9%; P = 0.015). At baseline, based on BWT ≥5 mm and an IPP >10 mm, 13/27 (48%) and 15/27 (55%) patients were defined at risk for BPO, respectively; while after 24 weeks of treatment they were 3/27 (11.1%) and 11/27 (40%), respectively.

CONCLUSIONS

Dutasteride add-on therapy significantly reduced IPP and detrusor mass and was effective in improving LUTS in patients with BPE not satisfied with αBs monotherapy. The possible role of BWT and IPP as proxies of medical treatment outcomes should be confirmed by further studies.

Clinical value of intravesical prostatic protrusion in the evaluation and management of prostatic and other lower urinary tract diseases

Intravesical prostatic protrusion (IPP) has emerged as a new prostatic morphometric parameter of significance to aid the clinicians in various aspects of managing the patients with some diseases of the lower urinary tract and the prostate. These include but may not be limited to its role in such conditions as: bladder outlet obstruction, trial without catheter, medical treatment effect, progression of lower urinary tract symptoms related to benign prostatic hypertrophy (LUTS/BPH), risk factor for bladder stone in BPH, overactive bladder, prostate carcinoma, and early urinary continence recovery after laparoscopic radical prostatectomy. In this review, I will try to summarize the different researchers' efforts on the potential practical application of this clinical tool. Technology is ever evolving to help us in the diagnosis and management of our patients. However, we as clinicians should contemplate their cost and possible suffering for the patient by wise and judicious utilization based on our clinical experience and tools. IPP seems to be one such promising clinical tool.

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

AIMS

We investigated predicting factors for the therapeutic effects of dutasteride in patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) based on a urodynamic study (UDS).

METHODS

This was a single-center, prospective study involving 120 male outpatients with LUTS. They received 0.5 mg of dutasteride per day for 12 months. IPSS, OABSS, IPSS-QOL, and UDS were used for assessing subjective and objective symptoms prior to and 12 months after administration. Patient's age, PSA level, prostate volume, IPSS, OABSS, maximum flow rate, and post-void residual urine volume, and intravesical prostatic protrusion (IPP) were set as pre-administration parameters to predict the therapeutic effect. We evaluated the relationship between these parameters and the therapeutic effects, depending on the extent of improvement of IPSS and bladder outlet obstruction (BOO).

RESULTS

A total of 104 patients with mean age of 68.9 years and mean prostate volume of 58.9 mL were included in the analysis. Thirty-two patients (30.8%) showed an insignificant IPSS improvement of <25%, while 41 patients (39.4%) showed excellent IPSS improvement of 50% or greater. On the multivariate logistic regression analysis, IPP (95% confidence interval: 0.606-0.810) was found to be the only factor related to the improvement in IPSS. Additionally, the multiple linear regression analysis demonstrated that IPP was the most powerful factor for predicting improvement of BOO (r = -0.51, P < 0.001).

CONCLUSIONS

IPP is considered a useful predictor of the therapeutic effects of dutasteride for both subjective symptoms and BOO.

Effects of dutasteride on lower urinary tract symptoms: a prospective analysis based on changes in testosterone/dihydrotestosterone levels and total prostatic volume reduction

This study analyzed the effects of dutasteride on lower urinary tract symptoms based on the association between changes in the total testosterone (TT)/dihydrotestosterone (DHT) levels and total prostate volume (TPV) reduction. Sixty participants diagnosed with benign prostatic hyperplasia were given 0.5 mg of dutasteride daily for 52 weeks. Measures of TT and DHT levels, TPV and uroflowmetry were obtained before and after dutasteride treatment. Forty-three patients demonstrated a TPV reduction of ≥5% (Group 1), whereas the remaining 17 patients demonstrated a TPV reduction of <5% (Group 2). DHT suppression and DHT/TT ratio at baseline were significantly higher in Group 1 than Group 2. International Prostate Symptom Scores (IPSS) and uroflowmetry were significantly improved in both groups. In Group 2, nine patients demonstrated some improvement in IPSS (Group 2A), whereas eight did not (Group 2B). The rate of TT increase and improvement in voiding symptoms were significantly higher in Group 2A than Group 2B. Dutasteride-induced TPV reduction is dependent on individual 5-α reductase inhibitor activity. Some patients demonstrating smaller dutasteride-induced TPV reduction may experience an improvement in voiding symptoms owing to an increased level of testosterone.

Intravesical Prostatic Protrusion as a Predicting Factor for the Adverse Clinical Outcome in Patients With Symptomatic Benign Prostatic Enlargement Treated With Dutasteride

OBJECTIVE

To evaluate the role of intravesical prostatic protrusion (IPP) as a predictive factor for adverse clinical outcomes in patients treated with dutasteride for lower urinary tract symptoms secondary to benign prostatic enlargement (BPE).

METHODS

In total, 111 patients treated with dutasteride for symptomatic BPE were analyzed. Stepwise multivariate logistic regression was applied to evaluate predictors for acute urinary retention (AUR) or benign prostatic hyperplasia (BPH)-related surgery. We applied an IPP cutoff value of 10 mm. The clinical variables were assessed using univariate analysis.

RESULTS

Of 111 patients, 27 (24.3%) developed AUR or required surgical intervention. On multivariate analysis, IPP remained as the independent predictor for AUR and need for BPH-related surgery (odds ratio, 1.27; P < .001). Both international prostate symptom score and maximum urinary flow rate significantly improved in patients with low IPP (P  =  .03 and P  <  .001, respectively), but not in those with high IPP. No significant reduction was found in the degree of IPP despite the significant reduction in prostate volume after dutasteride treatment (P  =  .84 and P  <  .001, respectively). The 3-year cumulative incidence of AUR or BPH-related surgery in the low IPP group vs the high IPP group was 9.9% vs 71.5%, respectively (P  <  .001).

CONCLUSION

High IPP is associated with a higher risk of treatment resistance, AUR, or the need for prostatic surgery in patients receiving dutasteride treatment for symptomatic BPE. Dutasteride might not be effective for IPP reduction.