A RANDOMIZED TRIAL COMPARING TRANSURETHRAL RESECTION OF THE PROSTATE, LASER THERAPY AND CONSERVATIVE TREATMENT OF MEN WITH SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC ENLARGEMENT: THE CLasP STUDY

A systematic review and network meta-analysis comparing Rezūm with transurethral needle ablation and microwave thermotherapy for the management of enlarged prostate

Objectives

We aim to compare efficacy and safety of water vapour therapy (Rezūm), transurethral needle ablation (TUNA) and transurethral microwave therapy (TUMT) for treating men with moderate to severe benign prostatic hyperplasia (BPH) symptoms.

Materials

PubMed/MEDLINE, EMBASE and Cochrane Library were searched from inception to 30 July 2023, followed by reference searching and dual-independent study selection. We analysed only randomized clinical trials. RoB-2, NIH-quality assessment tool and GRADE guidelines were used for quality-of-evidence (QoE) assessment. Relevant prospective studies without a critical risk-of-bias were included.

Results

At 12 months, Rezūm showed similar efficacy to TUNA and TUMT for improvement in International Prostate Symptoms Score - Rezūm versus TUMT: 1.33 points (95% CI: -1.66 to 4.35) favouring TUMT (QoE: Moderate) and Rezūm versus TUNA: 0.07 points (95% CI: -3.64 to 3.88) favouring TUNA (QoE: Low). Rezum had similar outcomes to TUNA and TUMT for Maximum Peak-Flow Rate (Qmax): Rezūm versus TUMT: 1.05 mL/s (95% CI: -4.88 to 2.82) favouring Rezūm (QoE: Low) and Rezūm versus TUNA: 0.37 mL/s (95% CI: -4.61 to 4.21) favouring TUNA (QoE: Low). Furthermore, post-void residual volume (PVR) comparisons demonstrated that Rezūm was similar, or inferior to other techniques at 12 months - Rezūm versus TUMT: 11.20 mL (95% CI: -32.40 to 10.30) favouring TUMT (QoE: Low) and Rezūm versus TUNA: 24.10 mL (95% CI: 2.81 to 45.10) favouring TUNA (QoE: Low). Rezūm also had a similar surgical retreatment rate with TUMT and TUNA up to 3-years - TUMT versus Rezūm RR: 1.21 (95% CI: 0.20 to 15.90) (QoE: Low) and TUNA versus Rezūm showed RR: 1.81 (95% CI: 0.2 to 24.60) (QoE: Low). In the first 12 months after treatment, Rezūm had a higher rate of serious adverse events (Clavien-Dindo ≥ Grade 3) than TUMT and TUNA. TUMT versus Rezūm with RR = 0.53 (95% CI: 0.13 to 3.14) (QoE: Low) and TUNA versus Rezūm with RR = 0.38 (95% CI: 0.04 to 3.49) (QoE: Low).

Conclusions

Moderate to weak evidence suggests that Rezūm is not superior to TUNA and TUMT in all domains studied.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

Chronic kidney disease, preoperative use of antispasmodics and lower resected prostate volume ratios are risk factors for postoperative use of adrenergic Alpha-blockers and antispasmodics

OBJECTIVES

Transurethral resection of prostate (TURP) and laser prostate surgery are common surgeries for benign prostate hyperplasia (BPH). We conducted an investigation using hospital database to evaluate the clinical factors associated with post-operative usage of alpha-blockers and antispasmodics.

METHODS

This study was conducted using retrospective clinical data from the hospital database, which contained newly diagnosed BPH patients between January 2007 and December 2012 who subsequently received prostate surgery. The study end-point was the use of alpha-blockers or antispasmodics for at least 3 months duration after 1 month of surgery. The exclusion criteria was prostate cancer diagnosed before or after the surgery, recent transurethral surgeries, history of open prostatectomy, and history of spinal cord injury. Clinical parameters, including age, body mass index, preoperative prostate specific antigen value, comorbidities, preoperative usage of alpha-blockers, anstispasmodics and 5-alpha reductase inhibitors, surgical methods, resected prostate volume ratios, and preoperative urine flow test results, were evaluated.

RESULTS

A total of 250 patients receiving prostate surgery in the database and confirmed pathologically benign were included. There was significant association between chronic kidney disease (CKD) and the usage of alpha-blockers after prostate surgery (OR = 1.93, 95% CI 1.04-3.56, p = 0.036). Postoperative antispasmodics usage was significantly associated with preoperative usage of antispasmodics (OR = 2.33, 95% CI 1.02-5.36, p = 0.046) and resected prostate volume ratio (OR = 0.12, 95% CI 0.02-0.63, p = 0.013).

CONCLUSIONS

BPH patients with underlying CKD were more likely to require alpha-blockers after surgery. In the meantime, BPH patients who required antispasmodics before surgery and who received lower prostate volume resection ratio were more liable to antispasmodics after prostate surgery.

Preservation of antegrade ejaculation after surgical relief of benign prostatic obstruction is a valid endpoint

PURPOSE

To review the current data on retrograde ejaculation (RE) and ejaculatory dysfunction (EjD) after endoscopic and minimally invasive surgical treatment of benign prostatic obstruction (BPO) and, their perceived impact in the quality of life (QoL) and sexual life of patients and their partners.

METHODS

Narrative review of systematic reviews (SR) assessing comparative rates of RE, EjD or erectile dysfunction (EF) was carried out. Relevant articles on the prevalence of RE, EjD or EF and on their impact in the QoL or sexual life of patients and partners were manually selected based on relevance.

RESULTS

Twelve SRs reporting on comparisons of different endoscopic/minimally invasive treatments of BPO were found. Data on outcomes varied widely. Overall, after conventional TURP or laser techniques 42-75% of patients present RE. Prostatic incision and ablative procedures present lowest rates of de novo RE or EjD whereas laser adenomectomy and ejaculation preservation procedures preserve antegrade ejaculation in 46-68% of patients. EjDs is associated to LUTS and present in 10% of sexualy active men before intervention. It modulates the QoL and sexual life of the couple. In spite of the scarce literature assessing patient's and partner's perception of postoperative EjD, it strongly suggests that both parties value the maintenance of the ejaculatory function.

CONCLUSION

Ejaculation-preserving techniques and minimally invasive techniques successfully prevent BPO treatment-induced RE or EjD in 70-100% of the cases. While this is appealing to patients and spouses, technique selection and treatment durability are issues to be discussed with the couple.

Which Anatomic Structures Should Be Preserved During Aquablation Contour Planning to Optimize Ejaculatory Function? A Case-control Study Using Ultrasound Video Recordings to Identify Surgical Predictors of Postoperative Anejaculation

OBJECTIVE

To identify key anatomic structures that should be preserved to decrease postoperative anejaculation after Aquablation.

METHODS

We conducted a case-control study design using patient data and operative video logs from Aquablation clinical trials. Cases were sexually active participants with functional baseline ejaculation and postoperative anejaculation. Controls were sexually active participants with functional baseline ejaculation and no postoperative decline in sexual function. Each case was matched to 1 or 2 controls. Video logs from the procedure were scored for: verumontanum cut coverage, penetration of ejaculatory ducts, depth of cut below the verumontanum, angle offset of verumontanum to centerline of protection zone, number of passes, and intraprostatic calcifications. Conditional logistic regression was used to calculate univariate odds ratios relating anatomic findings to case/control status.

RESULTS

We identified 24 cases and 27 controls. In univariate analysis, predictors of postoperative anejaculation were: penetration of the ejaculatory ducts (odds ratio [OR] 8.6 [95% CI 1.09-67.5], P = .041) and depth below the verumontanum (OR 1.92 [1.1-3.3], P = .015).

CONCLUSION

Violation of anatomic structures involved in ejaculation during the Aquablation procedure increases the risk of postoperative anejaculation. More careful attention to these structures during contour planning may further improve ejaculatory function after Aquablation.

Minimizing Sexual Dysfunction in BPH Surgery

Purpose of Review

To review the prevalence and risks of sexual dysfunction associated with current treatment options for benign prostatic hyperplasia and to characterize techniques and methods to manage postoperative sexual dysfunction-related side effects.

Recent Findings

Current surgical therapies available for the treatment of benign prostatic hyperplasia are associated with a substantial risk of both ejaculatory and erectile function. However, many of the novel minimally invasive treatment alternatives have demonstrated the ability to preserve postoperative sexual function to a better degree, all while providing significant relief of lower urinary tract symptoms in an equally safe and efficacious manner.

Summary

Benign prostatic hyperplasia remains a highly prevalent disease among the aging population. While surgical treatments are often necessary to relieve bothersome urinary symptoms, these procedures are associated with an increased risk of sexual dysfunction. As such, there has been an increased interest in the development of minimally invasive therapies, such as the UroLift®, Rezum®, and Aquablation®, with the hopes of achieving similar symptomatic relief while maintaining sexual function. Aside from reporting lower rates of sexual dysfunction, these procedures have also demonstrated comparable safety, durability, and efficacy to current gold standard therapies. Some procedures can even be performed in an outpatient setting, avoiding the need for general anesthesia altogether. Overall, an individualized, shared decision-making approach is necessary to determine the ideal treatment option for each patient.

Efficacy of a vaporization-resection of the prostate median lobe enlargement and vaporization of the prostate lateral lobe for benign prostatic hyperplasia using a 120-W GreenLight high-performance system laser: the effect on storage symptoms

GreenLight laser photoselective vaporization of the prostate (PVP) was established as a minimally invasive procedure to treat patients with benign prostatic hyperplasia (BPH). However, it may be difficult to achieve adequate tissue removal from a large prostate, particularly those with an enlarged median lobe. The purpose of this study was to investigate the feasibility and clinical effect of a 120-W GreenLight high-performance system laser vaporization-resection for an enlarged prostate median lobe compared with those of only vaporization. A total of 126 patients from January 2010 to January 2014 had an enlarged prostate median lobe and were included in this study. Ninety-six patients underwent vaporization only (VP group), and 30 patients underwent vaporization-resection for an enlarged median lobe (VR group). The clinical outcomes were International Prostate Symptoms Score (IPSS), quality of life (QOL), maximum flow rate (Q max), and post-void residual urine volume (PVR) assessed at 1, 3, 6, and 12 months postoperatively between the two groups. The parameters were not significantly different preoperatively between the two groups, except for PVR. Operative time and laser time were shorter in the VR group than those in the VP group. (74.1 vs. 61.9 min and 46.7 vs. 37.8 min; P = 0.020 and 0.013, respectively) and used less energy (218.2 vs. 171.8 kJ, P = 0.025). Improved IPSS values, increased Q max, and a reduced PVR were seen in the two groups. In particular, improved storage IPSS values were higher at 1 and 3 months in the VR group than those in the VP group (P = 0.030 and 0.022, respectively). No significant complications were detected in either group. Median lobe tissue vaporization-resection was complete, and good voiding results were achieved. Although changes in urinary symptoms were similar between patients who received the two techniques, shorter operating time and lower energy were superior with the vaporization-resection technique. In addition, vaporization-resection may have a beneficial effect on storage symptoms.

Review of current laser therapies for the treatment of benign prostatic hyperplasia

The gold standard for symptomatic relief of bladder outlet obstruction secondary to benign prostatic hyperplasia has traditionally been a transurethral resection of the prostate (TURP). Over the past decade, however, novel laser technologies that rival the conventional TURP have multiplied. As part of the ongoing quest to minimize complications, shorten hospitalization, improve resection time, and most importantly reduce mortality, laser prostatectomy has continually evolved. Today, there are more variations of laser prostatectomy, each with several differing surgical techniques. Although abundant data are available confirming the safety and feasibility of the various laser systems, future randomized-controlled trials will be necessary to verify which technique is superior. In this review, we describe the most common modalities used to perform a laser prostatectomy, mainly, the holmium laser and the potassium-titanyl-phosphate lasers. We also highlight the physical and clinical characteristics of each technology with a review of the most current and highest-quality literature.

Superselective α-adrenergic blockers versus transurethral resection of the prostate: a prospective comparison of health-related quality of life outcome after treating patients with benign prostatic hyperplasia

PURPOSE

We prospectively evaluated the impact of transurethral resection of the prostate (TURP) versus superselective α-adrenergic blocker treatment on health-related quality of life (HRQOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A total of 219 patients with lower urinary tract symptoms (LUTS) caused by BPH were recruited in this study. Treatment modalities consisted of standard TURP (n = 104) and tamsulosin medical treatment (n = 115). HRQOL was assessed by SF-36-Item Health Survey 1.0. LUTS were estimated by The International Prostate Symptom Score. Patients' outcome 4 weeks after treatment was compared to pre-treatment status and to that of the other group. Statistically significant changes in each HRQOL scale from baseline to follow-up period were investigated.

RESULTS

Baseline characteristics were similar in both groups except for the duration of disease before treatment that was longer in TURP group. Both treatments resulted in statistically significant improvements from pre-treatment in all scales of QOL after 4 weeks, with no significant differences observed between the two groups. In medical treatment group, there was a significant association between higher educational level and better QOL in all 8 scales. Our outcomes revealed a significant decrease in the IPSS in both groups but this improvement was more evident in TURP group.

CONCLUSION

All scales concerning HRQOL were favorably improved 4 weeks after both surgical and medical treatment, and no significant differences were observed between these two treatment modalities for patients with symptomatic BPH. This information may aid patients when deciding which treatment option to take.

Influence of intravesical prostatic protrusion on preoperative lower urinary tract symptoms and outcomes after 120 w high performance system laser treatment in men with benign prostatic hyperplasia

PURPOSE

To evaluate the efficacy of photoselective vaporization of the prostate (PVP) with the 120 W Greenlight high performance system (HPS) laser for the treatment of benign prostatic hyperplasia (BPH) with intravesical prostatic protrusion (IPP).

MATERIALS AND METHODS

This study was conducted on 389 BPH patients who underwent PVP with the 120 W HPS laser from April 2009 to August 2011. The patients were divided into groups according to IPP: group I was defined as IPP of 0 to 5 mm (n=216), group II as IPP of 5 to 10 mm (n=135), and group III as IPP above 10 mm (n=38). Prostate volume, prostate-specific antigen, International Prostate Symptom Score (IPSS), maximal urinary flow rate (Qmax), and postvoid residual volume (PVR) were assessed and checked at postoperative 1, 3, 6, and 12 months.

RESULTS

There was a significant difference in the mean prostate size in each group (p<0.05). The preoperative total IPSS score, IPSS voiding symptom score, and quality of life score were not significantly different. However, the IPSS storage symptom score was significantly different between groups 1 and 2 and group 3. IPSS scores, Qmax, and PVR at postoperative 1, 3, 6, and 12 months showed significant improvement compared with preoperative values.

CONCLUSIONS

The degree of IPP can affect storage symptoms. However, there is no significant correlation between the degree of IPP and postoperative results. Also, the degree of IPP does not affect short- and long-term PVP results. Proper elimination of bladder outlet obstruction is important for symptomatic relief.

Initial Experiences with a 980 nm Diode Laser for Photoselective Vaporization of the Prostate for the Treatment of Benign Prostatic Hyperplasia

Purpose

This study was conducted to analyze the efficacy of photoselective vaporization of the prostate (PVP) with the use of a 980 nm diode laser for benign prostatic hyperplasia (BPH) according to postoperative period.

Materials and Methods

Data were collected from 96 patients who were diagnosed with BPH and who underwent PVP with the 980 nm K2 diode laser. Postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum urinary flow rate (Qmax), and post-void residual volume (PVR), were assessed and compared with preoperative baseline values.

Results

The mean prostate volume was 45.3±15.6 g, the mean operative time (lasing time) was 22.9±18.3 minutes, the total amount of energy was 126±84 kJ, and the Foley catheter maintenance period after PVP was 24.8±5.6 hours. At 1 month, significant improvements were noted in IPSS (11.7±6.6), QoL score (2.3±1.1), Qmax (12.7±6.1 ml/sec), and PVR (41.9±30.5 ml). After 3 months, all follow-up parameters showed significant improvements that were sustained throughout a period of 6 months after PVP.

Conclusions

PVP using a K2 diode laser is a minimally invasive and effective surgical method for improvement of BPH and is associated with minimal morbidity.

Overactive bladder and outlet obstruction in men

Lower urinary tract symptoms (LUTS), overactive bladder, (OAB), and benign prostatic hyperplasia (BPH) are very commonly experienced in men. The mainstay of pharmacotherapy for OAB is the antimuscarinic class of drugs. There has been reluctance to prescribe these agents to men with BPH due to the risk of precipitating urinary retention. Several trials have supported the efficacy and safety of antimuscarinics in treating men with LUTS, alone, or in combination with α-blocker therapy. The combination of 5-α-reductase inhibitors with antimuscarinic agents or surgery are other effective treatments for men with BPH and OAB.

Urologic trauma guidelines: a 21st century update

Trauma is the leading cause of death between the ages of 1 and 44 years in the USA. While stabilization of life-threatening injuries is the primary goal in the evaluation of all trauma patients, subsequent diagnosis and treatment of secondary injuries are requirements for good trauma care. The genitourinary system is involved in 10% of trauma cases, and these injuries can be associated with considerable morbidity and mortality. Accordingly, physicians involved in the initial evaluation and subsequent management of trauma patients should be aware of the diagnosis and treatment of injuries that can occur in the genitourinary system. In 2009, the European Association of Urology provided specific recommendations for the evaluation, diagnosis and management of genitourinary trauma. Here, we review and discuss these recommendations in order to provide a concise summary for clinicians involved in the evaluation and management of trauma patients and their associated genitourinary injuries.

Comparative Analysis of Outcomes after Transurethral Resection of the Prostate according to Prostate Shape Shown by Transrectal Ultrasonography

PURPOSE

Transrectal ultrasonography (TRUS) is a non-invasive modality widely used in urology on an outpatient basis to measure the volume and anatomical structure of the prostate. However, the prostate volume measured by TRUS often varies from test to test. The aim of this study was to determine the clinical significance of the different shapes of the prostate, as shown by TRUS before and after transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

We evaluated 103 patients who underwent TURP. TRUS was performed preoperatively, and the International Prostatic Symptom Score (IPSS) and quality of life (QoL) were assessed preoperatively and at 6 months postoperatively. Patients were classified into two groups: patients with a bilaterally enlarged transitional zone were assigned to group A, and those with a protruding retrourethral zone were assigned to group B.

RESULTS

There were no statistically significant differences between the two groups in preoperative variables. However, postoperative IPSS scores were lower in group A than group B (9.87+/-6.15 vs. 13.18+/-8.07, p=0.02). With regard to postoperative IPSS scores relative to preoperative IPSS scores, both groups showed a significant decrease, but group A experienced a significantly greater decrease than group B (13.43+/-7.47 vs. 8.67+/-8.33, p=0.005).

CONCLUSIONS

Patients with a prostate protruding into the bladder have less of a decrease in their IPSS scores after TURP, compared to patients that do not have prostate protrusion, meaning that patients with protrusion experience less symptomatic relief.

Persistent detrusor overactivity after transurethral resection of the prostate

Detrusor overactivity is associated with aging and benign prostatic obstruction and often causes the troublesome symptoms of urgency and urgency incontinence (overactive bladder), persistent detrusor overactivity after transurethral resection of the prostate being the cause of more than a third of poor symptomatic outcomes following surgery. Most of the evidence currently suggests that neurons of the urothelium at the bladder neck play a significant role in the genesis of detrusor overactivity. Treatment options including botulinum toxin injections and intravesical vanilloids have been studied in the treatment of persistent detrusor overactivity, but further studies are needed specifically in patients with persistent detrusor overactivity after transurethral resection of the prostate. As urodynamic studies are able to predict a proportion of postoperative failures, more widespread use is advocated by many in the routine assessment of lower urinary tract symptoms thought to be due to benign prostatic obstruction.

Evidence-based guidelines for the management of lower urinary tract symptoms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary

BACKGROUND AND SCOPE

Despite the high prevalence and huge socio-economic impact of benign prostatic hyperplasia (BPH) in Italy, no national guidelines have been produced so far. This is a summary of the first Italian guidelines on the diagnosis and treatment of lower urinary tract symptoms (LUTS) related to uncomplicated BPH, prepared by a multidisciplinary panel under the auspices of the Italian Association of Urologists and introduced in Italy in 2003. An update compiled by the authors is also included.

METHODS

Relevant papers published from 1998 to 2003 (updated to 2006) were identified through a structured literature review and the quality of evidence presented therein was graded according to the Centre for the Evaluation of Effectiveness in Health Administration (CeVEAS) system. Recommendations were based on evidence from the literature, but also on feedback from practitioners and specialists. MAIN FINDINGS/RECOMMENDATIONS: Given the prevalence of BPH, all men aged > or = 50 years of age should be asked about LUTS and informed about disease characteristics and therapeutic options, while sexual function should always be assessed in patients with severe and long-standing LUTS. Initial assessment should include medical history (including drug and co-morbidity history), digital rectal examination, urinalysis, International Prostate Symptom Score-Quality of Life (IPSS-QoL) and a voiding diary, while prostate-specific antigen (PSA) and measurement of prostate volume by suprapubic ultrasonography are indicated in fully informed patients with a life expectancy of > or = 10 years in whom BPH progression could influence treatment choices. QoL considerations should dictate whether to start active treatment. When QoL is not affected by LUTS, watchful waiting is indicated if symptoms are mild, acceptable if they are moderate. When QoL is affected, medical therapy with alpha1-blockers or 5alpha-reductase inhibitors (the latter indicated in patients with increased prostate volume) is appropriate. Combined therapy with alpha1-blockers + 5alpha-reductase inhibitors should only be considered in patients at high risk for progression (prostate volume > 40 mL or PSA > 4 ng/mL), since the incremental cost of combination therapy vs. monotherapy with alpha1-blockers or finasteride is prohibitive. Selection of the type of surgery should be based on the surgeon's experience, the presence of co-morbid conditions and the size of the prostate. Open prostatectomy and transurethral resection of the prostate (TURP) are recommended in patients with acute or chronic retention of urine, and acceptable in obstructed patients with moderate/severe symptoms and worsened QoL. Transurethral incision of the prostate (TUIP) is acceptable when prostate volume is < or = 30 mL. Holmium laser enucleation of the prostate (HoLEP) may be proposed to motivated patients where expert surgeons are available. Transurethral microwave thermotherapy (TUMT) or transurethral needle ablation (TUNA) may be proposed to motivated patients who prefer to avoid surgery and/or do not respond to medical treatment. The possible effects of medical or surgical treatments on sexual function should always be discussed.

CONCLUSIONS

These guidelines are intended to provide a framework for health professionals involved in BPH management in order to facilitate decision-making in all areas and at all levels of healthcare.

Differences in stress response between patients undergoing transurethral resection versus endoscopic laser ablation of the prostate for benign prostatic hyperplasia

The objective of the study was to determine the differences in systemic stress response in patients undergoing transurethral resection of the prostate (TURP) versus endoscopic laser ablation of the prostate (ELAP) for benign prostatic hyperplasia (BPH). The study included 48 patients with BPH (24 treated by TURP and 24 by ELAP). Blood samples were taken from each patient before and immediately after the procedure and on postoperative days 1, 6, and 20, respectively. TURP caused more intense acute-phase response during 24 h after the procedure considering the serum c-reactive protein (CRP) level (p < 0,001) and absolute leukocyte (p = 0.001) and neutrophil number (p = 0.003) in peripheral blood. ELAP caused more decrease in the number of natural killer cells immediately after the procedure (p = 0.048). There were no statistically significant differences between TURP and ELAP procedures in protein and creatine kinase (CK) levels, adrenocorticotropic hormone, and cortisol as well as other immunological parameters. TURP causes more intense acute-phase response than ELAP.

Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

Many men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia can be managed safely and effectively by primary care providers. After a basic evaluation to exclude other diseases that may cause lower urinary tract symptoms, quantifying the degree of symptoms and bother, and perhaps making an assessment of prostate size, the primary care provider can determine which men require immediate evaluation by a urologist and which men may choose among various treatment options, including watchful waiting and various single agent or combination medication strategies. Recent information about risk factors for disease progression has also helped to inform patient decisions on which treatment option is best for the individual patient. The purpose of this review is to provide primary care providers with an approach to the management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

A Systematic Review of Holmium Laser Prostatectomy for Benign Prostatic Hyperplasia

PURPOSE

We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate.

MATERIALS AND METHODS

We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison.

RESULTS

Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia.

CONCLUSIONS

Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.

Effects of transurethral resection of prostate on the quality of life of patients with benign prostatic hyperplasia

BACKGROUND

This article investigated the effects of transurethral resection of prostate on quality of life (QOL) and urinary symptoms in patients with benign prostatic hyperplasia (BPH).

STUDY DESIGN

In a prospective study, 30 patients without significant comorbidities undergoing transurethral resection of prostate for BPH were studied. Patients completed four validated questionnaires: the International Prostate Symptom Score and the associated QOL index because urinary symptoms, the Montgomery and Asberg Depression Rating Scale, the McGill Pain Questionnaire, and the QOL questionnaire Short Form-36. These were completed preoperatively, on the first postoperative day, on discharge from hospital, and at 1 and 3 months postoperatively.

RESULTS

The QOL of patients who undergo transurethral resection of prostate for BPH had significantly improved at 3 months after their operation. The International Prostate Symptom Score scores at 1 month (9.3+/-4.6) and 3 months (5.4+/-5.6) were less than they were preoperatively (19.9+/-7.1). The QOL index because urinary symptoms was less at 1 month (2.4+/-1.9) and at 3 months postoperatively (1.5+/-1.4) in comparison with the preoperative scores (4.5+/-1.2). The Montgomery and Asberg Depression Rating Scale scores at 1 month (5.4+/-6.8) and 3 months (4.9+/-6.5) were less than they were preoperatively (9.2+/-8.3). The McGill Pain Questionnaire sensory and pain rating index scores were less at 3 months than they were preoperatively (p=0.02 and p<0.02 respectively). The McGill Pain Questionnaire affective score was less at 1 month than it was preoperatively (p<0.03). The McGill Pain Questionnaire evaluative scores were less than the preoperative score at all times postoperatively. The role physical (p=0.007), bodily pain (p=0.006), social function (p=0.007), and physical component summary (p=0.007) subsections of the Short Form-36 were greater at 3 months postoperatively when compared with the preoperative scores.

CONCLUSIONS

Transurethral resection of prostate is associated with significant improvement in the overall QOL, in addition to urinary symptoms, of patients with BPH at 3 months postoperatively. The magnitude and timing of this improvement may serve as a useful comparator in determining the optimal treatment of patients with BPH.

Laser prostatectomy for benign prostatic obstruction

BACKGROUND

Symptomatic benign prostatic obstruction is a common problem for older men. The gold standard treatment, transurethral resection of the prostate (TURP), significantly improves urinary symptoms and urinary flow. However, TURP has up to a 20% morbidity. Currently, there are a number of minimally invasive procedures that may be safe, effective alternatives to TURP. One promising surgical technique is laser prostatectomy.

OBJECTIVES

To assess the therapeutic efficacy and safety of laser prostatectomy techniques for treating men with symptomatic benign prostatic obstruction.

SEARCH STRATEGY

Randomized controlled trials were identified from the Cochrane Collaboration Library, MEDLINE, EMBASE, bibliographies of retrieved articles and reviews, and contacting expert relevant trialists and laser manufacturers.

SELECTION CRITERIA

All randomized controlled trials evaluating laser prostatectomy treatment for men with symptomatic BPH. Trials were eligible if they (1) were randomized comparisons of a laser technique with TURP, (2) included at least 10 men with BPO in each treatment arm, (3) provided at least 6-months follow-up, and (4) included clinical outcomes such as urologic symptom scales or urodynamic measurements.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of methodologic quality was performed independently by two reviewers. Information on study design, subject and treatment characteristics, adverse events, urinary symptoms, and urinary flow were extracted using a standard form.

MAIN RESULTS

20 studies involving 1898 subjects were evaluated, including studies 4 with multiple comparisons. We found 8 comparisons of TURP with contact lasers, 8 with non-contact lasers, 4 with hybrid techniques, and one with interstitial laser coagulation (ILC). Two studies compared transurethral electrovaporization (TUVP) with contact lasers, one study compared interstitial laser coagulation with transurethral microwave thermotherapy (TUMT), and one study compared holmium contact lasers (HoLRP) with open prostatectomy. Among the studies comparing laser prostatectomy with TURP, follow-up duration ranged from 6 to 36 months. Mean age (67.2 yrs), mean baseline symptom score (20.2), and mean baseline peak urinary flow (9.2 ml/s) did not differ by treatment group. The pooled percentage improvements for mean urinary symptoms ranged from 59% to 68% with lasers and 63% to 77% with TURP. The improvements for mean peak urinary flow ranged from 56% to 119% with lasers and 96% to 127% with TURP. Overall, laser subjects were less likely to receive transfusions or develop strictures and their hospitalizations were shorter. Non-contact laser subjects were more likely to have dysuria, urinary tract infection, and retention. Re-operation occurred more often following laser procedures.

REVIEWER'S CONCLUSIONS

Laser techniques are a useful alternative to TURP for treating BPO. Small sample sizes and differences in study design limit any definitive conclusions regarding the preferred type of laser technique. Data were insufficient to compare laser techniques with other minimally invasive procedures.

A 4-year follow-up of a randomized prospective study comparing transurethral electrovaporization of the prostate with neodymium: YAG laser therapy for treating benign prostatic hyperplasia

OBJECTIVE

To compare the safety, efficacy and durability of neodymium (Nd):YAG laser prostatectomy with transurethral electrovaporization of the prostate (TUVP) for treating benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

From March 1995 to March 1997, 180 patients with bladder outlet obstruction secondary to BPH were randomized equally either to Nd:YAG laser therapy or TUVP. Laser therapy combined two different techniques, side-fire coagulation of the lateral lobes and contact vaporization of the median lobe. Before treatment the two groups had a comparable International Prostate Symptom Score (IPSS), quality-of-life score (QoL), maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR), and prostate and adenoma volume. In all, 62 and 78 patients completed the 1, 2, 3 and 4-year follow-up from the laser and TUVP groups, respectively.

RESULTS

At each follow-up, the IPSS, QoL, Qmax and PVR were significantly better and more durable in the TUVP than in the laser group. In the TUVP and laser groups respectively, at the 4-year follow-up the mean value of the IPSS was 3.7 vs 11.9, the QoL 1.3 vs 3.1, the Qmax 21.4 vs 13.6 mL/s and the PVR 25.1 vs 64.6 mL (all P < 0.001). The mean prostate and adenoma volume were significantly lower after TUVP than after laser therapy (P < 0.001) at the 1- and 4-year follow-up, with final values of 27.9 vs 35.9 and 11.7 vs 20 mL (both P < 0.001) for the TUVP and laser groups, respectively. Retrograde ejaculation was significantly more common after TUVP (63%) than after laser therapy (18%; P < 0.001). Impotence was reported in 8% of men after TUVP and in none after laser therapy (P = 0.040). The re-operation rate was 12% after TUVP and 38% after laser treatment (P < 0.001).

CONCLUSION

These 4-year follow-up results confirm that TUVP is significantly more effective and durable than the Nd:YAG laser for treating BPH. Residual obstructing adenoma was the main cause of failure in the laser group, which reflects the inadequacy of laser therapy for removing the adenoma.

Benign prostatic hyperplasia

In both ageing men and women, there is an increasing incidence of lower urinary tract symptoms (LUTS) which are increasing. These infections have many possible causes, including smooth muscle dysfunction, neurological factors and benign prostatic hyperplasia. Up to 15% to 25% of men aged 50-65 years have LUTS of sufficient severity to interfere with their quality of life. Although benign prostatic hyperplasia is an important cause of these symptoms, and can have serious consequences, clinicians should be aware of these other causes so that the appropriate diagnosis is made before invasive treatments are started. New medical treatments, including alpha-adrenergic blocking agents and 5 alpha-reductase inhibitors mean that many men without complications such as infection, bleeding, or chronic retention, and with mild to moderate symptoms, should be managed in primary care. Combined local protocols between primary and secondary care will help to establish which men with persistent symptoms or complications need referral for a urological opinion to determine the need for further investigation and more invasive forms of management. We review the pathophysiology of the disease, and current approaches to investigation and management of this common problem.

Use and misuse of the concept of quality of life in evaluating surgical treatments for lower urinary tract symptoms

OBJECTIVE

To investigate how quality of life (QoL) components measured by given instruments direct the QoL perspective in treatment studies of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH).

METHODS

Computer searches were conducted in Medline, CINAHL and Psychinfo; MeSH terms covering QoL and surgical treatments for BPH and LUTS were combined for the search. The analysis was based on a framework linking components of QoL to patient outcome.

RESULTS

Of the 74 papers meeting the inclusion criteria, 48 were published in 1997-2001, showing the increase of interest of the topic. Most of the papers reported the change in QoL by a one-item scale, whilst only a few reported results from several of the components in the QoL concept. Some papers regarded the change in general health status or parts of health status as changes in QoL. Functional status and symptoms, and the bother of symptoms, were often regarded as indicators of a change in QoL.

CONCLUSION

These analyses show an increasing interest in measuring QoL after surgery for LUTS and BPH. In most of the studies analysed, the batteries of instruments selected were too narrow in scope to study the complexity of QoL. Most papers are based on instruments sensitive to change, but the reports do not distinguish the basic assumptions for understanding relationships important in QoL research and as a result, the reason for change is open to question.

Current indications for transurethral resection of the prostate and associated complications

Transurethral resection of the prostate (TURP) is the most common surgical procedure for relieving symptoms of benign prostatic hyperplasia. Here, we report our experience of current indications for TURP and their associated outcomes at Kaohsiung Medical University Hospital (KMUH). A total of 111 patients who underwent TURP at KMUH between May 2000 and December 2001 were included in this retrospective review. For each patient, the surgical indication was categorized into acute urinary retention, chronic complications (including renal impairment, recurrent urinary infection, bladder stone/diverticulum, post-void residue, and recurrent hematuria), and symptomatic prostatism. Thirty-five patients (31%) had acute urinary retention, 28 (27%) had chronic complications, and 48 (42%) had symptomatic prostatism. Most patients chose TURP only when medical treatment had failed to relieve symptoms, no matter what category they belonged to. Patients with acute urinary retention and chronic complications had larger prostates (p = 0.002) and more tissue resected (p = 0.05) than those with symptomatic prostatism. Patients with acute urinary retention seemed to be at greater risk of postoperative complications such as recurrent urinary retention and urinary tract infection. We suggest that urodynamic study may be necessary to rule out concomitant bladder dysfunction before surgery and that adequate prophylactic antibiotic treatment be used to decrease the risk of urinary tract infection during or after TURP, especially when pyuria is noted preoperatively in patients with acute urinary retention.

Laser prostatectomy versus transurethral resection for treating benign prostatic obstruction: a systematic review

PURPOSE

We conducted a systematic review of randomized controlled trials evaluating the efficacy and safety of laser prostatectomy techniques compared to transurethral resection of the prostate for symptomatic benign prostatic obstruction.

MATERIALS AND METHODS

We searched MEDLINE, the Cochrane library and reference lists of retrieved studies to identify randomized trials of 6 months or greater in duration with at least 10 subjects in each treatment arm. We extracted data on study design, subject and treatment characteristics, adverse events, urinary symptoms and urinary flow.

RESULTS

A total of 16 studies involving 1,488 subjects were evaluated, including 8 comparisons of transurethral resection with contact lasers, 7 with noncontact lasers and 4 with hybrid techniques. Study duration ranged from 6 to 36 months. Mean patient age (67.4 years), baseline symptom score (20.2) and peak urinary flow (9.5 ml. per second) did not differ by treatment group. Transurethral resection of the prostate provided slightly greater improvement in urinary symptoms and flow. The pooled mean percentage improvement for urinary symptoms ranged from 59% to 68% with lasers and 63% to 77% with transurethral resection. Improvement for peak urinary flow ranged from 56% to 119% with lasers and 96% to 127% with transurethral resection of the prostate. Laser procedures resulted in fewer transfusions (less than 1% versus 7%) and strictures (0% to 7% versus 8%), and required shorter hospitalizations. Reoperation occurred more often (RR = 5.7) following laser procedures.

CONCLUSIONS

Laser techniques are a useful alternative to transurethral resection of the prostate for treating benign prostatic obstruction. Small sample sizes and differences in study design limit any definitive conclusions regarding the preferred type of laser technique.

Transurethral prostate resection, noncontact laser therapy or conservative management in men with symptoms of benign prostatic enlargement? An economic evaluation

PURPOSE

We evaluated the cost-effectiveness of noncontact laser therapy compared with transurethral prostate resection and conservative treatment in men with symptoms associated with benign prostatic enlargement.

MATERIALS AND METHODS

A total of 340 men with uncomplicated lower urinary tract symptoms participated in a large multicenter pragmatic randomized trial called the CLasP (Conservative management, Laser therapy, transurethral resection of the Prostate) study. Costs to the United Kingdom National Health Service and patients were determined from the time of randomization to the 7.5-month followup. Incremental cost-effectiveness ratios using conservative management as the base case were calculated for certain trial outcomes, including International Prostate Symptom Score (I-PSS), I-PSS quality of life score, maximum urinary flow, post-void residual urine volume, quality adjusted life-years and a composite measure of success based on I-PSS and maximum urinary flow. One-way sensitivity analysis of the basic costs and incremental cost-effectiveness ratios were done from the NHS viewpoint.

RESULTS

Mean costs per patient were greatest for noncontact laser therapy and least for conservative management. The incremental cost-effectiveness ratios showed that transurethral prostate resection was more cost-effective than noncontact laser treatment for all primary trial outcomes. The incremental cost-effectiveness ratios of transurethral prostate resection compared with conservative management were pound 81 per unit decrease in the I-PSS score and pound 1,338 per additional successful case per 100 patients. Sensitivity analysis showed that the initial results were robust.

CONCLUSIONS

Noncontact laser was the mostly costly treatment option. Transurethral prostate resection was more cost-effective than noncontact laser therapy in terms of symptomatic improvement. In men wishing to delay treatment conservative treatment appears to provide a cost-effective alternative in the short term.

"Why don't they just tell me straight, why allocate it?" The struggle to make sense of participating in a randomised controlled trial

Randomised controlled trials are the acknowledged 'gold standard' method of evaluating the effectiveness of treatments, but little is known about how and why patients decide to participate in trials nor how much they understand about trial design. In this study, in-depth, semi-structured interviews were carried out with 33 middle aged and older men with lower urinary tract symptoms related to benign prostatic disease, 22 of whom had consented to participate and 11 refused to take part in a randomised trial. The trial was evaluating the effectiveness of a new technology (laser therapy) compared with standard surgery (transurethral resection of the prostate ) and conservative management (monitoring without active intervention) (the CLasP study). Purposive sampling was used to include participants from different centres, each treatment arm, and at different stages in participation, as well as those indicated to have refused participation. Interviews explored their recall and understanding of trial information, and their reasoning about how they were allocated to a treatment. Data were analysed thematically according to the methods of constant comparison, and by examining each participant's narrative of their experiences. Most participants recalled major aspects of trial design, including the involvement of chance, but the case studies showed that most also held other co-existing (and sometimes contradictory) views about their treatment allocation. The key to understanding their experiences was their engagement in a struggle to understand the trial in the context of their own beliefs, their recall of the study information and their actual experiences of the trial. The outcome of the struggle was the placing of trust in clinicians or the development of distrust. Non-participants made sense of their experiences in similar ways, but gave different reasons for non-participation than indicated by recruiters. This study shows that most eligible patients, whatever their level of knowledge, will struggle to make sense of their participation in randomised trials. The provision of clearer written information or time to discuss the trial with particular individuals might be beneficial, although greater public understanding of trials is also needed.

Outpatient lumbar microdiscectomy: a prospective study in 122 patients

BACKGROUND

Outpatient surgery saves the risk of nosocomial complications and health care dollars. Patients undergoing lumbar microsurgical discectomy are excellent candidates for outpatient surgery. The object of this study was to examine the feasibility of performing lumbar microdiscectomy on an outpatient protocol and to examine the potential savings associated with such a protocol.

METHODS

From February 1997 to September, 2001, 122 consecutive patients of the senior author were entered into a protocol of outpatient lumbar microdiscectomy. Only elective cases were considered for this study. Patients were excluded if they had significant co-morbidities, lived a significant distance out of town, or if their surgery was scheduled too late in the day. Success was defined as discharge home from the day-surgery unit approximately four hours after surgery.

RESULTS

During the study period, 150 elective lumbar microdiscectomies were performed. Twenty-four patients were excluded based on the above criteria and four patients requested not to participate in the study. Of the remaining 122, 116 successfully completed the protocol (95.1%). Six patients were admitted from the day surgery unit; two patients with dural tears and four patients with anaesthetic side-effects. No patient was readmitted to hospital after discharge and no complications of early discharge were observed. There was a total reduction in hospitalization of 1.2 nights per elective procedure considering the 150 patients, when compared with the hospitalization times prior to outpatient lumbar microdiscectomy.

CONCLUSIONS

Lumbar microdiscectomy can be performed safely as an outpatient procedure, resulting in a substantial reduction in hospitalization times.

Neodymium:YAG visual laser ablation of the prostate: 7 years of experience with 230 patients

PURPOSE

We evaluated the short and long-term outcome of neodymium:YAG visual laser ablation prostatectomy for treatment of benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A total of 230 patients with symptomatic BPH underwent visual laser ablation prostatectomy. Evaluation measures included the American Urological Association symptom score, maximum urinary flow rate, post-void residual urine volume and morbidity.

RESULTS

Median followup was 36 months (range 6 to 79). Of the patients 220, 196, 180, and 167 were available at 6 months, 1, 2 and 3 years, respectively. Moreover, 98 patients were followed for a minimum 5 years. At 6 months maximum urinary flow rate increased from 6.7 to 17.9 ml. per second, post-void residual urine volume decreased from 159 to 52 ml. and the American Urological Association symptom score was reduced from 22 to 7.2. Improvement in the evaluation parameters also continued at 5 years. Early complications consisted of prostatitis, urinary retention, and bleeding in 6 (2.6%), 3 (1.4%) and 1 (0.4%) patient, respectively. Irritative symptoms persisting greater than 4 weeks were seen in 28 (12.2%) patients. Late complications were bladder neck contracture, urethral stricture, and urinary retention in 3 (1.4%), 2 (0.9%) and 2 (0.9%) patients, respectively. Of the 153 sexually active men 5 noticed erectile impotence at 6 months. There were 20 (12.0%) patients who reported retrograde ejaculation. The reoperation rate was 5.5%.

CONCLUSIONS

Our results further confirmed that visual laser ablation prostatectomy is a safe and effective treatment for BPH. It has minimal morbidity and durable therapeutic effects. However, the major disadvantage is postoperative irritative voiding symptoms.

Transurethral resection of the prostate: the new old standard

A literature search was performed for articles between June 2000 and July 2001 pertaining to transurethral resection of the prostate. Eight of the most interesting and/or groundbreaking articles, as deemed by the authors, were selected for review. Topics discussed include transurethral vaporization of the prostate, laser prostatectomy, preoperative finasteride, pelvic floor rehabilitation, the impact of the quantity of tissue removed, bladder infusion prior to catheter removal, and ethanol-glycine in assessment of the absorption of irrigation fluid.

Lasers for median lobe hyperplasia

Laser treatment encompases a variety of techniques using different laser wavelengths, application systems, and surgical techniques to achieve contrasting tissue effects such as incision, resection, vaporization, or coagulation. Many studies have proven the clinical efficacy of the various laser techniques for the treatment of benign prostatiuc hyperplasia, including randomized studies versus transurethral prostatectomy (TURP). Recently, long-term follow-up of up to 5 years has demonstrated the durability of the results, although in some of the studies, retreatment rates were higher than after TURP. Median lobes were never seen as a contraindication for treatment in the laser based procedures. Technically, laser treatment techniques such as side-firing transurethral coagulation, contact- and free-beam laser vaporization, interstitial laser coagulation, and the holmium laser-based resection and enucleation are fully suitable for treatment of median lobes. Surprisingly, no studies focussing specifically on laser treatment of median lobes have been published.

Outpatient craniotomy for brain tumor: a pilot feasibility study in 46 patients

BACKGROUND

Since 1991 the author has routinely performed awake craniotomy for intra-axial brain tumors with low complication rate and low resource utilization. In late 1996 a pilot study was initiated to assess the feasibility of performing craniotomy for tumor resection as an outpatient procedure.

METHODS

A rigorous protocol was developed and adhered to, based around the patient's arrival at hospital at 6:00 a.m, undergoing image-guided awake craniotomy with cortical mapping, and being discharged by 6:00 p.m.

RESULTS

During the 48 month period from December 1996 to December 2000, 245 awake craniotomies were performed and of those, 46 patients were entered into the outpatient craniotomy protocol. Pathology in the 46 intent-to-treat group was: 21 metastasis, 19 glioma, and six miscellaneous. Four patients required conversion to inpatients and one patient was readmitted later the same evening due to headache. Thus 41/46 patients successfully completed the protocol (89%). There were five complications in the 46 intent-to-treat group (10.9%).

CONCLUSIONS

Outpatient craniotomy for brain tumor is a feasible option which appears safe and effective for selected patients. Besides being resource-friendly, the procedure may be psychologically less traumatic to patients than standard craniotomy for brain tumor. Proper prospective studies including satisfaction surveys would help resolve these issues and will be the next step.

Scoring the short form ICSmaleSF questionnaire. International Continence Society

PURPOSE

The International Continence Society (ICS) ICSmale questionnaire was devised to provide a thorough evaluation of the occurrence and bothersomeness of lower urinary tract symptoms and their impact on the lives of men with benign prostatic disease. This report completes the developmental work on the questionnaire, producing the concise short form instrument, ICSmaleSF, with a valid, reliable and scientifically justified scoring system.

MATERIALS AND METHODS

Two data sets were used. The short form version of the questionnaire was devised and initially evaluated using data on men with uncomplicated lower urinary tract symptoms who were involved in the CLasP randomized controlled trial comparing laser therapy with transurethral prostatic resection and conservative management or monitoring without active intervention. External validation of the scoring system was undertaken using data from phase II of the ICS benign prostatic hyperplasia (BPH) study, an observational study of outcome in men with lower urinary tract symptoms related to benign prostatic enlargement. All patients completed the developmental version of the ICSmale questionnaire. Parallel analysis on the CLasP data set identified items that were responsive to change or highly problematic, allowing other redundant and overlapping items to be eliminated. Factor analysis and Cronbach's alpha coefficients were used to examine the clustering of items. Regression models were used to investigate the validity of followup scores within and across treatment groups in the CLasP and ICS/BPH studies.

RESULTS

The questionnaire, which originally comprised 22 items, was shortened to 11 items in the 2 distinct factors of voiding (ICSmaleVS) and incontinence (ICSmaleIS) symptoms. Cronbach's alpha coefficients were high at 0.76 for ICSmaleVS and 0.78 for ICSmaleIS. A simple additive score was calculated by adding the 5 items in ICSmaleVS and 6 in ICSmaleIS. ICSmaleVS and ICSmaleIS detected expected improvement in the laser therapy and transurethral prostatic resection groups, and stability in the conservative management group within CLasP. Similarly each subscore but particularly ICSmaleVS was sensitive to differences in the outcome of the range of treatments in the ICS/BPH study. While frequency and nocturia were highly problematic and sensitive to change individually, they did not load into the other main factors or correlate with each other. It is suggested that these symptoms should be evaluated separately with the additional inclusion of a single item measure of the impact of lower urinary tract symptoms on daily life.

CONCLUSIONS

The ICSmaleSF represents a comprehensive, concise, valid and reliable instrument for evaluating men with lower urinary tract symptoms. Unlike other questionnaires in the field it contains subscores for the domains of voiding and incontinent symptoms as well as the separate consideration of frequency, nocturia and impact on daily life. We hope that it will become the tool of choice for the comprehensive evaluation of treatment of men with lower urinary tract symptoms associated with benign prostatic disease.

Minimally invasive procedures as an alternative to medical management for lower urinary tract symptoms of benign prostatic hyperplasia

Data are reviewed relating to the safety and efficacy of minimally invasive transurethral microwave thermotherapy and medical management in patients with lower urinary tract symptoms of benign prostatic hyperplasia. Recent evidence is summarized indicating more pronounced long-term beneficial effects of microwave treatment. alpha-Blockade, however, offers the advantage of more rapid action than microwave treatment. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement in patients receiving microwave treatment. Compared with medical management, microwave treatment possesses greater versatility, allowing patients with severe baseline symptoms and small prostate sizes to be treated with a high probability of success.

Quality-of-life assessment in patients with benign prostatic hyperplasia: effects of various interventions

A literature search was conducted to review quality-of-life (QOL) measurement in patients with benign prostatic hypertrophy (BPH). The different QOL instruments are discussed in relation to their correlation with symptom evaluation in studies of treatment options for BPH. Symptom evaluation of BPH has been standardised internationally with the International Prostatic Symptom Score (IPSS), but there is neither agreement nor data to decide which QOL instrument is preferable. The most widely used QOL instrument is the disease-specific QOL single question added to the IPSS. Other QOL instruments have been used, but none has gained unanimous approval. The results of QOL assessments obtained from comparative clinical studies of treatment options for BPH are discussed. These studies compare treatment options such as watchful waiting, drug treatment and surgery. Disease-specific QOL domains (interference with daily activities) tend to improve more with treatment interventions than general health measures (i.e. general well-being). The use of QOL instruments to evaluate patients with BPH, and their many treatment options, is still open to debate with regard to which instruments are preferred and their importance to the clinical evaluation of the patient. The challenge remains to find an acceptable disease-specific QOL instrument that adds information to currently used disease measures of BPH.