The role of sex steroid hormones in benign prostatic hyperplasia

Mechanisms and Efficacy of Chinese Herbal Medicines in Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is one of the most common diseases in elderly men, the incidence of which gradually increases with age and leads to lower urinary tract symptoms (LUTS), which seriously affects the quality of life of patients. Chinese herbal medicines (CHMs) are widely used for the treatment of BPH in China and some other countries. To explore the molecular mechanisms of CHMs for BPH, we conducted a review based on peer-reviewed English-language publications in PubMed and Web of Science databases from inception to December 31, 2023. This article primarily reviewed 32 papers on the use of CHMs and its active compounds in the treatment of BPH, covering animal and cell experiments, and identified relevant mechanisms of action. The results suggest that the mechanisms of action of CHMs in treating BPH may involve the regulation of sex hormones, downregulation of cell growth factors, anti-inflammatory and antioxidative effects, inhibition of cell proliferation, and promotion of apoptosis. CHMs also exhibit α-blocker-like effects, with the potential to relax urethral smooth muscle and alleviate LUTS. Additionally, we also reviewed 4 clinical trials and meta-analyses of CHMs for the treatment of BPH patients, which provided initial evidence of the safety and effectiveness of CHMs treatment. CHMs treatment for BPH shows advantages as a multi-component, multi-target, and multi-pathway therapy, which can mitigate the severity of the disease, improve LUTS, and may become a reliable treatment option in the future.

Shuangshi Tonglin Capsule treats benign prostatic hyperplasia through the ROS/NLRP3 signaling pathway

OBJECTIVE

To explore the effects of the SSTL on BPH and clarify the therapeutic mechanisms.

METHODS

Animal model of BPH was established by castration and subcutaneous injection of TP into SD rats; rats were orally administered SSTL for 28 days while modeling. Detection of PI, LI and RI in rats, to observe histopathological changes and collagen deposition in the prostate tissue. Detects levels of sex hormones and inflammatory factors in serum and tissues of rats, the test kit detects levels of lipid peroxides and antioxidants in serum and tissues. Fluorescent staining analysis of tissue ROS; the expression of NLRP3 inflammatory vesicles was observed by immunohistochemistry; Western blotting detected the expression of NOX4, NOX2, NLRP3 inflammatory vesicles, ASC, Cleaved Caspase-1, Caspase-1, IL-1β.

RESULTS

After SSTL capsule treatment, the PI and RI of the rats decrease. HE and Masson staining showed that SSTL ameliorated the pathological damage and reduced collagen deposition in the prostate tissue of BPH rats; ELISA results showed that SSTL was able to reduce T, DHT, TNF-α, IL-1β levels in BPH rats. The test kit showed that SSTL made the levels of MDA, CAT and GSH-Px in the serum and prostate tissue of rats and increased the activity of SOD. The results of ROS fluorescence showed that the ROS level was reduced in SSTL group; Western blotting showed that SSTL could cause down-regulation of NOX4, NOX2, NLRP3, ASC, Cleaved Caspase-1, IL-1β protein expression.

CONCLUSION

SSTL can reduce the PI and RI in BPH rats, it can also inhibit the level of sex hormones and inflammatory factors in BPH rats, which thereby reducing the histopathological damage of prostate gland in BPH rats, and can treat BPH in rats through ROS/NLRP3 pathway.

Association between dietary phytochemical index and risk of benign prostatic hyperplasia: a case-control study

BACKGROUND

Dietary intake of phytochemicals has been associated with a reduced risk of chronic diseases, but research on their relationship with benign prostatic hyperplasia (BPH) is limited. This case-control study aimed to investigate the association between a Dietary Phytochemical Index (DPI) and BPH risk in a Middle-Eastern population.

METHODS

The study recruited 112 BPH patients and 112 age-matched healthy controls (40-75 years) from Al-Zahra Hospital Clinic in Isfahan, Iran between 2021 and 2022. Dietary intake was assessed using a validated food-frequency questionnaire, and DPI was calculated as the ratio of energy intake from phytochemical-rich foods to total daily energy intake. Logistic regression analysis was performed, adjusting for potential confounders.

RESULTS

In the crude model, participants in the highest DPI tertile had a 70% lower odds of BPH compared to those in the lowest tertile (OR:0.3, 95% CI 0.15-0.61, P-trend = 0.001). After adjusting for confounders, this inverse association remained significant (OR:0.23, 95% CI 0.15-0.63, P-trend = 0.001). Participants with higher DPI consumed more whole grains (p = 0.02), nuts (p < 0.001), legumes (p = 0.02), fruits (p < 0.001), vegetables (p < 0.001), olives and oilve products (p = 0.02), and tomato and its products (p < 0.001) in their diet compared to the lowest tertile. However, red meat (p = 0.03) and refined grains (p < 0.001) were consumed in higher amounts in the lowest tertile compared to the highest DPI tertile.

CONCLUSIONS

This study demonstrates a protective association between DPI and BPH risk in the Middle-Eastern population. Encouraging higher intake of phytochemical-rich foods may help reduce the risk of BPH, highlighting the relevance of nutritional science in promoting prostate health.

One-year outcomes after prostate artery embolization versus laser enucleation: A network meta-analysis

Background

Although holmium laser enucleation (HoLEP) is considered a size-independent procedure for treatment of an enlarged prostate, prostate artery embolization (PAE) is emerging as an alternative modality to treat moderate and large benign prostatic hyperplasia. This study aims to compare the early post-operative and short-term efficacy of PAE and HoLEP.

Methods

PubMed, Cochrane Library and EMBASE databases were searched. Network meta-analysis was performed following PRISMA-N-guidelines. Post-operative parameters analysed include international prostate symptom score (IPSS), quality of life (QOL), post-void residual urine (PVR), maximal uroflow rate (Qmax) and serious adverse events (SAE). Random effects model calculated weighted mean differences (WMD). If 95%CI crossed the line of no effect (WMD = 0), evidence indicated no statistically significant difference between treatments compared.

Results

Qualitative and quantitative syntheses included 20 and 18 studies with 1991 and 1606 patients, respectively. At 3 months, there was no statistically significant difference between PAE and HoLEP in IPSS score improvement [WMD: -2.21: 95%CI: (-10.20, 5.78), favouring PAE], QoL score improvement [WMD: -0.22:95%CI: (-1.75, 1.32), favouring PAE] and PVR improvement [WMD: 26.97: 95%CI: (-59.53, 113.48), favouring HoLEP]. However, PAE was found inferior to HoLEP for Qmax improvement [WMD: 8.47, 95%CI: (2.89, 14.05), favouring HoLEP]. At 1-year follow-up, there was no statistically significant was found between PAE and HoLEP for IPSS score improvement [WMD:6.03, 95%CI: (-1.30, 13.35)], QoL score improvement [WMD: 0.03, 95%CI: (-1.19, 1.25)], PVR improvement [WMD:4.11, 95%CI: (-32.31, 40.53)] and Qmax improvement [WMD:2.60, 95%CI: (-2.20, 7.41)] with all differences favouring HoLEP. PAE was superior to HoLEP for SAE [PAE vs. HoLEP-OR: 0.68, 95%CI: (0.25, 1.37)].

Conclusion

HoLEP was superior to PAE at 3 months for Qmax improvement. There was no significant difference in IPSS, QoL, PVR and Qmax improvement at 1 year between PAE and HoLEP. PAE was also associated with lesser SAE compared to HoLEP. Studies on the long-term outcome of PAE are needed to establish the durability of early outcomes after PAE.

Metformin: A promising clinical therapeutical approach for BPH treatment via inhibiting dysregulated steroid hormones-induced prostatic epithelial cells proliferation

The occurrence of benign prostate hyperplasia (BPH) was related to disrupted sex steroid hormones, and metformin (Met) had a clinical response to sex steroid hormone-related gynaecological disease. However, whether Met exerts an antiproliferative effect on BPH via sex steroid hormones remains unclear. Here, our clinical study showed that along with prostatic epithelial cell (PEC) proliferation, sex steroid hormones were dysregulated in the serum and prostate of BPH patients. As the major contributor to dysregulated sex steroid hormones, elevated dihydrotestosterone (DHT) had a significant positive relationship with the clinical characteristics of BPH patients. Activation of adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK) by Met restored dysregulated sex steroid hormone homeostasis and exerted antiproliferative effects against DHT-induced proliferation by inhibiting the formation of androgen receptor (AR)-mediated Yes-associated protein (YAP1)-TEA domain transcription factor (TEAD4) heterodimers. Met's anti-proliferative effects were blocked by AMPK inhibitor or YAP1 overexpression in DHT-cultured BPH-1 cells. Our findings indicated that Met would be a promising clinical therapeutic approach for BPH by inhibiting dysregulated steroid hormone-induced PEC proliferation.

Bushen Tongluo formula ameliorated testosterone propionate-induced benign prostatic hyperplasia in rats

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common disease in older men worldwide. However, there is currently no effective treatment for BPH. Bushen Tongluo Formula (Kidney-supplementing and collaterals-unblocking formula [KCF]) is a traditional Chinese medicine formula commonly used to ameliorate the symptoms of BPH, although the specific molecular mechanisms remain unclear.

PURPOSE

We aimed to discover the effects and potential mechanisms of KCF against BPH.

METHODS

Sixty male SD rats were randomly assigned to one of six group (n = 10): control, low-dosage KCF, medium-dosage KCF, high-dosage KCF, BPH model, and finasteride. A rat model of BPH was established by surgical castration followed by subcutaneous injection of testosterone propionate (TP) for 4 weeks. After treatment, the prostate index, histopathological staining, serum levels of estradiol (E2) and dihydrotestosterone (DHT), protein/mRNA levels of E-cadherin, TGF-β1, caspase-3, Ki67, and vimentin, abundances of serum metabolites, and the proliferation, cell cycle, and apoptosis of BPH-1 cells were documented.

RESULTS

KCF treatment for 4 weeks reduced the prostate volume and prostate index, alleviated histopathological changes to the prostate of rats with TP-induced BPH, decreased serum levels of E2 and DHT, reduced protein/mRNA levels of TGF-β1 and vimentin, and increased E-cadherin levels. Moreover, KCF-spiked serum inhibited proliferation of BPH-1 cells, blocked the cell cycle, and promoted apoptosis. KCF was also found to regulate the contents of three metabolites (D-maltose, citric acid, and fumaric acid).

CONCLUSION

The present study was the first to report that KCF exhibited therapeutic effects against BPH by regulating energy metabolism and inhibiting epithelial-mesenchymal transition in prostate tissues. Hence, KCF presents a viable treatment option for BPH.

Effects of Dibutylphthalate and Steroid Hormone Mixture on Human Prostate Cells

Phthalates are a family of aromatic chemical compounds mainly used as plasticizers. Among phthalates, di-n-butyl phthalate (DBP) is a low-molecular-weight phthalate used as a component of many cosmetic products, such as nail polish, and other perfumed personal care products. DBP has toxic effects on reproductive health, inducing testicular damage and developmental malformations. Inside the male reproductive system, the prostate gland reacts to both male and female sex steroids. For this reason, it represents an important target of endocrine-disrupting chemicals (EDCs), compounds that are able to affect the estrogen and androgen signaling pathways, thus interfering with prostate homeostasis and inducing several prostate pathologies. The aim of this project was to investigate the effects of DBP, alone and in combination with testosterone (T), 17β-estradiol (E2), and both, on the normal PNT1A human prostate cell-derived cell line, to mimic environmental contamination. We showed that DBP and all of the tested mixtures increase cell viability through activation of both estrogen receptor α (ERα) and androgen receptor (AR). DBP modulated steroid receptor levels in a nonmonotonic way, and differently to endogenous hormones. In addition, DBP translocated ERα to the nucleus over different durations and for a more prolonged time than E2, altering the normal responsiveness of prostate cells. However, DBP alone seemed not to influence AR localization, but AR was continuously and persistently activated when DBP was used in combination. Our results show that DBP alone, and in mixture, alters redox homeostasis in prostate cells, leading to a greater increase in cell oxidative susceptibility. In addition, we also demonstrate that DBP increases the migratory potential of PNT1A cells. In conclusion, our findings demonstrate that DBP, alone and in mixtures with endogenous steroid hormones, acts as an EDC, resulting in an altered prostate cell physiology and making these cells more prone to cancer transformation.

Alterations in the balance of sex hormones may affect rat prostatic inflammation and fibrosis, and osteopontin might be involved in this process

OBJECTIVE

This study aimed to investigate the effects of sex hormone imbalance on rat prostatic inflammation and fibrosis and identify the key molecules involved.

METHODS

Castrated Sprague-Dawley (SD) rats were treated with a constant dose of oestradiol (E2) and different doses of dihydrotestosterone (DHT) to achieve different oestrogen/androgen ratios. After 8 weeks, serum E2 and DHT concentrations, relative seminal vesicle weights, histopathological changes and inflammation were measured, collagen fiber content and oestrogen receptor (ER) and androgen receptor (AR) expression were detected, mRNA sequencing and bioinformatics analysis were performed to identify differentially expressed genes (DEGs).

RESULTS

The severity of inflammation in the rat dorsolateral prostate (DLP) was higher, collagen fibre content and ER expression in the rat DLP and prostatic urethra were increased and AR expression in the rat DLP was decreased in the 1:1 E2/DHT-treated group than that in the 1:10 E2/DHT-treated group. RNA-seq analysis identified 487 DEGs, and striking increases in the expression of mRNAs encoding collagen, collagen synthesis and degradation enzymes, growth factors and binding proteins, cytokines and chemokines, and cell-surface molecules were confirmed in the 1:1 E2/DHT-treated group compared to the 1:10 E2/DHT-treated group. mRNA expression of secreted phosphoprotein 1 (Spp1) and protein expression of osteopontin (OPN, encoded by Spp1) were increased in the 1:1 E2/DHT-treated group compared to the 1:10 E2/DHT-treated group, and Spp1 expression correlated positively with Mmp7, Cxcl6 and Igfn1 expression.

CONCLUSIONS

The imbalance in the oestrogen/androgen ratio may affect rat prostatic inflammation and fibrosis, and OPN might be involved in this process.

Effects of Glycyrrhiza Glabra (Licorice) Root Extract on the Hormones, Serum Biochemicals, and Hematological Parameters in Dogs with Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is the most common prostate disorder in non-neutered dogs and is often caused by androgenic stimulation or changes in the ratio of androgen to estrogen. Also, it is commonly seen in neutered older dogs. Clinical signs may not be presented, but persistent or intermittent hematuria, hemospermia, or a primary hemorrhagic discharge are usually reported. In this research, ethanolic extract of licorice root (EELR) was used as the treatment, which has various antioxidant and healing properties and can reduce lesions by establishing an antioxidant balance and reducing inflammation. For this experiment, 30 dogs of approximately the same age and weight were randomly divided into 6 groups of 5 each. The treatment groups received the EELR at doses of 10 and 20 mg/kg separately, while the control group received no medications. At the end of the 9-week treatment period, biochemical and hormonal factors were measured and analyzed by blood sampling. The results showed that the EELR has multiple positive effects on the serum biochemical indices and also positively affects hormone levels, while it can decrease the prostate-specific antigen (PSA) level in BPH dogs. In conclusion, the EELR can effectively reduce BPH-induced lesions without any side effects.

The association between histological prostatitis and benign prostatic hyperplasia: a single-center retrospective study

OBJECTIVE

To investigate the relationship between histological prostatitis (HP) and clinical parameters related to benign prostatic hyperplasia (BPH) in male.

METHOD

The clinical data of 196 BPH patients who underwent transurethral resection of the prostate were collected. According to the results of hematoxylin-eosin (H&E) staining of prostate tissue, patients were divided into two groups: BPH with HP group and BPH without HP group. Differences in acute urinary retention (AUR), prostate volume (PV), serum sex hormones, lower urinary tract symptoms (LUTS) related parameters, and systemic inflammation indicators were compared between the two groups. SPSS software v.25 was used for statistical analysis.

RESULTS

Compared with the BPH without HP group, the BPH with HP group had greater AUR rate, PV, total IPSS, and IPSS-storage in BPH with HP group (p < 0.05). However, there were no significant differences in IPSS-voiding, post-void residual volume, maximum urinary flow rate, serum sex hormones, and systemic inflammation indicators between the two groups (p > 0.05).

CONCLUSIONS

This study suggests that patients with HP have larger PV, more severe LUTS, and a higher risk of AUR. HP is closely related to BPH and may be a key factor in the occurrence and clinical progress of BPH.

The relationship between prostatic microvessel density and different concentrations of oestrogen/androgen in Sprague-Dawley rats

BACKGROUND

Currently, there are relatively few studies on the effects of changes in oestrogen and androgen levels on prostatic microvessel density (MVD). This article aimed to study the changes in prostatic MVD in Sprague-Dawley (SD) rats after castration under the effect of oestrogen/androgen at different concentrations.

METHODS

Male SD rats aged 3-4 months were randomly divided into a control group, a castration group, and groups with different concentrations of oestrogen/androgen treatment after castration. Dihydrotestosterone (DHT) and oestradiol (E) were administered daily by subcutaneous injection for one month. All the rats were killed by cervical dislocation after one month, and the serum DHT and E concentrations of the rats in each group were measured by ELISA. Prostate tissue specimens were immunohistochemically stained with monoclonal antibodies against CD34 and factor VIII for MVD.

RESULTS

Compared with the control group, the MVD decreased significantly in the castration group (P < 0.05). When the exogenous E concentration was constant, in general, the MVD of rats in all the groups increased with increasing exogenous DHT concentration. Compared with the castration group, the MVD increased significantly in the E0.05 + DHT0.015 mg/kg, E0.05 + DHT0.05 mg/kg, E0.05 + DHT0.15 mg/kg, E0.05 + DHT0.5 mg/kg, and E0.05 + DHT1.5 mg/kg groups (P < 0.05). In addition, when the exogenous DHT concentration was constant, the MVD increased with increasing exogenous E concentration in all the groups. Among them, compared with the control and castration groups, the MVD increased significantly in the DHT0.15 + E0.015 mg/kg, DHT0.15 + E0.15 mg/kg, and DHT0.15 + E0.5 mg/kg groups (P < 0.05).

CONCLUSIONS

Androgens play an important role in the regulation of prostatic MVD in SD rats, and a decrease in DHT concentration can induce a decrease in prostatic MVD. In contrast, prostatic MVD can be increased with increasing DHT concentration. In addition, prostatic MVD can be increased gradually with increasing oestrogen concentration.

Associated Factors for Prostate Enlargement in Chinese Adult Men Aged <40 Receiving Checkups

PURPOSE

Prostate enlargement (PE) is an increase in prostate volume in morphology. PE was also observed in some patients aged <40 with chronic prostatitis. This study aimed to explore the associated factors for PE in Chinese adult men aged <40.

METHODS

The medical records of 1851 consecutive Chinese adult men aged <40 in a single center were retrospectively analyzed. The checkup indicator characteristics between the PE and non-PE groups were compared by univariate analysis, and the associated factors were analyzed by multivariate analysis.

RESULTS

The overall prevalence of PE (defined as prostate volume ≥ 20 ml) in adult men aged < 40 was 10.4%. Age and the proportions of subjects with prostate calcification or hypertension were different between the PE and non-PE groups (P < 0.05). Multivariate logistic analysis showed that prostate calcification (odds ratio [OR], 1.831; 95% confidence interval [CI], 1.281-2.619; P=0.001), hypertension (OR, 1.528; 95% CI, 1.125-2.076; P=0.007), and age (OR, 1.117; 95% CI, 1.078-1.159; P < 0.001) were associated factors for PE in adult men aged <40.

CONCLUSIONS

The prevalence of PE in Chinese adult check-up men aged <40 was not rare. In addition to age, prostate calcification and hypertension were associated factors for PE in Chinese adult men aged <40.

High altitude exposure affects male reproductive parameters: Could it also affect the prostate?†

Living at high altitudes and living with prostatic illness are two different conditions closely related to a hypoxic environment. People at high altitudes exposed to acute, chronic, or intermittent hypobaric hypoxia turn on several mechanisms at the system, cellular and molecular level to cope with oxygen atmosphere scarcity maintaining the oxygen homeostasis. This exposure affects the whole organism and function of many systems, such as cardiovascular, respiratory, and reproductive. On the other hand, malignant prostate is related to the scarcity of oxygen in the tissue microenvironment due to its low availability and high consumption due to the swift cell proliferation rates. Based on the literature, this similarity in the oxygen scarcity suggests that hypobaric hypoxia, and other common factors between these two conditions, could be involved in the aggravation of the pathological prostatic status. However, there is still a lack of evidence in the association of this disease in males at high altitudes. This review aims to examine the possible mechanisms that hypobaric hypoxia might negatively add to the pathological prostate function in males who live and work at high altitudes. More profound investigations of hypobaric hypoxia's direct action on the prostate could help understand this exposure's effect and prevent worse prostate illness impact in males at high altitudes.

Investigation of Lymphocyte Subsets in Peripheral Blood of Patients with Benign Prostatic Hyperplasia

OBJECTIVE

To investigate the immune profiles in benign prostatic hyperplasia, changes in the absolute number of lymphocyte subsets and the proportion of T lymphocyte subsets were detected.

METHODS

Absolute value of lymphocyte subsets in peripheral blood (T, B and NK cells) and the proportion of T lymphocyte (native CD4⁺ T cell, memory CD4⁺ T cell, CD8⁺CD28⁺ T cell, CD8⁺CDDR⁺ T cells and CD8⁺CD38⁺ T cell) were measured by flow cytometry.

RESULTS

The absolute values of CD3⁺ T cell (972.55±330.31 vs 1757.99±439.38), CD4⁺ T cell (656.43±252.39 vs 899.30±262.10), and CD8⁺ T cell (301.97±147.76 vs 728.45±230.34) in patients with benign prostatic hyperplasia were significantly reduced (all P<0.05). There was no significant difference in NK cell (285.58±182.84 vs 528.92±208.17) and B cell (186.66±86.62 vs 334.17±130.46). The proportion of naive CD4⁺ T cell (3.75±0.50 vs 8.54±1.61) in T lymphocyte subsets in patients with BPH was significantly reduced (P<0.05). There was no significant difference in memory CD4⁺ T cell (87.9±6.37 vs 92.63±5.94), CD8⁺CD28⁺ T cell (60.52±13.86 vs 64.32±12.78), CD8⁺CDDR⁺ T cell (36.58±12.87 vs 31.92±8.54) and CD8⁺CD38⁺ T cell (2.1±1.90 vs 2.55±2.01).

CONCLUSION

Immune dysfunction raised the risk of viral infection, inflammatory stimulation, and tumor induction in prostate cells, leading to hyperplasia, and immune non-response was potentially a key factor in the transformation of BPH into prostate cancer.

A Pilot Study on the Effects of Yi Jin Jing Exercise for Older Men with Benign Prostatic Hyperplasia

Benign prostatic hyperplasia and its associated lower urinary tract symptoms seriously affect both the physical and mental health of older men. In order to determine the efficiency of Chinese Qigong Yi Jin Jing on prostate health in older individuals, thirty participants were randomized into either an Yi Jin Jing group (n = 15) or a control group (n = 15). After the 6-month intervention, the Yi Jin Jing group showed a significant decrease in international prostate symptom score and a significant increase in maximal urinary flow rate (compared with the control group p = .005, p = .001, respectively). Also, testosterone level increased and estrogen/testosterone ratio decreased in the Yi Jin Jing group (compared with the baseline p = .004, p = .002, respectively); estrogen level and estrogen/testosterone ratio were lower in the Yi Jin Jing group (compared with the control group p = .029, p = .012, respectively). The results showed that Yi Jin Jing is a promising way to reduce the risk of benign prostatic hyperplasia-lower urinary tract symptoms in older men.

Variation of prostatic morphology in Chinese benign prostatic hyperplasia patients of different age decades

OBJECTIVE

Our study aimed to investigate the age-related growth in prostatic morphological parameters in Chinese benign prostatic hyperplasia (BPH) patients, and to find out the regularity of how these parameters change with aging.

METHODS

Medical records of 1038 BPH patients were obtained from a retrospective database of first-visit men with BPH. Change regularity of prostatic anatomical factors with aging was analyzed.

RESULTS

Patients were classified into four groups according to different age decades. All prostatic anatomical factors assessed in this research increased with age growth (p < .0001). However, these anatomical factors sustained stably when older than 70 years. By analyzing the detailed correlation between age and prostatic morphological parameters, transitional zone index (TZI) (Pearson r = 0.358, r² = 0.128, p < .0001) and transitional zone width (TZW) (Pearson r = 0.344, r ²= 0.118, p < .0001) showed the best correlation coefficient with age. After adjusted the influence of cardiovascular disease (CVD) and diabetes mellitus (DM), the result remained still similarly.

CONCLUSION

Prostatic morphological parameters increase progressively with age growth when patients were younger than 70 years, indicating reasonable interventions to be provided to BPH patients before 70 years. In addition, TZI and TZW are two practical, easy-to-measure prostatic parameters that are significantly associated with the growth of age compared to others.

Hyperlipidemia patients with long-term statin treatment are associated with a reduced risk of progression of benign prostatic enlargement

OBJECTIVE

To evaluate the impacts of statin treatment on the risk of benign prostatic enlargement (BPE) progression in hyperlipidemia patients.

METHODS

Newly diagnosed hyperlipidemia patients (n = 7961), identified from Taiwan's National Health Insurance Research Database, were divided into four statin cohorts (statin use >365 days, n = 1604; statin use 181-365 days, n = 813; statin use 91-180 days, n = 739; and statin use 31-90 days, n = 713) and one control cohort (cohort that used no statins, n = 4092). Study endpoint was occurrence of BPE progression (BPE diagnosis plus receiving BPE-related medications or surgery). Relative risks of BPE progression in the statin cohorts compared to the control cohort were analyzed.

RESULTS

Multivariable Cox proportional hazards regression analyses demonstrated that BPE progression risk in the cohort used statins for >365 days was significantly lower than the control cohort (adjusted hazard ratio: 0.70, 95% confidence interval: 0.58 ∼ 0.85, p < .001). However, BPE progression risks of the other three statin cohorts did not significantly differ from the control cohort. Trend analysis revealed that the effects of statin treatment on decreasing BPE progression risk were significantly related to statin treatment duration (p = .001).

CONCLUSIONS

Hyperlipidemia patients with long-term statin treatment (more than 365 days) are associated with a reduced risk of BPE progression.

Association between asthma and risk of benign prostatic hyperplasia: a retrospective population-based study

OBJECTIVE

The association between asthma and benign prostatic hyperplasia (BPH) has rarely been explored. We investigated whether male asthmatic patients had an increased risk of BPH by conducting this retrospective nationwide population-based study.

METHODS

We utilized data derived from the National Health Insurance Research Database (NHIRD) in Taiwan. A total of 9778 male patients aged >40 years who were newly diagnosed with asthma between 2000 and 2006 were included in the asthma group. Male enrollees without asthma were selected as the non-asthma group from the same database. Both the groups were followed up until the end of 2013. We performed Cox proportional hazard regression analysis to estimate the risk of BPH and transurethral resection of the prostate (TURP) in the male patients with asthma compared with that in those without asthma.

RESULTS

The risk of BPH and TURP in the asthma group was 1.40-fold (95% confidence interval [CI] = 1.30-1.42) and 1.30-fold (95% CI= 1.31-1.50) higher than that in the non-asthma group, respectively, after adjusting for comorbidities, relevant medications and number of annual outpatient visits.

CONCLUSIONS

The male patients with asthma were found to have a higher risk of BPH than did those without asthma.

Estrogen regulates the proliferation and inflammatory expression of primary stromal cell in benign prostatic hyperplasia

Background

To investigate the expression of estrogen receptor (ER) in prostate tissues of benign prostatic hyperplasia (BPH) individuals, and the effects of estrogen regulating the proliferation and inflammatory expressions of primary prostate stromal cells in BPH.

Methods

A total of 44 human BPH prostate tissues were collected to explore the expression of ER by immunohistochemistry (IHC). Cell proliferation, mRNA and protein expressions were analyzed in primary prostate stromal cells treated with estrogen or estrogen plus fulvestrant through cell count kit-8 (CCK-8) assay, quantitative real-time polymerase chain reaction (qPCR), IHC and western blot, respectively.

Results

Firstly, ERβ was positive, and ERα was negative in the transition zone of prostate among all the 44 individuals with BPH. Secondly, the effects could be partially inhibited by fulvestrant, of estrogen promoting the proliferation of primary prostate stromal cells cultured in dulbecco’s modified eagle medium (DMEM) supplemented with 2% fetal bovine serum (FBS). Thirdly, estrogen up-regulates the mRNA levels of C-C chemokine receptor type 3 (CCR3), CD40 ligand (CD 40L), C-X-C motif chemokine ligand 9 (CXCL9) and interleukin 10 (IL10), and down-regulates the mRNA levels of C-C chemokine receptor type 4 (CCR4) and interleukin 17C (IL17C). Then, the protein expressions of CCR3, CCR4, CD40L, IL10 and IL17C are positive, and CXCL9 is negative in the third-generation primary prostate stromal cells. Finally, the effects could be partially inhibited by fulvestrant, of estrogen up-regulating the protein levels of CD40L and IL10.

Conclusions

The expressions of ER in human BPH prostate tissues are zone-dependent. Estrogen promoting the proliferation of primary prostate stromal cells cultured in DMEM supplemented with 2% FBS. The expressions of CCR3, CCR4, CD 40L, IL17C, CXCL9 and IL10 are regulated by estrogen in primary prostate stromal cells.

Use of Tregs as a cell-based therapy via CD39 for benign prostate hyperplasia with inflammation

Benign prostatic hyperplasia (BPH) occurs most commonly among older men, often accompanied by chronic tissue inflammation. Although its aetiology remains unclear, autoimmune dysregulation may contribute to BPH. Regulatory T cells (Tregs) prevent autoimmune responses and maintain immune homeostasis. In this study, we aimed to investigate Tregs frequency, phenotype, and function in BPH patients and to evaluate adoptive transfer Tregs for immunotherapy in mice with BPH via CD39. Prostate specimens and peripheral blood from BPH patients were used to investigate Treg subsets, phenotype and Treg‐associated cytokine production. Sorted CD39^+/− Tregs from healthy mice were adoptively transferred into mice before or after testosterone propionate administration. The Tregs percentage in peripheral blood from BPH patients was attenuated, exhibiting low Foxp3 and CD39 expression with low levels of serum IL‐10, IL‐35 and TGF‐β. Immunohistochemistry revealed Foxp3+ cells were significantly diminished in BPH prostate with severe inflammatory. Although the Tregs subset was comprised of more effector/memory Tregs, CD39 was still down‐regulated on effector/memory Tregs in BPH patients. Before or after testosterone propionate administration, no alterations of BPH symptoms were observed due to CD39‐ Tregs in mice, however, CD39⁺Tregs existed more potency than Tregs to regulate prostatic hyperplasia and inhibit inflammation by decreasing IL‐1β and PSA secretion, and increasing IL‐10 and TGF‐β secretion. Furthermore, adoptive transfer with functional Tregs not only improved prostate hyperplasia but also regulated muscle cell proliferation in bladder. Adoptive transfer with Tregs may provide a novel method for the prevention and treatment of BPH clinically.

Mecanismos inflamatorios involucrados en la fisiopatología de la hiperplasia prostática benigna

La obstrucción del tracto de salida ha sido asociada con la hiperplasia prostática benigna (HPB), dado el crecimiento progresivo del adenoma, lo cual lleva a un incremento en la resistencia al flujo urinario, junto con un efecto deletéreo en la función renal. Se han descrito múltiples teorías asociadas con el desarrollo de la hiperplasia. Entre las cuales se encuentran: La edad, el incremento en la actividad simpática, alteraciones hormonales, el síndrome metabólico y la inflamación crónica. En los últimos años, el rol de la inflamación prostática local en el entendimiento de la patogénesis y progresión de la HPB ha cobrado relevancia. Esa hipótesis plantea que infiltrados inflamatorios conllevan a una lesión tisular, generando así un proceso crónico de cicatrización que condiciona el incremento en el tamaño prostático. El presente artículo se enfoca en describir los mecanismos inflamatorios involucrados en la fisiopatología de la hiperplasia prostática benigna.

Bakuchiol suppresses oestrogen/testosterone-induced Benign Prostatic Hyperplasia development through up-regulation of epithelial estrogen receptor β and down-regulation of stromal aromatase

Estrogens and androgens play critical roles during benign prostatic hyperplasia (BPH) development. Estrogen receptors (ERs), androgen receptor (AR) and aromatase, the key conversion enzyme of androgen to estrogen, are thought to be the effective targets for BPH treatment. Bakuchiol (Ba)-containing herb Psoralea corylifolia has been long-termed used for BPH patients in traditional Chinese medicine while the role and regulatory mechanism of Ba involved remain unclear. Human prostatic cell lines WPMY-1 and BPH-1 and oestrodial/testosterone-induced BPH rats were used as the in vitro and in vivo models. Ba significantly inhibited the proliferation of WPMY-1 and BPH-1 cells. In E2/T-induced BPH model, Ba treatment also significantly inhibited the enlargement of prostate, decreased PI values, reduced the thickness of periglanular smooth muscle layer, and down-regulated the expressions of PCNA and smooth muscle cell marker α-SMA, all of which were highly induced in BPH rats. Moreover, the basal and PGE2-induced expressions of aromatase were reduced in Ba-stimulated WPMY-1 cells, while the expression of ERβ was highly increased in Ba-stimulated BPH-1 cells, both of which are consistent with the findings in Ba group in vivo. Ba induced ERE activity in BPH-1 cells as E2 did; however, silence of ERβ not ERα, blocked Ba-induced ERE activity while E2 still exhibited the significant ERE activity, indicating the regulation of estrogen signaling by Ba is particularly via ERβ. In conclusion, by down-regulation of stromal aromatase and up-regulation of epithelial ERβ, Ba contributes to the balance of estrogen and androgen signaling and further inhibits BPH development.

Prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) in China: results from the China Health and Retirement Longitudinal Study

OBJECTIVE

Rapid population ageing in China is increasing the prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) among older people. The associated economic burden is increasing as well. Relevant data from China are currently insufficient.

DESIGN

Secondary analysis of a cohort sample.

SETTING

A nationally representative, cross-sectional survey-the China Health and Retirement Longitudinal Study (CHARLS)-was conducted in 2011 in mainland China.

PARTICIPANTS

The study included individuals in the community selected from CHARLS by multistage probability sampling. A total of 5888 participants aged 50 years and above were included.

OUTCOME MEASURES

Self-reported morbid state was derived from a structured questionnaire. The weighted prevalence of LUTS/BPH was estimated and stratified by age group, marital status, education level, economic level, residential area and geographical region. Multivariable weighted logistic regression was used to examine the association of socioeconomic status with the odds of BPH.

RESULTS

The weighted overall prevalence of LUTS/BPH was 10.66% (95% CI 9.36 to 12.12). Among individuals aged over 70 years, the prevalence was 14.67% (95% CI 11.80 to 18.09) and it increased with ageing (p<0.05). The prevalence of LUTS/BPH among subjects residing in urban areas was higher (13.55%, 95% CI 10.95 to 16.64) than those living in rural areas (8.38%, 95% CI 6.90 to 10.15). The prevalence of LUTS/BPH was lowest in the South-Central and South-West regions and highest in the North-West region.

CONCLUSIONS

We found an increasing trend of prevalence of LUTS/BPH with ageing. It varied according to marital status, socioeconomic status and geographical region.

Cynomorium songaricum Rupr demonstrates phytoestrogenic or phytoandrogenic like activities that attenuates benign prostatic hyperplasia via regulating steroid 5-α-reductase

ETHNOPHARMACOLOGICAL RELEVANCE

Cynomorium songaricum Rupr. (CS) belongs to the genus of parasitic perennial flowering plants, mostly used in Chinese traditional medicine for benign prostatic hyperplasia (BPH) treatment. BPH is a chronic disease in men that both androgen and estrogen play a crucial role in promoting its development via their receptors. Previously we have showed that compounds from CS have the phytoestrogenic and/or phytoandrogenic activities that may have the potential suppressive effects on BPH, while the mechanism remains unclear.

AIM OF THE STUDY

In this study, we aim to investigate the effect of CS and its derived compounds: luteolin (LUT), gallic acid (GA), protocatechuic acid (PA) and protocatechualdehyde (Pra) on inhibition of rat BPH and proliferation of BPH-1 cell line respectively, and further uncover whether it is related with the phytoestrogenic and / or phytoandrogenic activities.

MATERIALS AND METHODS

Estradiol/testosterone (1:100) was subcutaneous injected to induce BPH in a castrated rat model, and CS was orally administrated for 45 days. Then the weights of the body and prostate were recorded, the pathogenesis changes of prostate were analyzed by Hematoxylin and eosin (H&E) and immunohistochemical (IHC). The levels of 17β-estradiol (E₂), testosterone, and dihydrotestosterone (DHT) from rats' serum were measured by enzyme-linked immunosorbent assay (ELISA). In vitro, human benign prostatic epithelial cell BPH-1 was cultured and treated with or without different CS compounds and DHT or E₂. MTT and CCK-8 assays were performed to detect the regulatory effects on cell proliferation. The expressions of PCNA, AR, ERα, ERβ, and steroid 5-α-reductases (SRD5A1 and SRD5A2) were further analyzed by western blotting upon treatment.

RESULTS

Treatment with CS significantly inhibited rat prostate enlargement, improved the pathological feature and reduced the thickness of smooth muscle layer. The up-regulated AR and ERα expressions and down-regulated ERβ in BPH rat prostate were significantly blocked after CS administration. Moreover, the enhanced values of E₂/testosterone and the level of DHT in serum were also strongly inhibited in CS group compared with those in BPH groups. In cellular level, LUT, GA, PA, or Pra significantly inhibited DHT- or E₂- induced BPH-1 cell proliferation and PCNA expressions. Consistently with the data in vivo, compounds from CS interfered the DHT or E₂-regulated AR, ERα and ERβ expressions in BPH-1 cells as well. Importantly, the dramatic increased SRD5A1 and SRD5A2 expressions were observed in BPH rat prostates and DHT or E₂-stimulated BPH-1 cells. However, treatment with CS in rat or with compounds isolated from CS in BPH-1 cells significantly blocked the induction of SRD5A1 and SRD5A2.

CONCLUSIONS

CS suppressed BPH development through interfering with prostatic AR, ERα/β, and SRD5A1/2 expressions, which provided evidence of CS for BPH treatment.

Sex hormones and oxidative stress mediated phthalate-induced effects in prostatic enlargement

Prostatic enlargement might affect up to 30% of men and can cause signs and symptoms in the lower urinary tract in the elderly. Imbalanced estrogen and androgen secretions are important in prostatic physiopathology. Phthalates-environmental endocrine disruptors-affect androgen secretion and disrupt sexual organs, including testes and the prostate, but the underlying mechanisms are unclear. Using European Association of Urology (EAU) guidelines, we recruited from urology clinics in southern Taiwan 207 elderly men diagnosed with benign prostatic hyperplasia (BPH) and prostatic enlargement between 2015 and 2017. We took blood and urine samples from all patients on the same day. We used multivariate linear regression, associations, and potential interactions after we had measured and analyzed oxidative stress (OS) markers, steroidal hormones, and 11 urinary phthalate metabolites, and then we adjusted for confounders. Di(2-ethylhexyl) phthalate (DEHP) metabolite levels, particularly urinary mono-(2-ethylhexyl) phthalate, were positively associated with androgen, estrogen, hormone ratios, inducible nitric oxide synthetase (iNOS), 8-hydroxy-2'-deoxyguanosine (8-OHdG), prostate specific antigen (PSA), and prostate volume (PV) (p < 0.05). PV and PSA were positively associated with androgen, estrogen, hormone ratios and OS markers (p < 0.05). The estimated percentages of exposure to phthalates in prostatic enlargement mediated by androgen, estrogen, and OS markers ranged from 3.5% to 63.1%. Exposure to DEHP promoted the progress of BPH by increasing dihydrotestosterone (DHT), estradiol (E₂), the converted enzymes aromatase and 5α reductase, and reactive oxygen species (ROS) (8-OHdG and iNOS) production. Sex hormones and OS might be important hyperplasia-promoters after a patient has been exposed to phthalates, especially to DEHP.

Efficacy of newer medications for lower urinary tract symptoms attributed to benign prostatic hyperplasia: a systematic review

We conducted a systematic review to evaluate the efficacy and adverse effects of newer drugs used to treat lower urinary tract symptoms (LUTS). The drugs were either Food and Drug Administration (FDA) approved for benign prostatic hyperplasia (BPH) or not FDA approved for BPH but have been evaluated for treatment of BPH since 2008. We searched bibliographic databases through September 2017. We included randomized controlled trials (RCTs) lasting one month or longer published in English. Outcomes of interest were LUTS assessed by validated measures. Efficacy was interpreted using established thresholds indicating clinical significance that identified the minimal detectable difference. Twenty-three unique, generally short-term, RCTs evaluating over 9000 participants were identified. Alpha-blocker silodosin and phosphodiesterase type 5 inhibitor tadalafil were more effective than placebo in improving LUTS (moderate strength evidence) but these drugs had more adverse effects, including abnormal ejaculation (silodosin). Anticholinergics were only effective versus placebo when combined with an alpha-blocker. Evidence was generally low strength or insufficient for other drugs. Evidence was insufficient to assess long-term efficacy, prevention of symptom progression, need for surgical intervention, or long-term adverse effects. Longer trials are needed to assess the effect of these therapies on response rates using established minimal detectable difference thresholds, disease progression, and harms.

Epidemiology and risk factors of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction

Benign prostatic hyperplasia (BPH) is very common in aging men and causes lower urinary tract symptoms (LUTS), which decrease health-related quality of life. A number of evidence suggests that other than ageing, modifiable factors, such as increasing prostate volume, obesity, diet, dyslipidemia, hormonal imbalance, hypertension, metabolic syndrome, alcohol, and smoking, also contribute to the development of BPH and/or LUTS. More recently, erectile dysfunction (ED) has been linked to LUTS/BPH as a part of this syndrome, suggesting that patients with BPH or LUTS easily develop ED, and that LUTS/BPH symptoms often coexist with ED. This article focuses on the epidemiology and risk factors of the combined phenotype LUTS/BPH - ED.

Treatment of lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction

This article summarizes years of challenging research on erectile dysfunction (ED), a condition that has an important social and cultural relevance. Preclinical and clinical research progress has led to new therapeutic approaches to ED in patients with different comorbidities and particularly in those with low urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH). These goals were possible only by combined work of specialists and researchers of different and intertwined medical disciplines. Currently, tadalafil (5 mg/d) is the best choice; other phosphodiesterase-5 inhibitors (PDE5i) are not included among options, despite the growing evidence of therapeutic effects. Different regimens of tadalafil may be prescribed based on patient needs, severity of LUTS/BPH - ED profile, and clinical experience. An integrated approach is necessary to choose for a combined therapy with PDE5i and α-blockers following urological and cardiac counseling in terms of outcomes and adverse effects.

Comparison of the effectiveness of IPSS and VPSS without any help in LUTS patients: a prospective study

AIM

To compare the correlation of visual prostate symptom score (VPSS) and international prostate symptom score (IPSS). To investigate the effect of educational level and age in the responses to VPSS and IPSS.

METHOD

Three hundred and nine patients who gave consent and applied via LUTS to our institution were included in this study. They were requested to fill IPSS and VPSS. The patients were divided into two groups as middle-aged and elderly with a cutoff point of 65 years. They were divided into six groups based on educational level. SPSS was used for the statistical evaluation.

RESULTS

The mean age of the patients was 61.5 ± 8.9 years. The correlation was found between IPSS and VPSS (p < .05). Education was found not to contribute for answering IPSS and VPSS (p = .332 and .138, respectively). No difference was found between the middle-aged and elderly groups in terms of the rates of inability to answer IPSS and VPSS (p = .177 and .681, respectively).

CONCLUSIONS

There is a correlation between VPSS and IPSS. VPSS can be used as an auxiliary or alternative tool instead of IPSS in evaluating LUTS; however, has no superiority to IPSS in elderly group. Currently, the best option to exclude bias in illiterate group is VPSS.

Genetic variants in 5p13.2 and 7q21.1 are associated with treatment for benign prostatic hyperplasia with the α-adrenergic receptor antagonist

BACKGROUND

The etiology of benign prostatic hyperplasia (BPH) has not been well established. The preferred medical treatment for many men with symptomatic benign prostatic hyperplasia is either an α-adrenergic receptor antagonist (α-blocker), or a 5α-reductase inhibitor. Single nucleotide polymorphism (SNP) is a powerful tool for successful implementation of individualized treatment.

METHODS

Eighteen SNPs associated with drug efficacy in a Chinese population were genotyped in 790 BPH cases (330 aggressive and 460 non-aggressive BPH cases) and 1008 controls. All BPH patients were treated with α-adrenergic blockers for at least 9 months. We tested the associations between tagging single nucleotide polymorphism and BPH risk/aggressiveness, clinical characteristics at baseline, including the International Prostate Symptom Score (IPSS) and total prostate volume, and changes in clinical characteristics after treatment.

RESULTS

There were nine SNPs associated with BPH risk, clinical progression and therapeutic effect. (1) There were nine tSNPs been chosen in CYP3A4, CYP3A5 and RANBP3L genes. (2) The SNP, rs16902947 in RANBP3L at 5p13.2 (p = .01), was significantly associated with BPH. (3) We found two SNPs, rs16902947 in RANBP3L at 5p13.2 (p = .0388) and rs4646437 in CYP3A4 at 7q21.1 (p = .0325), associated with drug effect. (4) Allele "G" for rs16902947 was found to be risk alleles for BPH risk (OR= 2.357, 95%CI 1.01-1.48). The "A" allele of rs4646437 was associated with lower IPSS at baseline (β= -0.4232, p= .03255).

CONCLUSIONS

rs16902947, rs16902947 and rs4646437 single nucleotide polymorphisms are significantly associated with the clinical characteristics of benign prostatic hyperplasia and the efficacy of benign prostatic hyperplasia treatment.

Use of the International Prostate Symptom Score (IPSS) in Chinese male patients with benign prostatic hyperplasia

PURPOSE

To test the psychometric properties of the International Prostate Symptom Score (Hong Kong Chinese version 2) (IPSS) in Chinese male patients with benign prostatic hyperplasia (BPH) under secondary care.

METHODS

A prospective longitudinal study was done by interviewing subjects at baseline, at 2 week after baseline for assessing test-retest reliability and at 26 week after baseline for assessing responsiveness. All subjects were interviewed to complete a structured questionnaire including IPSS, Short Form-12 Health Survey version 2 (SF-12v2) and Depression Anxiety Stress Scale (DASS).

RESULTS

The IPSS HRQOL score had weak correlations with SF-12v2 summary and DASS domain scores. For reliability analysis, Cronbach's alpha coefficient was 0.90 for the seven symptom-related items. The intraclass correlation coefficients of the IPSS total symptom score and HRQOL score were 0.90 and 0.86, respectively. For sensitivity, statistically significant differences were detected between the subjects with BPH and those without for IPSS total symptom score (effect size = 0.68) but not the IPSS HRQOL score. The areas under ROC curves for the IPSS total symptom and HRQOL scores were 0.67 and 0.60, respectively.

CONCLUSIONS

The IPSS was valid, reliable instrument in Chinese patients with BPH. The IPSS total symptom score, but not the HRQOL score, is sensitive in differentiating subgroups.

Functional outcomes and complications following B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia: a review of the literature and Meta-analysis

OBJECTIVE

To conduct a systematic review and Meta-analysis of the literature on the efficacy and safety of B-TURP versus HoLEP for the treatment of benign prostatic hyperplasia (BPH) in terms of demographic and clinical baseline characteristics, peri-operative variables, and postoperative outcomes and complications.

METHODS

Trials comparing B-TURP and HoLEP were identified systematically using Pubmed, Embase, CNKI, Web of Science and the Cochrane Library. Primary outcomes were the peak urinary flow rate (Q_max), post-void residual volume (PVR) and international prostate symptom score (IPSS). Secondary outcomes were operation time, irrigation duration, catheterization duration, resected tissue and complications.

RESULTS

Four trials assessing B-TURP and HoLEP were considered eligible for Meta-analysis, including three randomized controlled trials (RCTs) and one retrospective study. There was no statistically significant difference between B-TURP and HoLEP in terms of Q_max, IPSS, PVR at 3-6 months follow-up, operation duration, catheterization duration, resected tissue and complications (p > 0.05). HoLEP was associated with a significantly shorter irrigation time as compared with B-TURP (p < 0.05).

CONCLUSION

Both B-TURP and HoLEP are safe and minimally invasive techniques that are similar in terms of symptomatic relief, although these findings need further validation in larger RCTs involving larger numbers of patients and over a longer follow-up duration for B-TURP or HoLEP before a new gold standard procedure emerges for surgical treatment of BPH.