Early treatment of benign prostatic hyperplasia: implications for reducing the risk of permanent bladder damage

New therapeutic targets to prevent benign prostatic enlargement and symptomatic progression to benign prostatic obstruction-ICI-RS 2023

AIMS

Benign prostatic enlargement (BPE) can impact lower urinary tract function due to its potential progression to benign prostatic obstruction (BPO). Treatment options include removal of the obstruction by surgery or through use of therapeutics designed to slow growth or reduce tissue stress imposed by muscular stromal components. Inflammation and development of fibrosis can also raise intrinsic tissue stress within the gland, further impacting obstruction. Outflow tract obstruction can also impact emission and ejaculation if the obstruction persists.

METHODS

This review summarizes an ICI-RS think tank considering novel drug treatments that might address BPO caused by progressive development of BPE, as well as manage decompensation changes to bladder function.

RESULTS

Topics included recent advances in our understanding of pathological changes occurring to the prostate and other lower urinary tract tissues during progressive development of BPE, and how prevention or reversal might benefit from the identification of novel drug targets. These included contractile properties of prostatic tissues, the impact of BPE and its effects on bladder function, the deposition of intramural fibrotic tissue with protracted BPO, the role of inflammation in the development of BPE and its progression to BPO. In particular, we discussed current therapeutic options for treating BPE/BPO, and new therapeutic targets, what they treat and their advantage over current medications.

CONCLUSION

Several new drug targets were identified, including soluble guanylate cyclase (sGC), the receptor for nitric oxide (NO•), and sGC activators that promotes sGC-mediated cGMP production when sGC is inactivated and unresponsive to NO•.

Differences in surgical and functional outcomes in benign prostate hyperplasia patients with only lower urinary tract symptoms versus those in retention: A systematic review and meta-analysis

AIMS

To evaluate outcomes after benign prostate hyperplasia (BPH) surgery among men with lower urinary tract symptoms (LUTS) only versus those with urinary retention (UR).

METHODS

The protocol was registered in PROSPERO with ID#232253. Eligible studies identified from four electronic databases. Search, data extraction and quality assessment were performed independently by two reviewers. Studies with perioperative, functional, early and late complication outcomes included.

RESULTS

Twenty-five studies, 14 593 patients including 1 randomized controlled trial, 11 prospective and 13 retrospective studies included for meta-analysis. This showed higher risk of immediate transient recatherization (risk ratio [RR]: 5.29, p < 0.00001), longer days to trial-off-catheter (mean difference [MD]: 0.25, p < 0.00001), longer hospitalization stay in the UR group (MD: 0.35, p < 0.00001), and higher risk of intraoperative blood transfusions (RR: 1.90, p = 0.002), postoperative urinary tract infections (RR: 1.49, p < 0.00001) and sepsis (RR: 8.15, p = 0.009) too. Failure of surgery like permanent recatheterization (RR: 5.27, p < 0.00001) was more in preoperative UR group. Negligible differences seen in long term functional outcomes between the two groups (International Prostate Symptom Score at 12 months, MD: -0.06, p = 0.68; Quality of Life at 12 months, MD: 0.20, p < 0.00001; maximum urinary flow rate at 12 months, MD: -0.33, p = 0.10; and postvoid residual volume at 12 months, MD: 4.32, p < 0.00001).

CONCLUSIONS

Preoperative UR patients undergoing surgery for BPH have higher risk of postoperative complications versus LUTS only group including the need for permanent catheterization. Both groups had similar long-term functional outcomes. We could infer that patients with UR on whom surgery is successful, with time may recover bladder function akin to patients with LUTS alone.

Serum interleukin 6 and acute urinary retention in elderly men with benign prostatic hyperplasia in China: a cross-sectional study

Background

While acute urinary retention (AUR) is a severe complication of benign prostatic hyperplasia (BPH), it can also indicate the progression of this common disease in aging men. This study aimed at exploring the possible relationship between serum interleukin 6 (sIL-6) and AUR in BPH patients.

Methods

A cross-sectional study was conducted based on 256 elderly men with BPH in China. The association between the sIL-6 level and the occurrence of AUR was evaluated by univariate and multivariable logistic regressions. The receiver operating characteristic (ROC) curve was utilized to determine the discriminant validity of the sIL-6 level and the optimal cut-off value.

Results

The concentration of sIL-6 was significantly elevated in the AUR group (P<0.001). A positive correlation was observed between the sIL-6 level and AUR in BPH patients [odds ratio (OR) =1.365, 95% confidence interval (CI): 1.174-1.586, P<0.001]. Based on the ROC curve analysis for sIL-6, the optimal cut-off point of 4.475 pg/mL was set to identify the occurrence of AUR in these patients [area under the curve (AUC) =0.7596, 95% CI: 0.6976-0.8216, P<0.001]. A high sIL-6 level (≥4.475 pg/mL) had a significantly stronger correlation with AUR (OR =9.666, 95% CI: 4.347-21.491, P<0.001).

Conclusions

There was a positive correlation between the sIL-6 level and the occurrence of AUR in elderly Chinese patients with BPH. This study provides potential strategies for the screening of BPH individuals with a possible risk of AUR, which may contribute to the early implementation of effective interventions to improve the quality of life and prognosis. Long-term prospective studies are still required to further illustrate the causal relationship.

The possible association between serum interleukin 8 and acute urinary retention in Chinese patients with benign prostatic hyperplasia

Acute urinary retention (AUR) is one of the progressive manifestations of benign prostatic hyperplasia (BPH). This cross-sectional study was conducted to analyse the possible association between serum interleukin 8 (sIL-8) and AUR in BPH patients to provide evidence of sIL-8 as a potential biomarker for the prediction of AUR. The relationship between sIL-8 levels and AUR was evaluated by logistic regressions in 245 ageing Chinese men with BPH. The discriminant validity of sIL-8 and the optimal cut-off value were determined by a receiver operating characteristic curve. The levels of sIL-8 increased significantly in BPH patients with AUR (p < 0.001). The sIL-8 concentration was positively correlated with AUR in BPH patients (OR = 1.024, 95% CI: 1.009-1.040, p = 0.002). The correlation with AUR in the group with a high sIL-8 level (≥43.05 pg/ml) was significantly enhanced (OR = 8.853, 95% CI: 2.433-32.205, p = 0.001). The sIL-8 level correlated with AUR in Chinese BPH patients independently. As a possible predictor, sIL-8 may contribute to the screening of high-risk populations for AUR to create opportunities for the early effective interventions to improve prognosis and enhance the quality of life. Prospective studies are needed to support all these results.

NLRP3/IL-1β mediates denervation during bladder outlet obstruction in rats

AIMS

Denervation of the bladder is a detrimental consequence of bladder outlet obstruction (BOO). We have previously shown that, during BOO, inflammation triggered by the NLRP3 inflammasome in the urothelia mediates physiological bladder dysfunction and downstream fibrosis in rats. The aim of this study was to assess the effect of NLRP3-mediated inflammation on bladder denervation during BOO.

METHODS

There were five groups of rats: (i) Control (no surgery); (ii) Sham-operated; (iii) BOO rats given vehicle; (iv) BOO rats given the NLRP3 inhibitor glyburide; and (v) BOO rats given the IL-1 receptor antagonist anakinra. BOO was constructed by ligating the urethra over a 1 mm catheter and removing the catheter. Medications were given prior to surgery and once daily for 12 days. Bladder sections were stained for PGP9.5, a pan-neuronal marker. Whole transverse sections were used to identify and count nerves while assessing cross-sectional area. For in vitro studies, pelvic ganglion neurons were isolated and treated with IL-1β. After a 48 h incubation apoptosis, neurite length and branching were assessed.

RESULTS

In obstructed bladders, the number of nerves decreased while total area increased, indicating a loss of cell number and/or branching. The decrease in nerve density was blocked by glyburide or anakinra, clearly implicating the NLRP3 pathway in denervation. In vitro analysis demonstrated that IL-1β, a product of the inflammasome, induced apoptosis in pelvic ganglion neurons, suggesting one mechanism of BOO-induced denervation is NLRP3/IL-1β triggered apoptosis.

CONCLUSIONS

The NLRP3/IL-1β-mediated inflammation pathway plays a significant role in denervation during BOO.

Acute urinary retention increases the risk of complications after transurethral resection of the prostate: a population-based study

Study Type--Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Higher mortality and morbidity rates in men presenting with AUR have been reported in previous studies. This study has comprehensive comparisons of post-TURP complications between patients with and without AUR. Furthermore, it shows that AUR is associated with increased risk of complications after TURP.

OBJECTIVE

• To assess the association between a history of acute urinary retention (AUR) and complications after transurethral resection of prostate (TURP).

PATIENTS AND METHODS

• We conducted a retrospective, national, population-based study using Taiwan's National Health Insurance Research Database. • We included men > 50 years old, diagnosed with benign prostatic hyperplasia (BPH) and divided these into two groups: an AUR(+) group--those with AUR who underwent TURP between 2002 and 2004; and an AUR(-) group--those without AUR who underwent TURP between those dates. • Prostate cancer, Parkinsonism and multiple sclerosis were exclusion criteria. • Postoperative complications, e.g. re-catheterization, haematuria or urinary tract infection (UTI), were compared using crude odds ratios (ORs), 95% confidence intervals (CIs), and Student's t-test. • A chi-squared test was used for potential confounding factors: preoperative UTI and anticoagulant use. • Univariate and multivariate analysis on medical expenses were conducted.

RESULTS

• The AUR(+) group contained 3305 men; the AUR(-) group contained 1062. • Re-catheterization (13.8%), septicaemia (1.1%) and shock (0.3%) were found only in the AUR(+) group. • The AUR(+) group had more UTIs (18.9% vs. 15.6%, OR: 1.26, 95% CI: 1.05-1.52), more lower urinary tract symptoms (22.8% vs. 16.9%, OR: 1.45, 95% CI: 1.21-1.73), fewer blood transfusions (3.2% vs. 1.5%, OR: 2.19, 95% CI: 1.29-3.72) and higher medical expenses. • There were no significant differences in haematuria, lower urinary tract stricture, or re-surgical intervention of the prostate and second-line antibiotic use.

CONCLUSION

• Patients in Taiwan with BPH with AUR who were treated by TURP were associated with a higher risk of complications, longer hospital stay and more comorbidities than those without AUR and a preoperative warning is warranted for these patients.

Real life practice in the management of benign prostatic hyperplasia

PURPOSE OF REVIEW

To review the current diagnostic and treatment options of lower urinary tract symptom due to benign prostatic hyperplasia and to put data from real life practice into perspective.

RECENT FINDINGS

The overall incidence rate of lower urinary tract symptom/benign prostatic hyperplasia was found at 15 per 1000 man-years (95% CI 14.8-16.1). The incidence increases with age from 3/1000 man-years at 45-49 years to 38/1000 man-years at 75-79 years. Recent diagnostic studies include the use of PSA to estimate prostate volume and its predictive value for the long-term risk of prostate enlargement. Variability of the International Prostate Symptom Score when filled at home and in the hospital is discussed. The first-line treatment option remains medical therapy. The most prescribed alpha-blockers are terazosin, alfuzosin, and tamsulosin, which are comparable in efficacy. The efficacy of finasteride is also confirmed, especially for enlarged prostates with the possibility of volume reduction up to 30%. Interventional therapy begins when there is evidence of moderate to severe symptoms. Long term results put transurethral microwave thermotherapy in advantage over other minimally invasive modalities. Surgical treatment remains the procedure with the best results. Open prostatectomy is still indicated for severely enlarged prostates. Transurethral resection for medium-sized prostates and bladder-neck incision for small prostates also remain the best option.

SUMMARY

Real life practice studies in the last few years have broadened our insight into the application of different diagnostic and treatment modalities. Since results from randomized controlled trials can not always be extrapolated to daily urological practice, real life practice studies made data available to complement data from randomized controlled trials.