Korean clinical practice guideline for benign prostatic hyperplasia

Serenoa repens for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Enlargement: An Updated Cochrane Review

PURPOSE

To assess the effects of Serenoa repens in the treatment of men with lower urinary tract symptoms (LUTS) consistent with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases up to September 2022 with no language or publication status restrictions. We included parallel-group randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment. We used standard Cochrane methods, including a GRADE assessment of the certainty of the evidence (CoE).

RESULTS

We included 27 studies involving a total of 4,656 participants. Serenoa repens results in little to no difference in urologic symptoms at short-term follow-up (International Prostate Symptom Score [IPSS]: mean difference [MD] -0.90, 95% confidence interval [CI] -1.74 to -0.07; I²=68%; 9 studies, 1,681 participants; high CoE). Serenoa repens results in little to no difference in the quality of life at short-term follow-up (high CoE). Serenoa repens probably results in little to no difference in adverse events (moderate CoE). Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short-term follow-up (IPSS: MD -2.41, 95% CI -4.54 to -0.29; I²=67%; 4 studies, 460 participants; low CoE). We are very uncertain about the effects of these agents on quality of life (very low CoE). These agents may result in little to no difference in the occurrence of adverse events (low CoE).

CONCLUSIONS

Serenoa repens alone provides little to no benefits for men with LUTS due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents.

Efficacy and safety of low power holmium laser enucleation of the prostate: A prospective short- and medium-term single-blind randomized trial

PURPOSE

We evaluated the efficacy and safety of mid-term follow-up in low-power (LP) Holmium laser enucleation of the prostate (HoLEP) compared with high-power (HP) surgery for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This prospective, single-blind, randomized controlled study was conducted between September 2020 and April 2021. Ninety male patients >50 years who underwent HoLEP for BPH were randomly assigned to HP (80 W/2 J/40 Hz) and LP (24 W/2 J/12 Hz) groups. The primary endpoint was the total International Prostate Symptom Score (IPSS) six months after surgery. The secondary endpoints were perioperative results and postoperative outcomes at two weeks, three and six months after the surgery, including Clavien-Dindo complication classification.

RESULTS

At six months after HoLEP, 41 and 42 patients were followed up in the HP and LP groups, respectively. There was no difference in the preoperative characteristics between the two groups. The prostate volumes were 67.1±23.7 mL for the HP group and 64.3±25.7 mL for the LP group (p=0.592), respectively. Although the total operative time was significantly longer by 13.1 minutes in the LP group (47.8±20.3 min vs. 60.9±23.3 min, p=0.006), the total delivered energy was significantly lower, which was only about 68% of the HP group (58.2±23.9 kJ vs. 39.9±13.2 kJ, p<0.001). Surgical outcomes significantly improved postoperatively in both groups compared to baseline, except for storage symptoms. Improvement in IPSS storage subscore was observed from the immediate postoperative 2 weeks in the LP group (8.1±3.1 to 6.9±3.8, p<0.001), whereas there was no significant recovery in the HP group (8.0±3.2 to 7.7±3.4, p=0.842). In the 6-month follow, there was no significant difference between the two groups in the IPSS total score (5.9±5.6 vs. 7.3±5.3, p=0.260) as well as IPSS storage subscore. In addition, there was no significant difference in postoperative complications, including bleeding or urinary incontinence, between the two groups.

CONCLUSIONS

The HoLEP procedure performed using an LP laser device resulted in lower total delivered energy, faster recovery, and significantly improved surgical outcomes up to mid-term follow-up. There was no difference in efficiency or safety between the HP device system.

Changes of resistance indices after medication in benign prostatic hyperplasia: a prospective study

Background

This study aimed to determine the relationship between resistive indices (RIs) and changes in prostate size after medical treatment in patients with benign prostatic hyperplasia (BPH).

Methods

A total of 86 patients with BPH were included in the study, excluding 42 patients with a total prostate volume (TPV) of <30 cc or taking α1-adrenergic blockers and 5α-reductase inhibitors (5ARI) before study participation. Therefore, the data for 44 patients were analyzed. All patients were treated with α1-adrenergic blockers and 5ARIs. The variables examined were prostate-specific antigen, International Prostate Symptom Score, quality of life score, maximal urinary flow rate, residual urine volume, TPV, transition zone volume, and RIs of the urethral artery and left and right capsular arteries. These variables were assessed at baseline and after 3 and 6 months of treatment.

Results

The mean TPV was 43.5 ± 10.9 and decreased to 35.2 ± 11.5 and 33.9 ± 9.8 after 3 and 6 months of treatment, respectively (p < 0.001). The mean RI of the urethral artery, right capsular artery, and left capsular artery at pretreatment did not decrease significantly. However, comparing the baseline with 3-month data, TPV at 3 months/TPV at baseline was significantly correlated with RI changes in the left capsular artery (r = 758; P < 0.001).

Conclusion

In patients with BPH, α1-adrenergic blocker and 5ARI medications for 3 and 6 months did not result in a significant reduction in the RI of the urethral artery and both capsular arteries. Larger scale, prospective studies are needed to evaluate the relationship between TPV and RI reductions.

Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement

BACKGROUND

Benign prostatic hyperplasia (BPH) is a non-malignant enlargement of the prostate, which can lead to obstructive and irritative lower urinary tract symptoms (LUTS). The pharmacologic use of plants and herbs (phytotherapy) for the treatment of LUTS associated with BPH is common. The extract of the berry of the American saw palmetto or dwarf palm plant, Serenoa repens (SR), which is also known by its botanical name of Sabal serrulatum, is one of several phytotherapeutic agents available for the treatment of BPH.

OBJECTIVES

To assess the effects of Serenoa repens in the treatment of men with LUTS consistent with BPH.

SEARCH METHODS

We performed a comprehensive search of multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 16 September 2022, with no restrictions on language or publication status.

SELECTION CRITERIA

We included randomized controlled trials of participants with BPH who were treated with Serenoa repens or placebo/no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias assessment and GRADE assessment of the certainty of the evidence. We considered review outcomes measured up to 12 months after randomization as short term, and beyond 12 months as long term. Our main outcomes included urologic symptom scores, quality of life, and adverse events.

MAIN RESULTS

For this update, we narrowed the review question to only comparisons with placebo. We included 27 studies (of which 9 were new) involving a total of 4656 participants, 19 studies comparing Serenoa repens with placebo, and 8 studies comparing Serenoa repens in combination with other phytotherapeutic agents versus placebo. Most studies included men aged > 50 (mean age range 52 to 68) with moderate urologic symptoms (International Prostate Symptom Score [IPSS] range 8 to 19). Ten studies were funded by the pharmaceutical industry; two studies were funded by government agencies; and the remaining studies did not specify funding sources. Serenoa repens versus placebo or no intervention Results for this comparison are based on predefined sensitivity analyses limited to studies at low risk of bias. Serenoa repens results in little to no difference in urologic symptoms at short-term follow-up (3 to 6 months; IPSS score range 0 to 35, higher scores indicate worse symptoms; mean difference (MD) -0.90, 95% confidence interval (CI) -1.74 to -0.07; I2 = 68%; 9 studies, 1681 participants; high-certainty evidence). Serenoa repens results in little to no difference in the quality of life at short-term follow-up (3 to 6 months; IPSS quality of life domain range 0 to 6, higher scores indicate worse quality of life; MD -0.20, 95% CI -0.40 to -0.00; I2 = 39%; 5 studies, 1001 participants; high-certainty evidence). Serenoa repens probably results in little to no difference in adverse events (1 to 17 months; risk ratio (RR) 1.01, 95% CI 0.77 to 1.31; I2 = 18%; 12 studies, 2399 participants; moderate-certainty evidence). Based on 164 cases per 1000 men in the placebo group, this corresponds to 2 more (38 fewer to 51 more) per 1000 men in the Serenoa repens group. Serenoa repens results in little to no difference in urologic symptoms at long-term follow-up (12 to 17 months, IPSS score, MD 0.07, 95% CI -0.75 to 0.88; I2 = 34%; 3 studies, 898 participants; high-certainty evidence). Serenoa repens results in little to no difference in quality of life at long-term follow-up (12 to 17 months, IPSS quality of life, MD -0.11, 95% CI -0.41 to 0.19; I2 = 65%; 3 studies, 882 participants; high-certainty evidence). There were no data on long-term adverse events for this comparison. Serenoa repens in combination with other phytotherapy versus placebo or no intervention Different phytotherapeutic agents that include Serenoa repens may result in little to no difference in urologic symptoms compared to placebo at short-term follow-up (12 to 24 weeks, IPSS score, MD -2.41, 95% CI -4.54 to -0.29; I2 = 67%; 4 studies, 460 participants; low-certainty evidence). We are very uncertain about the effects of these agents on quality of life (very low-certainty evidence). These agents may result in little to no difference in the occurrence of adverse events; however, the CIs included substantial benefits and harms (12 to 48 weeks, RR 0.91, 95% CI 0.58 to 1.41; I2 = 0%; 4 studies, 481 participants; low-certainty evidence). Based on 132 cases per 1000 men in the placebo group, this corresponds to 12 fewer (55 fewer to 54 more) per 1000 men in the combined phytotherapeutic agents with Serenoa repens group.

AUTHORS' CONCLUSIONS

Serenoa repens alone provides little to no benefits for men with lower urinary tract symptoms due to benign prostatic enlargement. There is more uncertainty about the role of Serenoa repens in combination with other phytotherapeutic agents.

Association of 5α-Reductase Inhibitor Prescription With Bladder Cancer Progression in Males in South Korea

Importance

The antiandrogenic effect of the 5α-reductase inhibitor (5-ARI) has been investigated for its role in preventing male-predominant cancers. Although 5-ARI has been widely associated with prostate cancer, its association with urothelial bladder cancer (BC), another cancer experienced predominantly by males, has been less explored.

Objective

To assess the association between 5-ARI prescription prior to BC diagnosis and reduced risk of BC progression.

Design, Setting, and Participants

This cohort study analyzed patient claims data from the Korean National Health Insurance Service database. The nationwide cohort included all male patients with BC diagnosis in this database from January 1, 2008, to December 31, 2019. Propensity score matching was conducted to balance the covariates between 2 treatment groups: α-blocker only group and 5-ARI plus α-blocker group. Data were analyzed from April 2021 to March 2023.

Exposure

Newly dispensed prescriptions of 5-ARIs at least 12 months prior to cohort entry (BC diagnosis), with a minimum of 2 prescriptions filled.

Main Outcomes and Measures

The primary outcomes were the risks of bladder instillation and radical cystectomy, and the secondary outcome was all-cause mortality. To compare the risk of outcomes, the hazard ratio (HR) was estimated using a Cox proportional hazards regression model and difference in restricted mean survival time analysis.

Results

The study cohort initially included 22 845 males with BC. After propensity score matching, 5300 patients each were assigned to the α-blocker only group (mean [SD] age, 68.3 [8.8] years) and 5-ARI plus α-blocker group (mean [SD] age, 67.8 [8.6] years). Compared with the α-blocker only group, the 5-ARI plus α-blocker group had a lower risk of mortality (adjusted HR [AHR], 0.83; 95% CI, 0.75-0.91), bladder instillation (crude HR, 0.84; 95% CI, 0.77-0.92), and radical cystectomy (AHR, 0.74; 95% CI, 0.62-0.88). The differences in restricted mean survival time were 92.6 (95% CI, 25.7-159.4) days for all-cause mortality, 88.1 (95% CI, 25.2-150.9) days for bladder instillation, and 68.0 (95% CI, 31.6-104.3) days for radical cystectomy. The incidence rates per 1000 person-years were 85.59 (95% CI, 80.53-90.88) for bladder instillation and 19.57 (95% CI, 17.41-21.91) for radical cystectomy in the α-blocker only group and 66.43 (95% CI, 62.22-70.84) for bladder instillation and 13.56 (95% CI, 11.86-15.45) for radical cystectomy in the 5-ARI plus α-blocker group.

Conclusions and relevance

Results of this study suggest an association between prediagnostic prescription of 5-ARI and reduced risk of BC progression.

Effectiveness and safety of electroacupuncture and its cotreatment with electronic moxibustion in the treatment of patients with moderate benign prostatic hyperplasia using alpha blocker: An assessor-blinded, randomized, controlled pilot study

BACKGROUND

Benign prostatic hyperplasia (BPH) is a disease that affects the quality of life by causing lower urinary tract symptoms (LUTS) in men. Electroacupuncture (EA) and moxibustion therapy have been suggested as an adjunct therapy for improving LUTS in patients with BPH, but clinical studies evaluating the effectiveness of EA and its cotreatment with electronic moxibustion (EM) in patients who have been prescribed alpha blockers have yet to be reported. Therefore, this study aimed to evaluate the effectiveness and safety of EA and EM.

METHODS

Twenty-eight patients diagnosed with BPH were randomized to treatment group (TG, n = 14) or control group (CG, n = 14). The TG continued to use the previously prescribed alpha blocker and received the cotreatment of EA and EM 3 times a week for 6 weeks. The CG continued to use the previously prescribed alpha blocker alone for 6 weeks. The primary outcome was the mean change in the international prostate symptom score (IPSS) from baseline to week 6. The secondary outcomes were IPSS at week 3 and 12, clinical relevance, IPSS life satisfaction, EuroQol-Five dimensions, average urinary flow rate, maximum urinary flow rate, and prostate volume.

RESULTS

The IPSS decreased at all time points with a statistically significant difference between the 2 groups (3W: P = .0313; 6W: P = .0010; 12W: P = .0304). Based on the minimal clinically important difference (MCID, 3 points), there were significant differences between the TG and the CG at week 3, 6, and 12 (3W: P = .0461; 6W: P = .0123; 12W: P = .0216). Significant group × week interaction effects were found for the IPSS score (P = .0018), as determined from analyses using repeated measures analysis of variance. There were no significant differences between the 2 groups in IPSS life satisfaction, EuroQol-Five dimensions, average urinary flow rate, maximum urinary flow rate, and prostate volume.

CONCLUSION

EA and its cotreatment with EM might have a beneficial effect as an adjunct therapy in improving LUTS in patients with BPH. Large-scale randomized controlled trials are warranted to confirm the effectiveness and safety of EA and its cotreatment with EM.

Robotic-assisted simple prostatectomy versus holmium laser enucleation of the prostate for large benign prostatic hyperplasia: a single-center preliminary study in Korea

Background

Holmium laser enucleation of the prostate (HoLEP) and robotic-assisted simple prostatectomy (RASP) are the two most important therapeutic modalities for large benign prostatic hyperplasia. However, there are currently no studies comparing these two treatments in a Korean setting. In this study, the authors seek to compare the safety and efficacy associated with these procedures.

Methods

The authors retrospectively analyzed 59 male patients who underwent HoLEP (n = 26) or RASP (n = 33) at single center. The following preoperative data were compared: age, the International Prostatic Symptom Score (IPSS), transrectal ultrasonography, uroflowmetry, and hemoglobin. Intraoperative data included operation time and specimen weight. Postoperative data included change in IPSS, uroflowmetry, and hemoglobin. Length of stay, catheterization time, and complications were also reviewed.

Results

No significant differences between the two groups were found in terms of age, total prostate, and transitional volume. Postoperatively, both groups showed similar improvement in the maximum flow rate, post-void residual urine, IPSS, and quality of life. Intraoperatively, there were no differences regarding operation time and resected prostate volume. Catheter removal time and length of stay were significantly shorter in the HoLEP group than the RASP group. In addition, postoperative hemoglobin changes were significantly lower in the HoLEP group. However, incontinence rates at 1 month and 2 months postoperative in the RASP group were lower than the HoLEP group.

Conclusions

Both HoLEP and RASP can produce excellent postoperative outcomes. However, catheter removal time, length of stay, and hemoglobin changes were more favorable in the HoLEP group. On the other hand, postoperative incontinence was more favorable in the RASP group. These factors must be heavily considered when deciding surgical the method for large benign prostatic hyperplasia.

Free combination of dutasteride plus tamsulosin for the treatment of benign prostatic hyperplasia in South Korea: analysis of drug utilization and adverse events using the National Health Insurance Review and Assessment Service database

Objective

To assess the use and safety of free combination therapy (dutasteride and tamsulosin), dutasteride monotherapy, or tamsulosin monotherapy in patients with benign prostatic hyperplasia (BPH).

Methods

This non-interventional retrospective cohort study used claims data from the Korea Health Insurance Review and Assessment-National Patient Sample database. Patients with BPH ≥ 40 years of age receiving combination therapy (dutasteride 0.5 mg and tamsulosin 0.4 mg daily) or dutasteride 0.5 mg, or tamsulosin 0.4 mg daily dose between 2012 and 2017 were included. The frequency, duration of treatment and risk of any adverse event (AE) or serious AE (SAE) was compared for combination therapy versus each monotherapy using non-inferiority testing.

Results

Of 14,755 eligible patients, 1529 (10.4%) received combination therapy, 6660 (45.1%) dutasteride monotherapy, and 6566 (44.5%) tamsulosin monotherapy. The proportion of patients treated with combination therapy exceeded the pre-specified 3% threshold for ‘frequent’ use. Safety results indicated a similar risk of any AE and SAE irrespective of treatment group. The adjusted relative risk for any AE over the treatment observation period comparing combination therapy with dutasteride monotherapy was 1.07 (95% confidence interval [CI] 1.03, 1.12), and with tamsulosin monotherapy was 0.98 (95% CI 0.95, 1.02) demonstrating non-inferiority. The adjusted relative risk for any SAE was 1.07 (95% CI 0.66, 1.74) and 0.90 (95% CI 0.56, 1.45), compared with dutasteride and tamsulosin monotherapy, respectively. Although the SAE results did not statistically demonstrate non-inferiority of combination therapy based on pre-specified margins, the 95% CI for the risk ratio estimates included the null with a lower limit below the non-inferiority margins, indicating no meaningful differences in SAE risk between groups. Absolute SAE risks were low.

Conclusion

Combination therapy with dutasteride and tamsulosin is frequently used in real-world practice in South Korea for treatment of BPH and demonstrates a safety profile similar to either monotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00941-1.

Serenoa repens for the treatment of lower urinary tract symptoms due to benign prostatic enlargement: A systematic review and meta-analysis

PURPOSE

To assess the effects of Serenoa repens alone or in combination with other phytotherapy compared to placebo in men with LUTS due to benign prostatic enlargement.

MATERIALS AND METHODS

Following a registered protocol (CRD42021226655), we searched (December 2020) MEDLINE, CENTRAL, Embase, ClinicalTrials.gov, WHO-ICTRP trials platform and other sources with no restrictions on language, publication date or status. We included randomized controlled trials, and we critically appraised them using the Cochrane Tool for Risk of Bias Assessment (RoB 2). We conducted random-effects meta-analysis when appropriate. The primary outcomes included urinary symptoms score, quality of life, and adverse events. The certainty of the evidence was rated using GRADE.

RESULTS

We included 27 trials with 4,853 participants. S. repens results in little to no difference in urinary symptoms, quality of life, and adverse events at short- and long-term follow-up. S. repens combined with other phytotherapy may slightly reduce urinary symptoms at short-term follow-up, but the results are uncertain. The results on quality of life and adverse events are also very uncertain.

CONCLUSIONS

S. repens alone may result in no clinical benefits for men with LUTS. There is greater uncertainty in the effects of S. repens in combination with other phytotherapy.

Evaluation of the pharmacokinetics and food effects of a novel formulation tamsulosin 0.4 mg capsule compared with a 0.2 mg capsule in healthy male volunteers

Tamsulosin, an alpha-1 adrenoreceptor antagonist, has been used as a primary option for medical treatment of benign prostate hyperplasia. An open-label, single-dose, randomized, three-treatment, three-period, three sequence crossover study was conducted to evaluate the pharmacokinetics (PKs) of 0.2 and 0.4 mg tamsulosin hydrochloride (HCl) in the fed versus the fasted state. Subjects were randomly assigned to three sequences and received one of the following treatments at each period: tamsulosin HCl 0.2 or 0.4 mg in the fed state with a high-fat meal, or tamsulosin HCl 0.4 mg in the fasted state. Blood samples for the PK analysis were collected at pre-dose and up to 48 h post-dose. The PK parameters were calculated by a non-compartmental method. The geometric mean ratio (GMR) and its 90% confidence intervals (CIs) of the plasma maximum concentration (C_max) and area under concentration curve from time zero to last measurable concentration (AUC_last) were calculated. Twenty-two subjects completed the study. The systemic exposure of tamsulosin 0.4 mg decreased approximately 9% in the fed state compared to the fasted state, and the time to reach peak concentration was slightly delayed in the fed state. The dose normalized GMR and its 90% CIs of C_max and AUC_last for 0.2 and 0.4 mg tamsulosin in the fed state were within 0.8 and 1.25 range. Systemic exposure of tamsulosin was decreased in the fed condition compared to the fasted condition. Linear PK profiles were observed between 0.2 and 0.4 mg tamsulosin in the fed state.

Trial Registration

ClinicalTrials.gov Identifier: NCT02529800.

The impact of tamsulosin on cognition in Alzheimer disease with benign prostate hyperplasia: A study using the Hallym Smart Clinical Data Warehouse

Studies suggest that the use of alpha-blockers increases the risk of dementia in patients with benign prostate hyperplasia (BPH). Due to study limitations, the relationship between the use of alpha-blockers, such as tamsulosin, and the risk of dementia is still unclear. However, alpha1-adrenoreceptors are also present in the brain, so there is potential for adverse effects on cognitive function. Therefore, we investigated possible associations between the use of alpha-blockers and aggravation of cognitive decline in dementia patients using a clinical data analytic solution called the Smart Clinical Data Warehouse (CDW).We retrospectively investigated clinical data using the Smart CDW of Hallym University Medical Center from 2009 to 2019. We enrolled patients with probable Alzheimer disease (AD) who had completed the Mini-Mental State Examination (MMSE) at least twice during follow-up, and who had BPH. We compared the difference in MMSE scores between patients who took tamsulosin for >1000 days and those who did not take any alpha-blocker. We tested the effect of tamsulosin on cognitive decline in patients with AD, using propensity score-matched logistic regression analysis.Eligible cases were included in the tamsulosin (n = 68) or no-medication (n = 153) groups. After propensity score matching, clinical characteristics such as educational attainment and vascular risk factors were similar in the tamsulosin and no-medication groups. The MMSE scores did not differ significantly between the tamsulosin and no-medication groups (P = .470).The results suggest that tamsulosin for BPH is not associated with worsening of the cognitive decline in patients with AD.

Expression of bladder α1-adrenoceptor subtype after relief of partial bladder outlet obstruction in a rat model

Purpose

Many patients with benign prostatic hyperplasia require treatment for persistent storage symptoms, even when the obstruction is successfully relieved by surgery. Previous studies identified a characteristic increase in α_1D-adrenoceptor levels in the bladder in a bladder outlet obstruction (BOO) model. Here, we investigated the expression of α₁-adrenoceptor subtypes in the bladder after relief of partial BOO (pBOO) in a rat model.

Materials and Methods

A total of 60 female Sprague–Dawley rats were randomly divided into three groups (sham-operated, pBOO, and pBOO relief groups), and the expression of α₁-adrenoceptor subtypes in the urothelium and detrusor muscle tissues was examined by western blot.

Results

The expression of the α_1D-adrenoceptor was significantly higher in the urothelium and detrusor muscle tissue of the pBOO and pBOO relief groups than in the corresponding tissue of the sham-operated group. Additionally, the α_1A-adrenoceptor was predominant in the sham-operated group but significantly decreased in the urothelium in the pBOO group. No significant differences were found in α_1A-adrenoceptor levels in detrusor muscle or whole bladder.

Conclusions

Our results showed that α_1D-adrenoceptor levels were consistently increased with pBOO, even after relief, suggesting that the α_1D-adrenoceptor might be a cause of persistent storage symptoms after relief of pBOO.

α1-Blockers and 5α-Reductase Inhibitors Are the Most Recommended Drugs in Treating Benign Prostatic Hyperplasia: An Evidence-Based Evaluation of Clinical Practice Guidelines

Objective

To systematically evaluate the quality of clinical practice guidelines (CPG) for medically treating benign prostatic hyperplasia (BPH), and to compare the context of recommendations in order to provide references for clinical application.

Methods

We searched databases of National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization (WHO), PubMed, Embase, CNKI, VIP, WanFang Data, CBM, and Medlive from their establishment to October 13, 2019, to collect evidence-based guidelines and/or consensus on BPH. Method quality of included guidelines was assessed according to the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, and differences and similarities among recommendations were compared.

Results

A total of 22 guidelines were included, of which eight were updated versions. According to the AGREE II instrument, the median score of scope and purpose, stakeholder involvement, rigor of formulate, clarity of presentation, applicability, and editorial independence was 71.5%, 41%, 25%, 64%, 18%, and 28%, respectively. Based on recommendations for medical treatment, almost all guidelines recommended α1-blockers and 5α-reductase inhibitors, and most guidelines also recommended muscarinic receptor antagonists. In terms of drug combination therapy, most guidelines recommended “α1 blockers and 5α-reductase inhibitors”, and some guidelines also recommended “α1 blockers and muscarinic receptor antagonists”.

Conclusion

The recommendations from different guidelines were basically similar, only showing conflicts in some areas. The quality of included guidelines remains to be unified, and their context can provide valuable implications for development or improvement.

A nurse-driven enhanced recovery after surgery (ERAS) nursing program for geriatric patients following lung surgery

Enhanced recovery after surgery (ERAS) is a multiprofessional, multidisciplinary and evidence-based program that aims to reduce complications, improve overall prognosis, shorten hospital stays, and promote fast recovery following major surgery. Nurses play a crucial role in the successful implementation of the ERAS program. Therefore, this research focuses on the trajectory optimized and acquired by nurses in the enhanced recovery of elderly patients undergoing radical surgery for lung cancer. This study concludes that the implementation of the proposed ERAS preoperative point-of-care trajectory is highly beneficial for improved outcomes and enhanced recovery of geriatric patients following lung surgery.

Moxibustion as an adjunct for lower urinary tract symptoms associated with benign prostate enlargement: A randomized controlled pilot trial

BACKGROUND

Benign prostatic enlargement (BPE) causes discomfort in daily life, including lower urinary tract symptoms (LUTSs) caused by the enlarged prostate, and requires long-term management as a chronic, irreversible disease. To improve LUTS, certain complementary therapies have been used with or without doctors' directions. Conventional treatments and complementary therapies tend to be combined unsystematically, depending on patient preference; thus, research for safe and efficient combination therapy is warranted.

METHODS

Twenty-nine participants were randomly assigned to an integrative group (IG, n = 15) or a conventional group (CG, n = 14). The IG received moxibustion (twice weekly for 4 weeks, at the acupuncture points SP6, LR3, and CV4) and conventional medication for 4 weeks, followed by conventional medication alone for 8 weeks. The CG received conventional medication alone for 12 weeks. The outcome measures were International Prostate Symptom Score (IPSS), patient's global impression of changes (PGIC), maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR), and frequency-volume chart.

RESULTS

Total IPSS (IG, -2.4 ± 4.2; CG, 0.9 ± 4.0; P = .039), PGIC-A (IG, 3.5 ± 1.0; CG, 2.2 ± 1.0; P = .001), and PGIC-B (IG, 3.5 ± 0.1; CG, 4.7 ± 0.6; P = .004) were significantly improved in the IG compared with the CG, 4 weeks after baseline. Among the IPSS items, incomplete emptying (IG, -0.6 ± 0.7; CG, 0.4 ± 1.2; P = .019), straining (IG, -0.6 ± 0.8; CG, 0.2 ± 1.2; P = .046), and nocturia (IG, -0.8 ± 1.4; CG, 0.1 ± 1.0; P = .045) showed significant differences. The Qmax and PVR volume did not differ significantly at 12 weeks after the baseline.

CONCLUSION

Moxibustion can be considered an adjunct therapy to improve LUTS in BPE patients. A full-sized randomized controlled trial would be feasible with comparator modifications and an extended study period. The study design should include a placebo group and narrow the eligibility to subjects who do not respond well to conventional treatments.

Influence of solifenacin on the improvement of storage symptoms in the early period after photoselective vaporization of the prostate

Purpose

We studied the effect of solifenacin on reducing storage symptoms after photoselective vaporization of the prostate (PVP).

Materials and Methods

This study included patients with persistent storage symptoms of urgency and frequency in a 3-day voiding diary, International Prostate Symptom Score (IPSS) storage subscore (IPSS-s) ≥5, overactive bladder symptom score (OABSS) ≥5, and OABSS for question 3 ≥4 at 5 days after urethral catheter removal. The patients were randomly assigned to receive once-daily solifenacin 5 mg or placebo for 4 weeks. Evaluation of the 3-day voiding diary, IPSS, and OABSS was performed at 2 and 4 weeks after treatment.

Results

At 2 and 4 weeks after treatment, the urgency and frequency in the 3-day voiding diary, IPSS, IPSS-s, and OABSS were decreased in the solifenacin group. Although the OABSS of the solifenacin group was not significantly different from that of the placebo group, the OABSS of the placebo group increased at 4 weeks compared with that at 2 weeks after treatment. The Benefit, Satisfaction, and Willingness to continue questionnaire showed no significant difference in patient satisfaction between the groups. Although the solifenacin group showed increased post-void residual volume compared with the placebo group, there was no statistically significant difference.

Conclusions

Storage symptoms measured using OABSS tended to decrease after medication with solifenacin in the early period after PVP. Therefore, we suggest that anticholinergics have a potential role in improving storage symptoms after PVP.

Immunohistochemical analysis of the impact of ischemic change in benign prostatic hyperplasia

OBJECTIVE

We conducted experiments to elucidate the impact of ischemic change on benign prostatic hyperplasia (BPH) using immunohistochemistry.

METHODS

Medical records of consecutive patients over 60 years of age who underwent transurethral resection of the prostate for BPH between January 2009 and September 2012 were evaluated. As vascular risk factors, the presence or absence of diabetes mellitus, hypertension, current smoking, obesity, dyslipidemia, and diseases related to bladder function were investigated. As BPH-related factors, International Prostate Symptom Score, quality of life, maximal flow rate, postvoid residual volume, prostate-specific antigen, prostate volume, prostate calculi, and medication state for BPH were investigated. Immunohistochemistry was performed for hypoxia-inducible factor (HIF-1α), sex hormone receptors, and smooth muscle actin. Additionally, microvessel density (MVD) and diffuse fibrosis (DF) were evaluated.

RESULTS

A total of 101 patients were included and HIF-1α expression in stroma and glands were observed in 56 (55.4%) and 34 (33.7%) cases, respectively. There was no significant association between HIF-1α expression and vascular risk factors or BPH-related variables. However, there was a significant correlation between the HIF-1α expression in stroma and higher MVD. HIF-1α expression in the stroma was also significantly correlated with higher expressions of the androgen and progesterone receptors in the stroma. DF was frequently found in cases with higher HIF-1α expression in the stroma than in those with lower HIF-1α expression.

CONCLUSION

In patients with response to ischemic changes of the prostate, HIF-1α expression could be confirmed, and the expression of the androgen receptor was significantly lower in these patients. Chronic ischemic damage in the prostate can progress to a condition that is refractory to pharmacologic therapy. Chronic ischemic damage, which can progress to refractory phase to pharmacologic therapy, is correlated with the hormonal status of prostate.

Correlation Analyses of Computed Tomography and Magnetic Resonance Imaging for Calculation of Prostate Volume in Colorectal Cancer Patients with Voiding Problems Who Cannot Have Transrectal Ultrasonography

Objective

To evaluate the value of computed tomography (CT) and magnetic resonance imaging (MRI) in determining total prostate volume (TPV) for patients with colorectal cancer, as an alternative to transrectal ultrasonography (TRUS) of the prostate when TRUS is not an option.

Methods

We retrospectively evaluated the medical records of 122 male cancer patients who were referred to our urology department between 2014 and 2016 for voiding problems. They underwent colorectal surgery within 3 months; we estimated the correlations of the TPV measurements made using CT, MRI, and TRUS. A total of 122 TRUS, 88 MRI, and 34 CT images were reviewed repeatedly, twice by 2 independent urologists within 1 month after the initial evaluation. The correlations were statistically evaluated using a Bland-Altman plot and Spearman and Pearson correlation analyses.

Results

Overall median age was 70.5 years and the median TPV, as measured using TRUS, CT, and MRI, was 33.2, 43.4, and 30.1 mL, respectively. There was a good correlation in TPV measured with CT (coefficient >0.7) and MRI (>0.8). There was not a good correlation between TRUS and preoperative and postoperative CT/MRI; preoperative CT/MRI had a higher correlation (>0.7) than postoperative CT/MRI (>0.8). When stratified by prostate volume, preoperative CT (>0.58-0.59) correlated better for <30 mL and preoperative MRI (0.70-0.75) correlated better for ≥30 mL.

Conclusions

The study showed that preoperative MRI had the best correlation with TRUS, especially in prostates ≥30 mL despite overestimations in CT and MRI measurements compared with TRUS.

Development and validation of a clinical nomogram predicting bladder outlet obstruction via routine clinical parameters in men with refractory nonneurogenic lower urinary tract symptoms

We aimed to develop and validate a clinical nomogram predicting bladder outlet obstruction (BOO) solely using routine clinical parameters in men with refractory nonneurogenic lower urinary tract symptoms (LUTS). A total of 750 eligible patients ≥50 years of age who had previously not responded (International Prostate Symptom Score [IPSS] improvement <4 points) to at least three different kinds of LUTS medications (including a-blocker) for the last 6 months were evaluated as subcohorts for nomogram development (n = 570) and for split-sample validation (n = 180). BOO was defined as Abrams–Griffiths number ≥40, or 20–39.9 with a slope of linear passive urethral resistance ratio >2 cmH₂O ml⁻¹ s⁻¹. A stepwise multivariable logistic regression analysis was conducted to determine the predictors of BOO, and b-coefficients of the final model were selected to create a clinical nomogram. The final multivariable logistic regression model showed that age, IPSS, maximum urinary flow rate, postvoid residual volume, total prostate volume, and transitional zone index were significant for predicting BOO; these candidates were used to develop the final nomogram. The discrimination performance of the nomogram was 88.3% (95% CI: 82.7%–93.0%, P < 0.001), and the nomogram was reasonably well-fitted to the ideal line of the calibration plot. Independent split-sample validation revealed 80.9% (95% CI: 75.5%–84.4%, P < 0.001) accuracy. The proposed BOO nomogram based solely on routine clinical parameters was accurate and validated properly. This nomogram may be useful in determining further treatment, primarily focused on prostatic surgery for BOO, without impeding the detection of possible BOO in men with LUTS that is refractory to empirical medications.

Efficacy and safety of tadalafil 5 mg once-daily in Asian men with both lower urinary tract symptoms associated with benign prostatic hyperplasia and erectile dysfunction: A phase 3, randomized, double-blind, parallel, placebo- and tamsulosin-controlled study

OBJECTIVE

To evaluate the efficacy and safety of tadalafil in Asian men with both lower urinary tract symptoms associated with benign prostatic hyperplasia and erectile dysfunction.

METHODS

The present phase 3, randomized, double-blind, parallel, placebo- and tamsulosin-controlled study was carried out at 40 study centers in the Asia-Pacific region (mainland China, Taiwan and Korea; NCT01937871). Participants were randomized to receive a placebo (n = 361), tadalafil 5 mg (n = 362) or tamsulosin 0.2 mg (n = 185) in a 2:2:1 ratio for 12 weeks.

RESULTS

A total of 909 Asian men were randomized into three groups. After 12 weeks of treatment, a statistically significant improvement in least squares mean change from baseline in total International Prostate Symptom Score was observed in the tadalafil versus the placebo group (-5.49 vs -4.08, respectively; P < 0.001). A statistically significant improvement in the change from baseline for the International Index of Erectile Function-Erectile Function domain score, was observed in tadalafil compared with the placebo at 12 weeks (5.24 vs 1.88, respectively; P < 0.001). A significant improvement was observed in the change from baseline in the percentage of "Yes" responses to Sexual Encounter Profile questions 2 and 3 in the tadalafil versus placebo group at 12 weeks (23.87% vs 10.90%; P < 0.001 and 36.62% vs 15.96%; P < 0.001, respectively). Safety results were consistent with the known tadalafil safety profile.

CONCLUSIONS

Tadalafil is efficacious and well tolerated in the treatment of Asian men with both lower urinary tract symptoms associated with benign prostatic hyperplasia and erectile dysfunction.

Superiority of dutasteride 0.5 mg and tamsulosin 0.2 mg for the treatment of moderate-to-severe benign prostatic hyperplasia in Asian men

OBJECTIVES

To assess the effectiveness and safety of dutasteride 0.5 mg + tamsulosin 0.2 mg combination compared with tamsulosin 0.2 mg in Asian men with moderate-to-severe benign prostatic hyperplasia.

METHODS

A 4-week, single-blind, placebo, run-in was followed by a 2-year double-blind randomized controlled trial in men age ≥50 years with symptomatic benign prostatic hyperplasia, International Prostate Symptom Score ≥12, prostate volume ≥30 cc, prostate-specific antigen ≥1.5 and ≤10 ng/mL, peak urinary flow >5 and ≤15 mL/s, and voided volume of ≥125 mL. Participants were randomized to oral daily dutasteride 0.5 mg + tamsulosin 0.2 mg combination or tamsulosin 0.2 mg. The primary efficacy end-point was change in International Prostate Symptom Score at year 2.

RESULTS

Data from 607 participants showed a significant reduction in International Prostate Symptom Score (P < 0.05) at month 24, along with greater improvements (P ≤ 0.006) in peak urinary flow at every assessment and significant prostate volume reduction at months 12 and 24 (P < 0.001) in the combination group. Combination therapy was associated with a significant reduction in the risk of acute urinary retention or benign prostatic hyperplasia-related surgery (P = 0.012), primarily due to a significant reduction in the risk of acute urinary retention (P = 0.005). The safety and tolerability profile of combination therapy was consistent with the known profiles for the individual monotherapies.

CONCLUSIONS

Dutasteride 0.5 mg + tamsulosin 0.2 mg combination therapy showed better clinical outcomes than tamsulosin 0.2 mg monotherapy, making it an effective and safe treatment option for Asian men with moderate-to-severe benign prostatic hyperplasia.

Effects of 5-alpha reductase inhibitors: new insights on benefits and harms

PURPOSE OF REVIEW

The use of 5-alpha reductase inhibitors (5ARIs) for the treatment of benign prostatic hyperplasia (BPH) and other diseases has been proposed and studied. However, the controversy about its benefits and harms for other diseases has persisted. In this review, we will discuss the newly identified effects of 5ARIs based on recently published studies.

RECENT FINDINGS

These drugs are currently recommended in clinical guidelines for BPH. However, the reporting of adverse effects, including sexual dysfunction as well as neurologic, endocrine, and cardiovascular effects, have been controversial. There are reports of additional effects of 5ARI in prostate cancer and bladder cancer. Although 5ARIs have been prescribed for the treatment of androgenic alopecia (AGA), postfinasteride syndrome can result, with symptoms that range from sexual dysfunction to muscle atrophy.

SUMMARY

Clinical applications of 5ARIs have been established for the treatment of BPH and AGA from a series of randomized controlled trials. The adverse effects of 5ARIs affect only a small proportion of treated patients and can be resolved with discontinued treatment. It will be necessary to establish the mechanism by which 5ARIs elicit these effects through better designed studies.

Changes in autonomic nervous system activity after treatment with alpha-blocker in men with lower urinary tract symptoms

Purpose

To determine changes in autonomic nervous system activity after treatment in men with lower urinary tract symptoms (LUTS), we evaluated changes in patients' symptoms, uroflowmetry, and heart rate variability (HRV) after treatment with alpha-blockers for 12 weeks.

Materials and Methods

Ninety-five men who had LUTS (International Prostate Symptom Score [IPSS] ≥8) were included in this study. We divided them into two groups on the basis of a low frequency/high frequency (LF/HF) ratio of 1.6. After treatment with Xatral XL (Handok Inc., Korea) 10 mg for 3 months, we rechecked their IPSS, uroflowmetry, HRV and compared these with the baseline measurements.

Results

Fifty-four men were assigned to the low LF/HF group (group A: LF/HF ≤1.6) and 41 men to the high LF/HF group (group B: LF/HF >1.6). At baseline and 12 weeks, none of the parameters differed significantly between the groups except for HF, which is one of the parameters of HRV. IPSS, the IPSS-voiding subscore, and the IPSS-storage subscore decreased and maximal uroflow increased significantly after 12 weeks of treatment. Whereas the baseline LF/HF ratio increased from 0.89±0.407 to 1.80±1.804 after treatment in group A, it decreased from 3.93±5.471 to 1.79±1.153 in group B.

Conclusions

The efficacies of Xatral XL were clear in both groups. We found that the LF/HF ratio in the two groups merged to a value of approximately 1.79 after treatment. We suggest that this could be a clue to the importance of balance in autonomic nervous system activity in men with LUTS.

5-year long-term efficacy of 120-W GreenLight photoselective vaporization of the prostate for benign prostate hyperplasia

PURPOSE

To investigate 5-year long-term postoperative efficacy in benign prostate hyperplasia (BPH) following 120-W GreenLight high-performance system photoselective vaporization of the prostate (HPS-PVP).

METHODS

This was a retrospective study of surgical outcomes in 159 men who underwent HPS-PVP and were followed over 60 months postoperatively. Definitions of treatment success were established based on the following three variables: international prostate symptom scores (IPSS), maximum flow rates (Qmax), and quality of life scores QoL). Logistic regression analyses were performed to determine predictors of the postoperative success.

RESULTS

Postoperative IPSS/QoL, Qmax and post-voided residual urine volume were significantly improved after HPS-PVP. Postoperative Prostate specific antigen and prostate volume were also well reduced and sustained for 5 years. The postoperative success rate was assessed as 82.1%, 80.8% and 76.1% for each 1-, 3-, and 5-year. Thirty-eight (23.9%) patients had immediate postoperative complications, which were managed successfully with nonsurgical methods. None required transfusions, two (1.2%) patients required endoscopic reoperation for postoperative voiding difficulty due to bladder neck contracture or urethral stricture, and five (3.1%) required HPS-PVP reoperation. Presence of diabetes, voiding symptom subscore, QoL, maximal cystometric capacity, and bladder outlet obstructive index were valuable preoperative parameters for predicting postoperative success.

CONCLUSIONS

HPS-PVP is an effective, long-term treatment option for BPH, with sustained efficacy of 76.1% at 5-year follow up. Several preoperative parameters could help to predict the durable surgical improvements.

Safety and Effectiveness of Once-Daily Tadalafil (5 mg) Therapy in Korean Men with Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms in a Real-World Clinical Setting: Results from a Post-Marketing Surveillance Study

Purpose

The aim of this study was to investigate the safety and effectiveness of tadalafil 5 mg once daily (quaque die [everyday], QD) among Korean men with benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) in a real-world clinical setting.

Materials and Methods

This was a single-country, prospective, observational cohort study in which patients newly prescribed tadalafil 5 mg QD for the treatment of BPH/LUTS were followed-up for 12±2 or 24±2 weeks, or to the last treatment, during post-marketing surveillance. Safety was evaluated in terms of the frequency of treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs). Effectiveness was assessed by changes in the International Prostate Symptom Score (IPSS) from baseline to each endpoint.

Results

All patients receiving ≥1 dose of tadalafil 5 mg QD (N=637) were included in the safety population. Two percent of patients (n=13) experienced 15 TEAEs of mild (n=10; 66.7%) or moderate (n=5; 33.3%) severity. No severe TEAEs and no SAEs were reported. Effectiveness evaluations included all patients receiving tadalafil who had both baseline and endpoint observations (12-week, N=265; 24-week, N=44). Compared with baseline, the mean IPSS total score (±standard error) significantly improved by 4.7±0.3 and 6.4±0.7 points at the 12- and 24-week endpoints, respectively (p<0.0001), with significant improvements also observed on the storage, voiding, and quality of life subscores. In total, 69.1% of the patients had a clinically meaningful ≥3-point improvement in the IPSS total score.

Conclusions

Tadalafil 5 mg QD was well tolerated and effective in Korean men with BPH/LUTS in a real-world clinical setting.

Tailoring pharmacotherapy for male lower urinary tract symptoms: A prospective, multicenter, observational trial

OBJECTIVES

The aim of this study was to evaluate the pattern of tailoring and efficacy of several types of pharmacotherapy in male LUTS.

METHODS

Prospectively 404 male subjects were included who were over 40 years old, had at least 3 months symptom duration, and 12 or higher international prostate symptom score (IPSS). Subjects were treated with several types of pharmacotherapy for 6 months and were evaluated with IPSS/QoL at every follow-up. Subjects were subdivided into storage (44%), nocturia (18.5%), and voiding symptom (37.5%) groups according to the most bothersome symptom.

RESULTS

At 6 months, 188 subjects (46.5%) completed the study. The mean age was 64.2±8.5 years, and symptom duration was 30.6±32.6 months. PSA was 2.98±7.96 ng/mL, and prostate size was 32.8±14.2 cc. IPSS continually decreased from baseline (18.7) to last follow-up (10.8). Combination therapy increased from 33.0% to 52.7% at last follow-up (P=.006). However, there was no difference of IPSS changes between combination and monotherapy groups (P>.05). Only antimuscarinic prescription significantly increased from 15.4% to 28.2% (P=.004). Mean number of visits to the clinic was 3.6±1.3 and the number of treatment changes was 0.31±0.47. The nocturia (0.47±0.51) group changed treatment more than voiding group (0.21±0.41, P=.003). However, the voiding group (-9.4) had significantly more improvement than e storage (-6.4) and nocturia (-7.8) groups (P=.011).

CONCLUSIONS

Male LUTS continually improved over 6 months with customised treatment. Pharmacotherapy for male LUTS should be tailored by symptom type and alteration of symptoms during treatment.

Korean clinical practice guideline for benign prostatic hyperplasia

In 2014, the Korean Urological Association organized the Benign Prostatic Hyperplasia Guideline Developing Committee composed of experts in the field of benign prostatic hyperplasia (BPH) with the participation of the Korean Academy of Family Medicine and the Korean Continence Society to develop a Korean clinical practice guideline for BPH. The purpose of this clinical practice guideline is to provide current and comprehensive recommendations for the evaluation and treatment of BPH. The committee developed the guideline mainly by adapting existing guidelines and partially by using the de novo method. A comprehensive literature review was carried out primarily from 2009 to 2013 by using medical search engines including data from Korea. Based on the published evidence, recommendations were synthesized, and the level of evidence of the recommendations was determined by using methods adapted from the 2011 Oxford Centre for Evidence-Based Medicine. Meta-analysis was done for one key question and four recommendations. A draft guideline was reviewed by expert peer reviewers and discussed at an expert consensus meeting until final agreement was achieved. This evidence-based guideline for BPH provides recommendations to primary practitioners and urologists for the diagnosis and treatment of BPH in men older than 40 years.