Despite the more prevalent use of medical therapy for men suffering from LUTS associated with BPH, there remain clinical scenarios where surgery is indicated as the initial intervention for LUTS/BPH and should be recommended, providing other medical comorbidities do not preclude this approach. Applicable to a wide variety of patients. Urol Int 2002; Ozdal OL, Ozden C, Benli K et al: Effect of short-term finasteride therapy on peroperative bleeding in patients who were candidates for transurethral resection of the prostate (tur-p): A randomized controlled study. 8. ICH GCP. World J Urol 2014; Yan H, Ou TW, Chen L et al: Thulium laser vaporesection versus standard transurethral resection of the prostate: a randomized trial with transpulmonary thermodilution hemodynamic monitoring. This reduces (if not eliminates) the risk for acute dilutional hyponatremia during prolonged resection, which may lead to the so-called TUR syndrome. On the 5 mg dose at 6 weeks, the proportion of participants on the 5 mg dose of tadalafil was also significantly greater than participants on placebo 49% versus 36%. The depth of penetration with PVP is 0.8 mm. The Panel concluded that substantial issues remain in recommending PAE for the routine treatment of bothersome LUTS attributable to BPH. It is also used to monitor tissue resection in real time during the procedure. 2007; Salonia A, Gallina A, Briganti A et al: Remembered international index of erectile function domain scores are not accurate in assessing preoperative potency in candidates for bilateral nerve-sparing radical retropubic prostatectomy. JSM 2017; Gacci M, Vittori G, Tosi N et al: A randomized, placebo-controlled study to assess safety and efficacy of vardenafil 10 mg and tamsulosin 0.4 mg vs. tamsulosin 0.4 mg alone in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. Prostate Cancer Prostatic Dis 2019; McVary KT, Gange SN, Shore ND et al: Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. The procedure is generally performed with saline irrigation, eliminating the possibility of TUR syndrome that can occur with non-ionic irrigation. 2006; Gupta NP, Doddamani D, Aron M et al: Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc. (Moderate Recommendation; Evidence Level: Grade C), PUL may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. Urologe A 1995; 34: 153. (Moderate Recommendation; Evidence Level: Grade B), PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe. Blouin M, Blouin J, Perreault S et al: Intraoperative floppy-iris syndrome associated with α1- adrenoreceptors Comparison of tamsulosin and alfuzosin. (Moderate Recommendation; Evidence Level: Grade C). 1995; 154: 1779. Despite the rigorous methodology and detail used in these various areas, supporting high-quality data (i.e., randomized controlled trials) could not be identified for some topics. Actas Urol Esp. Six RCTs (n=601) compared effectiveness of TUVP and bipolar TURP, all with followup ≤1 year.44-49 Mean age was 66 years (range 60 to 69), baseline IPSS was 21 (range 18 to 24), and mean prostate volume was 56mL (range 32 to 64). (Expert Opinion), Clinicians should consider assessment of prostate size and shape via transrectal or abdominal ultrasound, cystoscopy, or cross-sectional imaging (i.e., magnetic resonance imaging [MRI]/ computed tomography [CT]) if such studies are available, prior to intervention for LUTS/BPH. Studies have attempted to discern efficacy differences between different alpha blockers and to identify subgroups of patients who may respond better to one alpha blocker or another. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 1996; Kirby RS, Roehrborn C, Boyle P et al: Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in treatment of symptomatic benign prostatic hyperplasia: the Prospective European Doxazosin and Combination Therapy (PREDICT) trial. In support of the concept of 120W PVP use in anticoagulated patients, recent publications report that the need for a blood transfusion was lower for PVP with 120W compared to TURP.296,297, For additional information on the use of anticoagulation and antiplatelet therapy in surgical patients, refer to the ICUD/AUA review on Anticoagulation and Antiplatelet Therapy in Urologic Practice.372. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there may or may not be evidence in the medical literature. Urologists should inform identified patients with planned cataract surgery of IFIS risk and delay initiation of alpha blocker therapy until after the procedure. Andriole GL, Bostwick DG, Brawley OW et al: Effect of dutasteride on the risk of prostate cancer. 32. Indian J Urol 2009; Al-Hashimi MM: Alfuzosin 10 mg once daily in the management of acute urinary retention of benign prostatic hyperplasia. (Conditional Recommendation; Evidence Level: Grade C). Peer Review. J Urol 2005; 173: 757. The enlarged gland has been proposed to contribute to the overall lower urinary tract symptoms (LUTS) complex via at least two routes: (1) direct bladder outlet obstruction (BOO) from enlarged tissue (static component) and (2) from increased smooth muscle tone and resistance within the enlarged gland (dynamic component). Risk of Bias (ROB) and Data Extraction. 2018;25:944-951. In terms of sexual side effects, ED was reported for 8% of TUIP participants compared to 20% for TURP participations, though this difference was not significant (RR: 0.4; 95%CI: 0.1, 1.3). The L.I.F.T. Euro Urol 2008; Bishop CV, Liddell H, Ischia J et al: Holmium laser enucleation of the prostate: comparison of immediate postoperative outcomes in patients with and without antithrombotic therapy. Roehrborn C, Prajsner A, Kirby R et al: A double-blind placebo-controlled study evaluating the onset of action of doxazosin gastrointestinal therapeutic system in the treatment of benign prostatic hyperplasia. Length of follow-up ranged from 3 months to 10.1 years. Fwu CW, Eggers PW, Kirkali Z et al: Change in sexual function in men with lower urinary tract symptoms/benign prostatic hyperplasia associated with long-term treatment with doxazosin, finasteride and combined therapy. Gilling P, Mackey M, Cresswell M et al: Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year followup. Kuntz R, Lehrich K: Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm. To fully determine the etiology of an elevated PVR, formal urodynamics testing with a pressure flow study would need to be performed. If concordance is present, it is reassuring for the provider and patient to continue with therapy or jointly reassess and change to alternative strategies. J Urol 2000; Malaeb BS, Yu X, McBean AM et al: National trends in surgical therapy for benign prostatic hyperplasia in the United States (2000-2008). Chin Med J (Engl) 2005; 118: 1610. There was no difference in mean reduction in IPSS within each group (- 15.1) or QoL outcomes (mean change approximately -2.0). View the full description of the methodology presented in Chapter 2. However, surgeons should be aware that longer catheterization and irrigation with an increased rate of complications has been reported, and delayed bleeding is more pronounced in these patients.367-370 A 2017 study confirmed these findings in 59 of 373 patients undergoing PVP. 3. (Clinical Principle), Clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum; however, evaluation for the presence of bladder outlet obstruction (BOO) should be considered. Investig Clin Urol 2017; Lee DJ, Rieken M, Halpern J et al: Laser vaporization of the prostate with the 180-W XPS-Greenlight laser in patients with ongoing platelet aggregation inhibition and oral anticoagulation. Clin Epidemiology 2017; Fang Q, Chen P, Du N et al: Analysis of data from breast diseases treated with 5-alpha reductase inhibitors for benign prostatic hyperplasia. esteban.rubinstein@hospitalitaliano.org.ar § Servicio de Urología del Hospital Italiano de Buenos Aires. BJU International 2012; Bozzini G, Seveso M, Melegari S et al: Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): a randomized prospective trial to compare intra and early postoperative outcomes. 23. The expert Panel examined three overarching key questions for pharmacotherapeutic, surgical and alternative medicine therapies: (1) What is the comparative efficacy (the extent to which an intervention produces a beneficial result under ideal conditions such as clinical trials) and effectiveness (the extent to which an intervention in ordinary conditions produces the intended result) of currently available and emerging treatments for BPH? (Strong Recommendation; Evidence Level: Grade A). 18. Surgical management of BOO attributed to BPH; and 3. N Eng J Med 1996; 33: 533. The Panel reviewed and discussed all submitted comments and revised the draft as needed. Clínica del Country . (Clinical Principle), While the evidence base is limited, multiple organizations and their guidelines include PVR measurement as part of the basic evaluation of LUTS. Panel Formation. However, 11 studies were included with 3 trials54,315,316,327-330 reporting long-term results in IPSS reduction (mean change approximately -15), ranging from 18 to 60 months (WMD: 0.4 points; 95%CI: -0.9, 1.6). (Moderate Recommendation; Evidence Level: Grade C), WVTT may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. Pharmacotherapies-- including complementary and alternative medications (CAM) and watchful waiting, as well as lifestyle issues-- are addressed. Men assigned to combination therapy also experienced significant worsening in EF and sexual problem assessment. Pharmacotherapy 2017; Wei L, Lai E, Kao-ang Y et al: Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors: population based cohort study. Helfand B, Mouli S, Dedhia R et al: Management of lower urinary tract symptoms secondary to benign prostatic hyperplasia with open prostatectomy: results of a contemporary series. dolorconlosmovimientosy,portanto,laapariciónde polaquiuria,micciónimperiosayhematuriaqueseali-vianconelreposo.Lapolaquiuria,inicialmentenoctur- In comparison, ED and RE occurred in 9% and 20%, respectively, of the participants in the TURP group. More specifically, computational biology and genomic factors should be aimed toward understanding drivers of BPH and prostate growth and therapeutic targets. Eur Urol 2009; Kaplan SA. The lack of improvement of urodynamic profile is clearly paradoxical and serves as a potential warning to clinicians that tadalafil has no established role in men with impaired bladder function, urinary retention, or those in the midst of a TWOC. While there are several medical and surgical ways to reduce the influence of androgenic steroids on the growth of the prostate (e.g., medical or surgical castration), the only hormonal therapies with an acceptable benefit-to-RR are the 5-ARIs. Hospital Universitario San Ignacio. The key questions were divided into three topics for surgical management of LUTS/BPH: 1. LUTS/BPH can have a progressive natural history that is more profound in men with larger glands and/or higher PSA values. 96. 29. Sotelo R, Spaliviero M, Garcia-Segui A et al: Laparoscopic retropubic simple prostatectomy. The potential role of PAE in the management of refractory hematuria is evolving. The rationale for this treatment is for men to initially gain the benefit of the alpha blocker and once the efficacy of the 5-ARI is fully developed at a later time, the alpha blocker may be removed. Andriole G, Bruchovsky N, Chung L et al: Dihydrotestosterone and the prostate: the scientific rationale for 5alpha-reductase inhibitors in the treatment of benign prostatic hyperplasia. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. J Endourol 2017; Mourmouris P, Keskin SM, Skolarikos A et al: A prospective comparative analysis of robot-assisted vs open simple prostatectomy for benign prostatic hyperplasia. Most men with BOO will void with low urinary flow (Qmax < 10 cc/s) at peak voiding pressures and a pressure flow study will confirm BOO if high voiding pressures accompany the low urinary flow.36 Nomograms that combine voiding pressures and maximum urinary flow rate can also be used to better assess probability of the patient having BOO.36 Patients with BOO may have an elevated PVR; however, the correlation between residual volume and degree of obstruction is weak.37. Of note, LUTS may result from abnormalities of the peripheral and/or central nervous systems that provide neural control to the lower urinary tract. 71. Scribd es red social de lectura y publicación más importante del mundo. He does not have a history suggesting non-BPH causes of LUTS and his LUTS may or may not be associated with an enlarged prostate gland, BOO, or histological BPH. (Clinical Principle). 22. One trial reported need for retreatment at 3 years due to recurrence of BOO symptoms, where retreatment included the use of medications such as alpha blockers, or surgery.54 This study reported significantly higher retreatment rates in the TURP group compared to HoLEP group, 27.4% versus 5% (P=0.03). Professional societies, national and international, and other government organizations are also suggested as participants. McMaster University, 2015 (developed by Evidence Prime, Inc.). 17. However, there were differences regarding safety parameters. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. Fourteen RCTs evaluating 1,828 participants compared bipolar TUVP with TURP.252,253-271 Mean age among participants was 67 years (range 56 to 70). Fisiopatología De La Hiperplasia Prostática Benigna. Eur Urol 2016; Elhilali MM and Elkoushy MA: Greenlight laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic obstruction: evidence from randomized controlled studies. However, endoscopic enucleation, particularly with laser energy, has clearly become an accepted modality; as such, further applications and support in guidelines are likely in the future. In one study of 56 patients (32 on aspirin, 8 on clopidogrel or clopidogrel plus aspirin, and 16 on phenprocoumon), 4 patients needed blood transfusions, and 4 patients required immediate reoperation. 30. When body of evidence strength is Grade A in support of a Conditional Recommendation, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. J Urol 2016; McVary KT, Gange SN, Gittelman MC et al: Erectile and ejaculatory function preserved with convective water vapor energy treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: randomized controlled study. In: 6th International Consultation on New Developments in Prostate Cancer and Prostate Diseases. Eye (Lond) 2007; Andriole G, Bruchovsky N, Chung L et al: Dihydrotestosterone and the prostate: the scientific rationale for 5alpha-reductase inhibitors in the treatment of benign prostatic hyperplasia. 2011; Thompson IM, Goodman PJ, Tangen CM et al: The influence of finasteride on the development of prostate cancer. 25. Following initial publication in 2018, this Guideline underwent an amendment in 2019 that included literature published through January 2019. The risk of overall clinical progression, defined as an increase above base line of at least four points in the AUA-SI, AUR, urinary incontinence, renal insufficiency, or recurrent UTI, was significantly reduced by doxazosin (39% risk reduction; p<0.001) and finasteride (34% risk reduction; p=0.002), as compared with placebo. Interventions for LUTS/BPH have clear sexual side effects and tthese treatments have a significant rate of EjD. BJU Int 2011; Nitti VW, Rosenberg S, Mitcheson DH et al: Urodynamics and safety of the b3-adrenoceptor agonist mirabegron in males with lower urinary tract symptoms and bladder outlet obstruction. Prostate Cancer Prostatic Dis 2007; 10: 149. Need for blood transfusions were similar between groups (RR: 1.2; 95%CI: 0.4, 3.4). Data were insufficient to compare IPSS changes. 84. J Sex Med 2008; Helfand BT, Fought A, Manvar A, McVary KT: Determining the utility of recalled lower urinary tract symptoms. Regardless, the concept of LUTS secondary to BPH (LUTS/BPH) is meaningful to clinicians. BJU Int 2019; Carnevale FC, Iscaife A, Yoshinaga EM et al: Transurethral resection of the prostate (TURP) versus original and PErFecTED prostate artery embolization (PAE) due to benign prostatic hyperplasia (BPH): preliminary results of a single center, prospective, urodynamic-controlled analysis. The prevalence and the severity of LUTS in the aging male can be progressive, and is an important diagnosis in the healthcare of our patients and the welfare of society. Further, symptoms may result from interactions of these organs as well as with the central nervous system or other systemic diseases (e.g., metabolic syndrome, congestive heart failure). Based on the lack of peer-reviewed publication in the literature review timeframe and TUNA’s substantially diminished clinical relevance, the Panel does not recommend TUNA. After review of the recommendations for diagnosis published by the 2005 International Consultation of Urologic Diseases12 and reiterated in 2009 in an article by Abrams et al (2009), the Panel unanimously agreed that the contents were valid and reflected "best practices". Post hoc analysis showed that in men with prostates <29 mL, IPSS change was -7.8 for tolterodine compared to -6.1 for placebo (p=0.06). Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options by clinicians, depending on their expertise with these techniques, only in patients with large to very large prostates. Clin Ophthalmol 2020; Chang DF, Osher RH, Wang L, Koch DD. In addition to alpha blockers, several other non-urologic drugs, including benzodiazepines, donepezil and duloxetine, have been associated with IFIS.7 Even in verified high-risk IFIS patients, ophthalmologists can decrease complication rates to baseline through a variety of mitigation strategies.99-101, 13. Discrepancies were resolved by consensus. 10. Statements without size criteria are those modalities that the Panel concluded are efficacious and safe for a broad range of prostate sizes. In the second trial, overall withdrawals were 18.3% with combination therapy and 10.5% with tadalafil monotherapy ([RR: 1.7; 95%CI: 1.01, 2.99]; [ARD: 7.8%; 95%CI: 0.4, 15]). (Clinical Principle), Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of change in medical management or surgical intervention. Actas Urol Esp 2012; Demir A, Gunseren KO, Kordan Y et al: Open vs laparoscopic simple prostatectomy: A comparison of initial outcomes and cost. Urology 2010; Simforoosh N, Abdi H, Kashi AH et al: Open prostatectomy versus transurethral resection of the prostate, where are we standing in the new era? Originalul nou. Barcelona: Doyma, 1989;1808-9. 57. BPH and ensuing LUTS is a significant health issue affecting millions of men. Superiority of dutasteride 0.5 mg and tamsulosin 0.2 mg for the treatment of moderate-to-severe benign prostatic hyperplasia in Asian men. All four favored bipolar TURP; however, the differences in the effect estimate were highly variable as was the degree of heterogeneity. However, the natural history of symptomatic disease progression is more accelerated in men with larger glands and higher serum PSA values; correspondingly, the outcomes between finasteride and placebo groups become more accentuated in men with larger glands over time.115-118. Clinicians should perform a PVR assessment prior to intervention for LUTS/BPH. Three-year results showed sustained improvements for the IPSS IPSS-QoL, and Qmax, with scores remaining significantly improved from baseline;70 Qmax improvement was > 50% from 3 to 24 months and 39% at 36 months.13 At 36 months in the intent-to-treat population of the original 136 participants, mean change from baseline in IPSS was -11.0 points and the mean score was 10.4 points, representing a 50% improvement from baseline. Int Urol Nephrol 2006; 38: 275. The major difference is that holmium is a pulsed laser while thulium is continuous, which impacts how quickly the temperature rises in the tissue. Bladder outlet obstruction (BOO) is the generic term for all forms of obstruction to the bladder outlet (e.g., urethral stricture) including BPO. In a study looking at initiation of combination dutasteride and tamsulosin, or no medication, Roehrborn et al.134 found that initial combination medication intervention improved QoL outcomes compared to later initiation of tamsulosin when men had disease progression. BPE may cause BPO, but not all men with BPH will develop BPE, and not all BPE will cause BPO. In the GOLIATH study,50,51 an international multicenter RCT comparing the higher powered 180W PVP to TURP, 24-month data reported a similar overall need for reoperation (RR: 1.4; 95%CI: 0.6, 3.0) between the two modalities. Thus, addition of sildenafil 25 mg daily may be considered in patients with LUTS/BPH who have an inadequate response to tamsulosin, especially if they desire concomitant therapy for ED. Urology 2004; Mattiasson A, Wagrell L, Schelin S et al: Five-year follow-up of feedback microwave thermotherapy versus TURP for clinical BPH: a prospective randomized multicenter study. J Endourol 2009; Garcia-Segui A, Gascon-Mir M: Comparative study between laparoscopic extraperitoneal and open adenomectomy. First, there are no properly designed studies (e.g., using appropriate controls and addressing the issues described above with respect to the study of sexual function) that report a significant association between discontinuation of finasteride and persistence of sexual dysfunction. Lund L, Moller Ernst-Jensen K, torring N et al: Impact of finasteride treatment on perioperative bleeding before transurethral resection of the prostate: a prospective randomized study. BJU Int 2008; Tasci AI, Tugcu V, Sahin S et al: Rapid communication: photoselective vaporization of the prostate versus transurethral resection of the prostate for the large prostate: a prospective nonrandomized bicenter trial with 2-year follow-up. HoLEP, PVP, and ThuLEP should be considered as treatment options in patients who are at higher risk of bleeding. La hipertrofia (aumento de volumen de la glándula prostática) es secundaria a una Hiperplasia de sus células a nivel de estroma músculo y glándulas de ahí que pueda The hypotensive effects of terazosin and doxazosin can be potentiated by concomitant use of a PDE5, such as sildenafil or vardenafil. Control Clin Trials 2003; Lightner DJ, Gomelsky A, Souter L et al: Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU Guideline amendment 2019. Holmium Laser Enucleation of the Prostate, Laparoscopic Simple Prostatectomy/Enucleation, Male Lower Urinary Tract Symptoms Secondary/attributed to BPH, Photoselective Vaporization of the Prostate, Robotic-Assisted Laparoscopic Simple Prostatectomy, Thulium Laser Enucleation of the Prostate, Transurethral Vaporization of the Prostate. The Panel decided that the diagnostic section of the 2003 Guideline required updating. Benign prostatic hyperplasia (BPH) is a histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone. BJU Int 1999; 83: 857. Mayo Clin Proc 2004; Nieminen T, Tammela TL, Kööbi T et al: The effects of tamsulosin and sildenafil in separate and combined regimens on detailed hemodynamics in patients with benign prostatic enlargement. Male LUTS may be caused by a variety of conditions, which include BPE and BPO. Impacto del brote de COVID-19 en las listas de espera de. Combination of Low-Dose Daily Tadalafil with Finasteride. Rapid and durable relief of symptoms, 3. Ophthalmology 2011. In the absence of standardized prostate size categories in the literature, the Panel recommends consideration of the following categorical size descriptions when planning treatment: small (< 30 g), average (30-80 g), large (>80 to 150 g), and very large (>150 g). Given the similar efficacy of the approved alpha-1-adregergic antagonists, the choice of specific agent should consider the differing adverse events profiles of each. Int Urol Nephrol 2014; McNeill SA, Daruwala PD, Mitchell IDC et al: Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled trial. J Urol 2004; Tan A, Gilling P, Kennett K et al: A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). An additional literature search was conducted through September 2019 and serves as the basis for a 2020 amendment. Chadha V, Borooah S, Tey A et al: Floppy iris behaviour during cataract surgery: associations and variations. (Conditional Recommendation; Evidence Level: Grade C), Compared to many other surgical interventions, WVTT has a higher likelihood of preserving sexual function. In men concerned about new onset of ED and/or EjD, PUL likely does not pose additional risk. TUVP showed similar need for reoperation (RR: 1.5; 95%CI: 0.6, 3.9). The key questions were divided into two topics for medical management of BPH: 1. This document was written by the Benign Prostatic Hyperplasia Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2016. As such, many studies evaluate sexual side effects by looking at reported adverse events only, rather than specifically assessing sexual function. Revisión de las evidencias actuales . JU 2008; Takeda M, Nishizawa O, Imaoka T et al: Tadalafil for the treatment of lower urinary tract symptoms in japanese men with benign prostatic hyperplasia: results from a 12-week placebo-controlled dose-finding study with a 42-week open-label extension. (Moderate Recommendation; Evidence Level: Grade C), TUIP should be offered as an option for patients with prostates ≤30cc for the surgical treatment of LUTS/BPH. 46. Three RCTs (n=433) compared OSP techniques to TURP.235,236,252 Three trials used an open standard transvesical approach. In addition to the flow rate, the shape of the curve and duration of voiding provide useful information as a screening tool for LUTS. If interventional therapy is planned without clear evidence of the presence of obstruction, the patient needs to be informed of potentially higher failure rates of the procedure. 5-ARI in combination with an alpha blocker should be offered as a treatment option only to patients with LUTS associated with demonstrable prostatic enlargement as judged by a prostate volume of > 30cc on imaging, a PSA >1.5ng/dL, or palpable prostate enlargement on DRE. It is the hope that this revised Guideline will provide a useful reference on the effective evidence-based management of LUTS/BPH. 3. The mean age was 63 years, and the baseline BMI was 29 kg/m2. Several publications from a low ROB RCT (n = 181) assessing RWT were evaluable by the Panel.80,337-340 Other recent publications evaluating RWT were excluded from analysis because of their cohort (not comparative) study design.341 The trial utilized standard inclusion/exclusion criteria limiting participants to prostate sizes between 30-80g.80,337-340 Treatment response through 12, 24, and 36 months, defined as at least a 5-point improvement in IPSS, was similar for RWT and TURP (quality of evidence was rated moderate for long-term treatment response for RWT compared to TURP). Urologia Internationalis 2008; Shah T, Palit V, Biyani S et al: Randomised, placebo controlled, double blind study of alfuzosin SR in patients undergoing trial without catheter following acute urinary retention. 27. Available from gradepro.org. Farmacología SNA: Adrenérgicos y antiadrenérgicos. Further evaluation may include a post-void residual (PVR) and uroflowmetry. (Expert Opinion), After exclusion of other causes of hematuria, 5-ARIs may be an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding. Time intervals, tests to be conducted, and consequences of changes in parameters such as the IPSS, QoL score, flowrate recordings, or residual urine volume have not been systematically studied in the literature. Safety and QoL issues can be treated with bladder drainage such as intermittent catheterization while the patient is being evaluated for BOO. J Endourol 2016; Gravas S, Bach T, Drake M, Gacci M, Gratzke C, Herrmann T.R.W. Many unanswered questions exist, including but not limited to the role of inflammation, metabolic dysfunction, obesity, and environmental factors in etiology, as well as the role of behavior modification, self-management, and evolving therapeutic algorithms in both the prevention and progression of disease. In such instances, clinicians should discuss the key treatment classes with patients and engage in a shared decision-making approach to reach a treatment choice, which may necessitate a referral to another clinician for the chosen treatment. Canadian Journal of Urology 2017; Gratzke C, Barber N, Speakman M, et al: Prostatic urethral lift vs transurethral resection of the prostate: 2-year results of the BPH6 prospective, multicentre, randomized study. Nat Clin Pract Urol 2008; Kirby R: A randomized, double-blind crossover study of tamsulosin and controlled-release doxazosin in patients with benign prostatic hyperplasia. (Strong Recommendation; Evidence Level: Grade A), Anticholinergic agents, alone or in combination with an alpha blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS. Comparison of tamsulosin and silodosin in the management of acute urinary retention secondary to benign prostatic hyperplasia in patients planned for trial without catheter. These agents are both widely available and utilized by men suffering from voiding symptoms that they believe may be attributable to an enlarged prostate and remedied by such compounds. J Urol 2003; 169: 2253. Other harms classified as Clavien-Dindo grades 1-4 occurred at similar rates in both groups, including bladder spasms, bleeding, dysuria, pain, and urethral damage. Kramer B, Hagerty K, Justman S et al: Use of 5alpha-reductase inhibitors for prostate cancer chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline. 50. BJU Int 1999; De la Rosette JJ, Floratos DL, Severens JL et al: Transurethral resection vs microwave thermotherapy of the prostate: a cost-consequences analysis. neither satisfied/pleased/happy nor unsatisfied/displeased/unhappy. Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. The mechanism of action of this PDE5 effect is only partially understood. Urodynamic studies can also categorize LUTS related to DO or low bladder compliance. This Guideline does not offer an in-depth discussion of the utility of supplements, nutraceuticals, and herbal preparations. The evidence review identified 10 key reports from 10 trials that compared tadalafil 5 mg to placebo (n=5,129).170-179 One study started with 5 mg and escalated the dose to 20 mg after 6-weeks.170 All studies had a relatively short follow-up period of 12 weeks and were industry funded. For example, intravesical protrusion (e.g., intravesical lobe, ball-valving middle lobe) has been recognized to predict poor outcomes from watchful waiting and most medical therapies.29Some of the available MISTs are indicated for prostates between specific sizes (i.e. Prostate 1997; Auffenberg G, Helfan B, McVary K: Established medical therapy for benign prostatic hyperplasia. Indeed, definitions of retreatment or treatment failure have varied considerably across trials, and not all the mentioned categories are standard in BPH studies. 19. For IPSS and IPSS-QoL, reviewers determined the statistical significance of the effect of interventions versus control but defined clinical efficacy based on whether the mean or median effect between intervention and control exceeded thresholds for clinical significance (i.e., the MDD). There are no thresholds in the literature for monitoring changes in Qmax to help guide therapy. (Moderate Recommendation; Evidence Level: Grade C). Figure 3. That said, testosterone does not act alone. In the phase III silodosin studies, it was noted that the number of men reporting EjD as an adverse event decreased from 46% to 11% for men in their 50s versus 70s, respectively, and the number of men discontinuing treatment due to the adverse events decreased from 4.7% to 0 %.91,92. Am J Manag Care 12 2006; 5 Suppl: S122. Similar to statements in the AUA ED Clinical Guideline, sildenafil improves EF in men with LUTS/BPH with and without co-morbid ED.182, 18. The Panel recommends consideration of these issues when interpreting outcomes of trials comparing different therapeutic modalities or of trials of a single modality with different lengths of follow-up. It is the hope that this revised clinical Guideline will provide a useful reference on the effective evidence-based management of male LUTS secondary to BPH. Urol Int 2004; Baldwin K, Ginsberg P, Roehrborn C et al: Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia. Paris, France: Health Publications, 2006. J Urol 2019; Van Kerrebroeck P, Haab F, Angulo JC et al: Efficacy and safety of solifenacin plus tamsulosin ocas in men with voiding and storage lower urinary tract symptoms: Results from a phase 2, dose-finding study (saturn). Tech Urol 2001; 7: 252. However, mean IPSS change showed little to no difference (-5.9 versus -5.6). Finally, in patients with medically refractory LUTS associated with BPH or who choose not to pursue other minimally invasive therapies, surgery should be offered. Numbers above bars indicate total number of cancers detected by treatment group; numbers within bars report occurrence by Gleason score. There are two independently-conducted double-blind, placebo controlled, parallel group trials that were done using a specific extract of the berries of the American dwarf palm tree (saw palmetto), which is the most commonly found ingredient of such supplements.13,14 Both studies found no benefit over placebo in terms of symptoms, bother, QoL, flowrate recordings, serum PSA, or any other measurable parameter. 42. During the follow-up visits, patients should be queried regarding the occurrence of typical adverse events of the medication taken, the IPSS and QoL score should be re-administered, and uroflowmetry and residual urine determination is advised. For longer acting drugs such as 5-ARIs, the first follow-up visit may be within three to six months if adverse events do not necessitate an earlier visit. La glándula . study. J Urol 2002; 168: 1470. Boccon-Gibod L, Valton M, Ibrahim H et al: Effect of dutasteride on reduction of intraoperative bleeding related to transurethral resection of the prostate. Wasson J, Reda D, Bruskewitz R et al: A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Qmax after ThuLEP and TURP were similar at 3 months,76,77,331-333 12 months,320,335,336 18 months,330 48 months,335 and 5-year follow-up.329 Prostate volume was reported in one study with significantly lower prostate volume post-procedure in the ThuLEP group (mean 11.7g) compared to TURP (mean: 18.3g);34 one study reported mean resected volumes of 51g in the ThuLEP group and 49g in the TURP group,31 and another study reported median resected volume of 7g in the ThuLEP group compared to 20g in the TURP group.33, Two studies reported IIEF scores were similar between the thulium laser and TURP groups at 18 months28 and 12 months.25 RE was reported in five studies with all reporting similar outcomes for the thulium laser and TURP groups.20-23,34 One study reported higher incidence of ED after TURP (44%) compared to ThuLEP (17%).32. Hiperplasia benigna de próstata. BJU Int 2003; Floratos DL, Lambertus LA, Rossi C et al: Long-term followup of randomized transurethral microwave thermotherapy versus transurethral prostatic resection study. Eur Urol 2014; Thomas JA, Tubaro A, Barber N et al: A multicenter randomized noninferiority trial comparing GreenLight-XPS laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: two-yr outcomes of the GOLIATH Study. Patients should be counseled on a slower improvement in symptoms if men are treated with 5-ARI alone. Place published: Arnhem, The Netherlands. 34. Urology 2018; [Epub ahead of print]. 0 = Delighted1 = Pleased2 = Mostly Satisfied3 = Mixed about equally satisfied and dissatisfied4 = Mostly Dissatisfied5 = Unhappy6 = Terrible. (Moderate Recommendation; Evidence Level: Grade B), Due to the chromophore of water and minimal tissue depth penetration with both holmium and thulium (0.4mm for holmium, 0.2 mm for thulium), these two lasers achieve rapid vaporization and coagulation of tissue without the disadvantage of deep tissue penetration. Mean baseline IPSS was 23 (range 18 to 27) and mean prostate volume was 51 mL (range 36 to 65 mL). This difference in activity leads to a reduction in serum levels of DHT by approximately 70% with finasteride, compared to approximately 95% with dutasteride.108 However, in the prostate, and specifically in BPH tissue, type II 5-AR is far more common than type I.102 Therefore, the reduction of DHT in prostate tissues relative to placebo is less pronounced and has been measured at approximately 80% (finasteride)110 and approximately 94% (dutasteride).111 The serum half-life of finasteride ranges from six to eight hours, whereas that of dutasteride is five weeks. J Urol 2014; Reynard JM, Yang Q, Donovan JL et al: The ICS-'BPH' Study: uroflowmetry, lower urinary tract symptoms and bladder outlet obstruction. The review team worked closely with the Panel to refine the scope, key questions, and inclusion/exclusion criteria. These two trials, the STEP trial published in 200613 and the CAMUS trial published in 2011,14 point to the of the lack of efficacy in the target population for this Guideline; however, it is noted that formal detailed review beyond these two publications was not conducted for this topic. For the medical management of BPH, the Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, the Cochrane Library, and the AHRQ databases to identify eligible studies published and indexed between January 2008 and April 2019. It is becoming widely accepted that the symptom we relate in many older males may not have an etiology in prostate enlargement. Given the increasing aging male population, the health burden of benign prostate disorders such as BPH, will be a major arena for research in the future. Qmax was significantly lower in participants allocated to PUL at all follow-up intervals. Urol Ann 2017; Kuntz RM, Ahyai S, Lehrich K et al: Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. Recommendations for follow-up after initiating medical therapy for bothersome LUTS/BPH remain undefined. Other post-surgical complications (e.g., urethral stricture, urge incontinence, urinary retention, UTI) were similar between groups. Urology 2014; Kumar S, Tiwari DP, Ganesamoni R et al: Prospective randomized placebo-controlled study to assess the safety and efficacy of silodosin in the management of acute urinary retention. Mean improvement in LUTS based on the IPSS through 12, 24, and 36 months was similar for RWT and TURP (quality of evidence was rated moderate for IPSS mean-change from baseline for RWT compared to TURP). Varkarakis I, Kyriakakis Z, Delis A et al: Long-term results of open transvesical prostatectomy from a contemporary series of patients. ICH GCP. 102. Urology 1999; Administration USFaD: 5-alpha reductase inhibitor information. Cooperative study of 13 participating institutions evaluating 3,885 patients. Palabras clave: hiperplasia prostática benigna; escala internacional de síntomas prostáticos, calidad de vida. 91. Colon Patologia Benigna April 2021 0. Reasons for reoperation were prostate tissue regrowth/insufficient removal, bladder neck contracture, and urethral stricture. Based on 6 studies reporting long-term follow-up comparing HoLEP to TURP, ranging from 12 to 92 months, mean changes in IPSS (approximately -19) between groups favored HoLEP, but they did not meet the MDD of 3 points (WMD: -1.3; 95%CI: -2.3, -0.3). Overheated irrigant can cause thermal injury to any tissue that is subsequently exposed to the fluid and thermal injuries to the bladder have been reported after endoscopic prostate surgery. Ther Adv Urol 2015; Xue B, Zang Y, Zhang Y et al: GreenLight HPS 120-W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a prospective randomized trial. The reduced risk of hyponatremia and TUR syndrome allows for longer resection times; therefore, bipolar TURP may be used in larger glands compared to monopolar TURP. Scand J Urol Nephrol 2005; Hahn RG, Fagerstrom, T., Tammela, T. L., Van Vierssen Trip, O., Beisland, H. O., Duggan, A. and Morrill, B.: Blood loss and postoperative complications associated with transurethral resection of the prostate after pretreatment with dutasteride. The primary outcome was prostate cancer-specific mortality (PCSM). BJU Int 2007; Sairam K, Kulinskaya E, McNicholas TA et al: Sildenafil influences lower urinary tract symptoms. 2016. It is the assessment of the Panel that much of these data are susceptible to bias. J Urol 1984; Gades NM, Jacobson DJ, McGree ME et al: Dropout in a longitudinal, cohort study of urologic disease in community men. BJU Int 2000; Kumar N, Vasudeva P, Kumar Aet al: Prospective randomized comparison of monopolar TURP, bipolar TURP and photoselective vaporization of the prostate in patients with benign prostatic obstruction: 36 months outcome. Elzayat E., Habib E, Elhilali M: Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders. Bookmark. Libido does not appear to be affected significantly by surgical therapy, and some studies have even shown an improvement in erectile function (EF) after surgical treatment ((this improvement is controversial as other studies show a worsening of EF).20 Most importantly, sexual side effects from surgical treatments are more likely to be permanent than those from medical treatments, which can often be reversed by stopping medical treatment or switching to an alternative treatment. Rating the quality of evidence. While other laser technologies can be utilized for laser ablation/vaporization of the prostate, the Panel concluded that these were either still investigational or had results that were not considered sufficient or safe to recommend them for routine use. Based on these examples, it is reasonable to select alpha blockers with equal efficacy based on expected adverse events. Uroflowmetry is a simple and risk-free, office-based procedure that can be an important adjunct in the evaluation of LUTS. The Greenlight laser has undergone several upgrades since its inception. BJU Int 2010; Karaman MI, Kaya C, Ozturk M et al: Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-yearfollow-up. Similar to other studies, the therapeutically anticoagulated group had a significantly longer length of hospital stay and duration of catheterization as compared to the controls. July 2021. Doses of solifenacin ranged from 5 to 9 mg and tamsulosin from 0.2 to 0.4 mg. Mean age was 63 years and baseline IPSS was 21 points, indicating severe LUTS. The mission of the panel was to develop recommendations that are analysis based or consensus-based, depending on panel processes and available data, for optimal clinical practices in the surgical treatment of benign prostatic hyperplasia. The steam travels through the transition zone, denaturing tissue and thereby ablating the adenoma to create an opening. Incidence of urinary retention did not differ between mirabegron 100 mg and placebo (2%). Reoperation was significantly higher with TUMT (9.9%) compared to TURP (2.3%). Male lower urinary tract dysfunction: evaluation and management. Voiding symptoms have often been attributed to the physical presence of BOO. Evidence regarding efficacy, symptom improvement, adverse events and urinary flow rates are inconsistent. These time intervals were chosen by the Panel prior to the literature search based on the available literature at that time. Landmark studies done in the 1990s showed that the risk of complications (e.g., bleeding, transfusion, hyponatremia, TURP syndrome, death) following monopolar TURP using sorbitol, mannitol, glycine, or a combination or mixture of such solutions, increase with increasing prostate size and increased duration of resection.234 These studies lead to recommended resection time limits of 60 or 90 minutes, and alternate therapies were employed for prostates that could not be adequately resected within that time frame. Br J Clin Pharmacol 1999; 47: 53. The I-PSS also assesses the degree of bother associated with the seven symptoms in the aforementioned symptom severity score with one additional QoL question: "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?" Prostate Cancer Prostatic Dis 2011; Chang D, Campbell J: Intraoperative floppy iris syndrome associated with tamsulosin. 80. Pareek G, Shevchuk M, Armenakas N et al: The effect of finasteride on the expression of vascular endothelial growth factor and microvessel density: a possible mechanism for decreased prostatic bleeding in treated patients. Conflicts between investigators on inclusion status were resolved through discussion or by a third investigator when necessary. There have been a number of new therapeutic options utilized for LUTS/BPH over the past few years. Despite the variability and limitations stated above, the Panel attempted to provide some evidence of retreatment rates for the majority of the modalities included in this Guideline. Develop preventive strategies aimed at underlying common pathophysiology of benign prostate disease. World J Urol 2007; 25: 627. What are the predictors of beneficial effects from treatments? J Endourol 2020; Jhanwar A, Sinha RJ, Bansal A et al: Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: A prospective randomized study. Br J Ophthamol 2007; 91: 40. Urology 2003; 62: 15. This low ROB trial had a follow-up of 12 weeks, was conducted in the US, and was industry funded. (Moderate Recommendation; Evidence Level: Grade B), Bipolar TUVP may be offered as an option to patients for the treatment of LUTS/BPH. While there are no data to indicate the threshold at which an elevated PVR becomes “dangerous,” a “large” PVR (>300 mL) is worth monitoring, at the very least. J Urol 2015; Rukstalis D, Grier D, Stroup SP: Prostatic Urethral Lift (PUL) for obstructive median lobes: 12 month results of the MedLift Study. Develop studies that assess disease "phenotypes" and lead to better disease definitions (e.g. Assim, - 717 36. Minerva Urol Nefrol 2017; Gilling P, Barber N, Bidair M et al: WATER: A double-blind, randomized, controlled trial of Aquablation vs transurethral resection of the prostate in benign prostatic hyperplasia. ED was reported in 65% of participants. These contractions may be spontaneous or provoked. Urology 2001; 58: 972. While a clinically useful test that may drive management choices, PVR does not seem to be a strong predictor of AUR.35, 7. Br J Urol 1998; Brown CT, Yap T, Cromwel DA et al: Self management for men with lower urinary tract symptoms: randomised controlled trial. BJU Int 2017; Albala DM, Fulmer BR, Turk TT et al: Office-based transurethral microwave thermotherapy using the TherMatrx TMx-2000. J Urol 2001; Norby B, Nielsen HV, Frimodt-Moller PC et al: Transurethral interstitial laser coagulation of the prostate and transurethral microwave thermotherapy vs transurethral resection or incision of the prostate: results of a randomized controlled study in patients with symptomatic benign prostatic hyperplasia. Although transient urethral catheterization with concomitant medical therapy using an alpha-adrenergic antagonist can be considered, it is unlikely that the latter will adequately ameliorate the obstructive process to sufficiently prevent further upper urinary tract deterioration. (Moderate Recommendation; Evidence Level: Grade B). Crea G, Sanfilippo G, Anastasi G et al: Pre-surgical finasteride therapy in patients treated endoscopically for benign prostatic hyperplasia. BJU Int 2018; [Epub ahead of print]. Pre-treatment transrectal ultrasound is used to map out the specific region of the prostate to be resected with a particular focus on limiting resection in the area of the vermontanum. Currently, there are few animal and human tissue models for LUTS/BPH. Finally, in contrast to minimally-invasive and newer surgical therapies, (including but not limited to WVTT and PUL), older clinical trials do not consistently report retreatment with medical therapy as an outcome. Semmens J, Wisniewski Z, Bass A et al: Trends in repeat prostatectomy after surgery for benign prostate disease: application of record linkage to healthcare outcomes. Note, additional studies published outside of search date ranges may have been included to inform background sections or provide historical context.

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