BPH procedures and med use: Two sides of a coin

Dr. Kaplan, a member of the Urology Times Editorial Council, is professor of urology at the Icahn School of Medicine at Mount Sinai, New York.

When analyzing efficacy of minimally invasive/surgical therapies for lower urinary tract symptoms secondary to BPH, we appropriately focus on subjective criteria (eg, symptom improvement and sexual adverse events) and objective criteria (eg, changes in uroflow and post-void residual urine). While we discuss retreatment rates, we don’t measure failure of therapies by how many men restart LUTS/BPH medications. It’s an important question both in terms of economics and managing patient expectations.

Also see: Live demos of prostate procedure found safe

Gill et al shed light on medication discontinuation after either a minimally invasive surgical therapy (MIST) or surgical therapy for BPH/LUTS (see article here). Not surprisingly, the more tissue removed, the greater likelihood of discontinuing pre-procedure drugs. Gill et al analyzed BPH procedures between 2001 and 2016 and included men who underwent laser vaporization (n=2,549), electrosurgical transurethral resection (2,304), microwave or needle ablation (165), and open prostatectomy (132). At 3 months, 80.3% of MIST patients discontinued therapy versus 91.5% of laser vaporization and 98.6% of open prostatectomy patients.

Notwithstanding the differences in the number of patients in each group, this makes intuitive sense. The more tissue removed, the more likely patients will have initial success as manifested by discontinuing medications. That’s the good news. The other side of the coin is that the more tissue removed, the greater likelihood of ejaculation issues with open prostatectomy than with MIST. We convinced ourselves that this might not matter to patients. It does!

Next:"Why the high rate of restarting medications after BPH procedures?"Also, while the report is valuable in helping us discern medication discontinuation rates, it did not address how many patients go back on a LUTS/BPH drug months or years after the procedure. Numerous reports show that from 33% to 50% of men may go back on medication after a BPH procedure, including TURP.

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Why the high rate of restarting medications after BPH procedures? Potential factors include proper patient selection (ie, in individual men, is LUTS secondary to BPH and bladder outlet obstruction versus other non-medical factors?) and varied experiences of urologists with various procedures. Moreover, do newer forms of MIST, such as UroLift and Rezum, result in different post-procedure profiles? In addition, patients and urologists may have varied thresholds for stopping and/or restarting medications. Given the retrospective nature of the study, it’s hard to define treatment success and/or failure.

Finally, we should ask ourselves if long-term medical therapy for what is essentially a quality of life disorder is reasonable. Data are evolving about the potential role of long-term alpha-blocker and finasteride use in dementia. Should we be advocating medical therapy given the improvement of MIST and surgical therapies for BPH? Thought processes are evolving, and urologists need to take the lead as the recognized experts in managing LUTS secondary to BPH.