BPH: Current, forthcoming modalities show efficacy

R. Caleb Kovell, MDFour-year data on the prostatic urethral lift and data on an investigational water-jet ablation treatment were among BPH/LUTS highlights from this year’s meeting. The BPH/LUTS take-home messages were presented by R. Caleb Kovell, MD, of the University of Pennsylvania, Philadelphia.

Experience with holmium laser enucleation of the prostate (HoLEP) showed linear improvement in enucleation, AUA Symptom Score (AUA-SS) improvement of at least 50% across range of prostate volume, and greater improvement with larger glands.

Four-year follow-up of a trial of the prostatic urethral lift (UroLift, Neotract) in 206 men showed sustained improvement from baseline, including a 46% decrease in International Prostate Symptom Score (IPSS), no sustained erectile or ejaculatory dysfunction, and 19 repeat procedures.

Robot-assisted water-jet ablation (AquaBeam System, PROCEPT BioRobotics) required an average of 38 minutes in the operating room and decreased IPSS from 22.9 to 6.8 at 6 months and increased Qmax from 7.8 to 16.7 cc/sec at 1 year, with no retrograde ejaculation, urinary incontinence, or erectile dysfunction seen.

Ejaculation-sparing thulium laser ablation allowed 165 of 167 patients to leave the hospital without a catheter, led to sustained increase in Qmax, maintenance of ejaculatory function in 56%, and significant decreases in IPSS at 1 and 6 months.

A 10-year follow-up survey of 100 treated with HoLEP showed durable decline in AUA-SS from 21.9 to 5.1, 95% patient satisfaction, 3.5% need for ancillary surgical procedures, and mean PSA value of 1.57 ng/mL.

Continue to the next page for more take-home messages.

• A retrospective study of 434 men with large prostates (>100 cc) treated with 180W laser photovaporization showed a low complication rate until prostate volume exceeded 200 cc.

• A subset analysis of the GOLIATH trial comparing photoselective vaporization of the prostate (PVP) and bipolar transurethral resection of the prostate showed similar improvements in IPSS, IPSS-Quality of Life, Qmax, postvoid residual, prostate volume, and PSA. Better outcomes were seen in PVP patients with respect to mean catheterization time, time to stable health, and length of stay.

• A review of digital rectal exam for the evaluation of benign prostate pathology in 30,500 participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial found only marginal clinical utility.

• A subanalysis of REDUCE trial data showed that baseline PSA level predicted subsequent risk of developing lower urinary tract symptoms.

• A prospective ultrasound study showed that structural variation of the prostatic urethra within the prostate (ratio of prostatic urethral length to prostate volume) predicted severity of obstructive symptoms.

• A study of 20 men with LUTS showed that daily tadalafil (Cialis) improved penile endothelial function, IPSS, and penile brachial index.

Next: Study of comb. of an anticholinergic and an alpha-blocker in men with benign prostatic enlargement complicated by OAB

• A study of men with benign prostatic enlargement complicated by overactive bladder showed that the combination of an anticholinergic and an alpha-blocker led to significantly greater improvement in IPSS quality of life scores, OAB total symptoms, and OAB urge symptoms as compared with an alpha-blocker alone.

• An evaluation of 950 men who had prostate surgery for benign or malignant conditions showed a positive linear relationship between improvement in IPSS score post treatment and age. However, when considering percentage improvement, there was a negative linear relationship between percentage improvement change and age.

• Long-term follow-up (median, 50.9 months) after HoLEP enucleation showed that 89% of patients with detrusor underactivity were catheter free and maintained significant improvement in AUA-SS, Qmax, and postvoid residual volume, and 62.5% of patients with acontractility remained catheter free.

• A comparison of prostate tissue specimens after HoLEP showed that men receiving an antiandrogen had similar decreases in blood testosterone and dihydrotestosterone (DHT), adrenal androgen, and prostate DHT and testosterone, whereas men treated with 5-alpha-reductase inhibitors had decreased blood and prostate DHT and marked increases in testosterone and androstenedione.

• Estradiol [10-7M] directly modulated spontaneous smooth muscle contractility within the transition zone of the human prostate, indicating that estrogen may directly influence both the static and dynamic components of BPH.

• A group identified miRNAs that discriminated between the urodynamically defined states of bladder outlet obstruction (BOO)-induced lower urinary tract dysfunction with high sensitivity and specificity. These miRNAs have promising diagnostic performances in patients with urodynamically established BOO with and without detrusor overactivity or with detrusor underactivity and can be potentially used as a tool to evaluate disease progression.

More AUA 2016 take-homes:

Kidney Ca: Cytoreductive nephrectomy appears to be protective

Stone Disease: New AUA guide discusses SWL vs. URS

Infection/Inflammation: A new class of agents for IC shows promise

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