BPH/LUTS: AUA guideline recommends assessing prostate size, shape

The AUA 2018 take-home messages for BPH/LUTS also encompassed multiple treatment approaches for BPH as well as combination therapies for LUTS. The take-homes were presented by Harris E. Foster, Jr., MD, of Yale University School of Medicine, New Haven, CT.

• New AUA guidelines on lower urinary tract symptoms (LUTS) associated with BPH were presented, and the focus is on surgical and newer, minimally invasive treatments. Also addressed were recommendations for evaluation and preoperative testing, the most significant of which is a suggestion that assessment of prostate size and shape be considered by using a variety of techniques, including ultrasound, cystoscopy, or pre-existing, cross-sectional imaging. Some of the new treatments are limited by prostate size and/or anatomy, in particular, the presence of an obstructing middle lobe.
• Increased free T4 appears to be related to the development of LUTS.
• Men with Peyronie’s disease have a higher rate of LUTS, and a disorder in myofibroblast could explain this association.
• Researchers found only a weak association between obesity and LUTS/overactive bladder.
• Metabolic syndrome and smoking were associated with a higher risk of nocturia in patients undergoing TURP in one study, and another group examining metabolic syndrome also found an increased prevalence of BPH, specifically related to decreased HDL.
• In a study of prostate specimens from radical prostatectomies, local atherosclerosis was associated with increased prostate size.
• A rat model of prostatic inflammation caused bladder overactivity and regulation of growth factors, which may provide some insight into the storage symptoms of LUTS.
• In a study of inflammation in stroma versus non-stroma from human prostate, inflammation found in the stroma was associated with increased severity in LUTS and bladder outlet obstruction.
• A finding that non-adrenergic smooth muscle contraction is mediated by endothelium and thromboxane may explain the limited efficacy of alpha-blockers.
• Researchers noted an androgenic to estrogenic milieu change in obesity that altered the 5-alpha-reductase inhibitor, which may affect response to this therapy.
• A large cohort of men with LUTS/BPH who are untreated may be interested in self-directed care. These men tend to have longer term symptoms that are moderate or severe.
• Tissue-eliminating transurethral prostate procedures achieved superior rates of medication discontinuation compared with tissue-necrosing procedures.
• The combination of anticholinergic and alpha-blocker therapy for LUTS had clinical effects similar to that of alpha-blocker therapy, and there was no increased risk of retention with combination therapy.
• Combination behavioral and drug therapy for LUTS in men resulted in lower urinary frequency.
• Metformin improved IPSS scores in men with LUTS and metabolic syndrome.
• The combination of tamsulosin (Flomax) and tadalafil (Cialis) provided improved LUTS and erectile function versus tamsulosin alone and led to no significant increase in adverse events.
• Three-fourths of men with LUTS have some form of urinary incontinence, predominantly post-void dribbling, but also have increased bowel and psychological symptoms.
• In older men, higher lean body mass and muscle strength are associated with lower prevalence of incontinence, but changes in BMI and muscle strength did not change incontinence prevalence.
• In a study of postoperative urinary retention, catheter-dependent men who had failed prior surgery and were told they were no longer surgical candidates underwent urodynamics. Most had detrusor underactivity, and 88% were catheter free after repeat surgery.
• Among patients with detrusor underactivity and retention prior to photoselective vaporization of the prostate (PVP), most voided postoperatively despite the diagnosis of detrusor underactivity.
• Post-op urinary retention after joint replacement was higher after knee than hip replacements.
• Predictors of success of the prostatic urethral lift (UroLift) at 5 years were total IPSS, weak stream, and incomplete emptying.
• Water vapor therapy using the Rezum system showed modest improvement in symptoms and flow rate in a large series, and 90% of patients stopped all their BPH medications. A high UTI rate was noted.
• In patients undergoing TURP, increased surgical duration was associated with an increased complication rate.
• In studies of robotic, high-velocity waterjet prostate resection (Aquablation): Waterjet resection showed noninferior symptom relief versus TURP in men with moderate to severe symptoms, but the rate of retrograde ejaculation was three times higher in the TURP group. Complication rates were lower with waterjet resection versus TURP in men with large prostates and moderate to severe LUTS. Waterjet resection showed a significantly decreased reduction in IPSS in a specific group of patients with large prostates and low flow rates.
• In studies of Holmium laser enucleation of the prostate (HoLEP): Patients undergoing HoLEP who were taking antithrombotics had higher risk of bleeding complications, particularly with double and triple therapy. Another group had no transfusions with HoLEP at 18 years, and only 1.4% of patients needed a redo procedure. In small prostates, HoLEP performed just as well as TURP with better reduction in PVR, but it took longer. Almost two-thirds of HoLEP patients can be discharged on the same day.
• In studies of PVP: Obesity did not affect outcomes of 180W PVP (Greenlight XPS-180W) procedures, but operative times were significantly longer. Predictive factors for incontinence after PVP mainly revolved around large prostate size. And then there was discussion about specific procedures to spare ejaculation after TURP and other types of ablative procedures. Twelve-year experience with resecting the middle lobe only showed an ejaculatory dysfunction rate of only 2.8%. Antegrade ejaculation was preserved at 90% using an ejaculation-preserving PVP.