Treating a man with benign prostatic disease requires complex decision-making

In the “good old days,” it was simple: An older man complaining of nocturia got his prostate resected. We have come a long way since then and are more aware of patient-centered outcomes, validated symptom scores, and objective parameters. The guidelines have evolved from benign prostatic hyperplasia (BPH) to male lower urinary tract symptoms (LUTS) due to BPH and not yet to the male LUTS due to benign prostatic obstruction (BPO).

The interview in this issue with Alexis E. Te, MD, a recognized expert in the field, reflects the complex decision-making now required when a man presents with LUTS.

An older man presenting with LUTS may have higher odds of having BPO, but older age also increases the incidence of bladder dysfunction, volume-induced nocturia, and metabolic health conditions affecting the urinary system. With younger individuals (<40 years), outlet obstruction is less likely but “prostatitis” is even less likely—but is most commonly diagnosed. Underactive bladder, pelvic floor dysfunction, and bladder neck obstructions should be on the forefront of the thought process.

Although the International Prostate Symptom Score (IPSS) should be a standard, the need for a physical exam is emphasized in the latest guidelines. The rectal exam, in addition to the prostate, can assess the regional neuro status and pelvic muscle behavior. Prostate-specific antigen screening has become the substitute for exam for some clinicians but is not supported by the guidelines.

Medical therapy has undergone significant advances to consider drugs for outlet obstruction (α-blockers), reducing size and preventing retention (5α-reductase inhibitors), treating overactive bladder (OAB) symptoms with anticholinergics (with or without concomitant α-blockers). The use of phosphodiesterase 5 inhibitors have labeling indications for tadalafil (Cialis), but daily dosing is cost prohibitive if not covered by insurance. The biggest challenge is continued use of meds after a procedure for the prostate. Whether that should be considered a treatment failure is an unresolved question. Although use of anticholinergics for persistent OAB symptoms after treatment can be justified, the use of α-blockers is not.

Among the myriad treatment options, the terminology of minimally invasive therapy (MIT) is abused to the point that Dr Te refers to robotic surgery as a “maximally invasive minimally invasive” procedure to substitute for open simple prostatectomy. The goal of MIT has always been office-based treatment under local anesthesia, which was realized with microwave and radiofrequency therapy, but the fact that they are no longer done is a saga for another day!

Objective outcomes failure and retreatment rate are what caused their demise. In the American Urological Association’s 2020 amendment to its Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia guideline,1 the authors wrote, “Guideline 6 is a new guideline recommending that patients be counseled as to the potential risks of treatment failure and need for additional therapies.…First, rates of treatment failure and retreatment are influenced by both the duration and the completeness of follow-up.…Second, the risks of objective (eg, urinary retention, reduction of flow rate, increasing residual urine, infection) and subjective failure (eg, worsening of IPSS and/or quality of life) increase with longer duration of follow-up. Third, retreatment may take the form of medical therapy, a minimally invasive intervention, or a surgical procedure. Fourth, thresholds for and types of retreatment may vary substantially by provider, patient, category of failure (ie, objective, subjective, or both), and initial treatment modality.”

Retreatment is the new buzz word and is very controversial, as parameters keep changing. Perhaps the newly formed Society of Benign Prostatic Disease can define this better. Quality of life immediately after treatment and catheter duration affects patients a lot more and is not reflected in 3-, 6-, and 12-month follow-up data.

The other nuance to maneuver around is in patients at higher risk of bleeding, such as those on antiplatelet/anticoagulation drugs. (For additional information on the use of anticoagulation and antiplatelet therapy in surgical patients, please refer to the “Anticoagulation and Antiplatelet Therapy in Urologic Practice: ICUD and AUA Review Paper.”²)

The bias of the surgeon and their level on the learning curve for a new treatment are known only to the surgeon. Thus, quoting results of an expert trial as expected outcomes may not be realized by the patient in practice.

References

1. Parsons JK, Dahm P, Köhler TS, Lerner LB, Wilt TJ. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline amendment 2020. J Urol. 2020;204(4):799-804. doi:10.1097/JU.0000000000001298

2. Culkin DJ, Exaire EJ, Green D, et al. Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper. J Urol. 2014;192(4):1026-1034. doi:10.1016/j.juro.2014.04.103