Clinical Conditions

Natural History

Medical treatment and new devices are the most news-worthy topics of publication in the management of benign prostatic diseases. Information on the natural history of the disease was provided by the PLESS (Proscar Long-Term Efficacy; Safety Study) trial. Progressive prostatic growth was documented in the placebo-treated group. Baseline serum PSA was a stronger predictor of prostate growth than age or initial volume. Men with an initial PSA greater than 2.0 ng/mL had a higher risk of subsequent prostate growth, which is a risk factor for subsequent urinary retention (Roehrborn et al., 2000.) A prospective study of men with urinary retention who were conservatively managed again showed that 55% of men voided spontaneously after an initial period of catheterization for 8 to 24 months (Kumar et al., 2000.) Men with larger prostates were less likely to be able to void after catheter removal.

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Medical Therapy

A literature review of direct comparative trials of medications suggested that alpha-blockers were more effective than finasteride at improving symptoms and increasing peak flow rate. Finasteride appeared more beneficial in patients with prostate volumes >50 cc (Zimmern, 2000.) A literature review of treatment with the phytotherapy, saw palmetto, was published by Gerber et al. (2000.) He reviewed the mechanism of action and clinical results for treatment of men with benign prostatic hypertrophy (BPH). He concluded that saw palmetto has a significant effect on urinary flow rates and symptom scores compared to placebo without recognized adverse effects or serum PSA. It has been assumed that medical treatment is providing relief for lower urinary tract symptoms (LUTS) which are caused by obstruction. The presence of obstruction is thought to be most accurately evaluated by pressure-flow studies. Sonke et al. (2000) evaluated the repeatability of pressure-flow studies and found that 42% of patients had significant differences from test to test on these studies. Another study evaluating the effects of alpha blockers on urodynamic parameters found that the majority of patients had no clear improvement in obstructive parameters during treatment, suggesting that alpha blockade improves symptoms but doesn't necessarily relieve obstruction (Rossi et al., 2001.) Since most patients are treated for symptoms, urodynamic improvement alone may not be critical to successful management. The side effects of the alpha blocker terazosin were reported by Lepor et al. (2000) who found that dizziness, asthenia, postural hypotension and syncope occurred for 19%, 6%, 6%, and 1% of treated patients, respectively. Interestingly, dizziness and asthenia were not associated with blood pressure changes, suggesting that these complications are not necessarily related to vascular events.

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Devices for BPH

A randomized prospective trial of contact laser prostatectomy versus visual laser coagulation suggested that relief of bladder outlet obstruction and peak flow rates were similar for both treatments (Bryan et al., 2000.) Better hemostasis was obtained with visual laser coagulation. A review of laser prostatectomy studies by Floratos et al. (2000) indicated that patients with obstruction demonstrated before the procedure on urodynamic studies predicted a better outcome. These authors supported the use of urodynamics prior to treatment. Transurethral microwave thermotherapy (TUMT) results were reported with five year followup in 71 patients (Daehlin et al., 2000.) Only 29 of the 71 had monotherapy with TUMT - all other patients required additional treatment or had intercurrent disease affecting voiding. Only a limited number of patients had long-term benefit. The mechanism of action is not well delineated. Brehmer et al. (2000) studied the sensory threshold in the posterior urethra after TUMT. They concluded that TUMT causes decreased posterior urethral sensitivity, and the decreased sensitivity may result in improved symptoms.

Use of a new prostatic urethral stent was reported by Traxer et al. (2000) in 17 men with urinary retention and contraindications to surgical intervention. The stents were placed under local anesthesia for most men and provided effective relief of retention. However, 3 patients had stent migration or pain and stents need to be changed every 1 to 6 months. The ability to remove UroLume endoprostheses was reported by Gajewski et al. (2000). Although there has been concern about how complicated removal of devices could be, devices were apparently easily removed after migration or misplacement. Only 2 serious complications (bleeding and urethral injury) occurred during removal, although most devices had to be removed in parts or wire-by-wire. No permanent disability nor malignancies were associated with use of this device in this study with brief followup.

An overview of randomized controlled trials of invasive and minimally invasive treatment modalities for LUTS was prepared by Tubaro et al. (2000.) They noted that retreatment was higher with minimally invasive therapies whereas open surgery and TURP had the lowest rates of requiring further intervention. The authors concluded that none of the minimally invasive treatments were superior to TURP from a cost/benefit standpoint, and that TURP was still the standard of effective treatment.