madman
Super Moderator
Abstract
Introduction: The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.
Methods: A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α-blockers, 5α-reductase inhibitors, phosphodiesterase-5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re-treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.
Results: AEEP offers the greatest long-term improvement in maximum flow rate, IPSS, and prostate volume reduction, with the lowest re-treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.
Conclusion: Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long-term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.
1 | INTRODUCTION
The management of bothersome lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) consists of behavioral and dietary modifications, pharmacological therapy, and interventional approaches.1 Pharmacological treatment has traditionally been the mainstay of initial management for men with bothersome voiding LUTS once conservative measures have failed. Interventional or surgical treatment is typically recommended for men who have not responded to or are unable to take (due to contraindications, adverse events, or personal preference), pharmacological treatments. However, there is increasing evidence that long-term pharmacological treatment for BPO is associated with significant cognitive and psychiatric side effects (such as dementia and depression), and so men should be thoroughly counseled about these long-term risks prior to commencing treatment.2 In recent years, advances in technology have led to the development of several novel and minimally invasive interventional treatments for LUTS secondary to BPO, with the aim of reducing morbidity, complications, and length of hospitalization compared to the current standard of care—transurethral resection of the prostate (TURP). Each modality offers unique risk/benefit profiles and has led to increased treatment choices for patients. In view of potentially serious long-term consequences associated with the pharmacological treatment, men may prefer interventional treatment as an alternative to long-term pharmacological therapy. As a result, the urologist must be aware of the evidence for the efficacy, safety, and unique characteristics of each option so that patients can be optimally counseled based on their individual values and preferences. Treatments for BPO must demonstrate evidence of efficacy in different clinical scenarios, safety, reproducibility, and durability.3 We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist (Tables 1 and 2).
2 | PHARMACOTHERAPY (NOT INCLUDING PHYTOTHERAPY)
2.1 | α1-Antagonists
2.1.1 | Efficacy
2.1.2 | Special situations Acute Urinary Retention and Trial Without Catheter
------------*Acute Urinary Retention and Trial Without Catheter
2.1.3 | Adverse effects
2.2 | 5 α -reductase inhibitors (5-ARI)
2.2.1 | Efficacy
2.2.2 | Adverse effects
2.2.3 | Special attention
------------*Time to onset
------------*Hematuria and non-urological indications
2.3 | Combination therapy
2.3.1 | Efficacy
2.3.2 | Special attention
2.4 | Phosphodiesterase-5 inhibitors (PDE-5i)
2.4.1 | Efficacy
2.4.2 | Adverse effects
2.5 | Adherence and contributing factors
3 | MINIMALLY INVASIVE SURGICAL TREATMENTS (MIST)
3.1 | Prostatic urethral lift (PUL)
3.1.1 | Efficacy
3.1.2 | Periprocedural safety
3.1.3 | Functional outcomes
3.1.4 | Durability and long-term efficacy
3.1.5 | Special conditions
------------*Median lobe
------------*Prostate size
------------*Urinary retention
------------*Anticoagulants
3.2 | Convective radiofrequency water vapor thermal therapy (Rezum)
3.2.1 | Efficacy and durability
3.2.2 | Periprocedural safety
3.2.3 | Functional complications
3.2.4 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
3.3 | Temporary implantable Nitinol Device (TIND)
3.3.1 | Efficacy
3.3.2 | Periprocedural safety
3.3.3 | Functional complications
3.3.4 | Durability
3.3.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
3.4 | Prostate artery embolization (PAE)
3.4.1 | Efficacy
3.4.2 | Periprocedural safety
3.4.3 | Functional complications
3.4.4 | Durability
3.4.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
4 | SURGICAL TREATMENTS
4.1 | Transurethral resection of the prostate (TURP)
4.1.1 | Efficacy
4.1.2 | Periprocedural safety
4.1.3 | Functional complications
4.1.4 | Durability
4.1.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
4.2 | Aquablation
4.2.1 | Efficacy and durability
4.2.2 | Periprocedural safety
4.2.3 | Functional complications
4.2.4 | Special situations
------------*Median lobe
------------*Prostate size
------------*Anticoagulants
4.3 | Photoselective vaporization of the prostate (PVP)
4.3.1 | Efficacy
4.3.2 | Periprocedural safety
4.3.3 | Functional complications
4.3.4 | Durability
4.3.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
------------*Tissue for histopathological analysis
4.4 | Anatomical Endoscopic Enucleation of the Prostate (AEEP)
4.4.1 | Efficacy and durability
4.4.2 | Periprocedural safety
4.4.3 | Functional complications
4.4.4 | Special situations
------------*Median lobe
------------*Acute urinary retention
------------*Anticoagulants
6 | CONCLUSION
Over the last 10 years, several new treatments have been introduced to the market to treat voiding LUTS due to BPE causing BOO. These mainly consist of minimally invasive treatment trying to reduce the hospital stay and postoperative complications. To date, no treatment has withstood the test of time compared to TURP in terms of long-term efficacy, except HoLEP; nonetheless, it is important to counsel patients appropriately regarding all available treatment options as patients may favor reduced efficacy in association with reduced side effects.
Introduction: The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.
Methods: A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α-blockers, 5α-reductase inhibitors, phosphodiesterase-5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re-treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.
Results: AEEP offers the greatest long-term improvement in maximum flow rate, IPSS, and prostate volume reduction, with the lowest re-treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.
Conclusion: Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long-term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.
1 | INTRODUCTION
The management of bothersome lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) consists of behavioral and dietary modifications, pharmacological therapy, and interventional approaches.1 Pharmacological treatment has traditionally been the mainstay of initial management for men with bothersome voiding LUTS once conservative measures have failed. Interventional or surgical treatment is typically recommended for men who have not responded to or are unable to take (due to contraindications, adverse events, or personal preference), pharmacological treatments. However, there is increasing evidence that long-term pharmacological treatment for BPO is associated with significant cognitive and psychiatric side effects (such as dementia and depression), and so men should be thoroughly counseled about these long-term risks prior to commencing treatment.2 In recent years, advances in technology have led to the development of several novel and minimally invasive interventional treatments for LUTS secondary to BPO, with the aim of reducing morbidity, complications, and length of hospitalization compared to the current standard of care—transurethral resection of the prostate (TURP). Each modality offers unique risk/benefit profiles and has led to increased treatment choices for patients. In view of potentially serious long-term consequences associated with the pharmacological treatment, men may prefer interventional treatment as an alternative to long-term pharmacological therapy. As a result, the urologist must be aware of the evidence for the efficacy, safety, and unique characteristics of each option so that patients can be optimally counseled based on their individual values and preferences. Treatments for BPO must demonstrate evidence of efficacy in different clinical scenarios, safety, reproducibility, and durability.3 We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist (Tables 1 and 2).
2 | PHARMACOTHERAPY (NOT INCLUDING PHYTOTHERAPY)
2.1 | α1-Antagonists
2.1.1 | Efficacy
2.1.2 | Special situations Acute Urinary Retention and Trial Without Catheter
------------*Acute Urinary Retention and Trial Without Catheter
2.1.3 | Adverse effects
2.2 | 5 α -reductase inhibitors (5-ARI)
2.2.1 | Efficacy
2.2.2 | Adverse effects
2.2.3 | Special attention
------------*Time to onset
------------*Hematuria and non-urological indications
2.3 | Combination therapy
2.3.1 | Efficacy
2.3.2 | Special attention
2.4 | Phosphodiesterase-5 inhibitors (PDE-5i)
2.4.1 | Efficacy
2.4.2 | Adverse effects
2.5 | Adherence and contributing factors
3 | MINIMALLY INVASIVE SURGICAL TREATMENTS (MIST)
3.1 | Prostatic urethral lift (PUL)
3.1.1 | Efficacy
3.1.2 | Periprocedural safety
3.1.3 | Functional outcomes
3.1.4 | Durability and long-term efficacy
3.1.5 | Special conditions
------------*Median lobe
------------*Prostate size
------------*Urinary retention
------------*Anticoagulants
3.2 | Convective radiofrequency water vapor thermal therapy (Rezum)
3.2.1 | Efficacy and durability
3.2.2 | Periprocedural safety
3.2.3 | Functional complications
3.2.4 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
3.3 | Temporary implantable Nitinol Device (TIND)
3.3.1 | Efficacy
3.3.2 | Periprocedural safety
3.3.3 | Functional complications
3.3.4 | Durability
3.3.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
3.4 | Prostate artery embolization (PAE)
3.4.1 | Efficacy
3.4.2 | Periprocedural safety
3.4.3 | Functional complications
3.4.4 | Durability
3.4.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
4 | SURGICAL TREATMENTS
4.1 | Transurethral resection of the prostate (TURP)
4.1.1 | Efficacy
4.1.2 | Periprocedural safety
4.1.3 | Functional complications
4.1.4 | Durability
4.1.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
4.2 | Aquablation
4.2.1 | Efficacy and durability
4.2.2 | Periprocedural safety
4.2.3 | Functional complications
4.2.4 | Special situations
------------*Median lobe
------------*Prostate size
------------*Anticoagulants
4.3 | Photoselective vaporization of the prostate (PVP)
4.3.1 | Efficacy
4.3.2 | Periprocedural safety
4.3.3 | Functional complications
4.3.4 | Durability
4.3.5 | Special situations
------------*Enlarged median lobe
------------*Prostate size
------------*Acute urinary retention
------------*Anticoagulants
------------*Tissue for histopathological analysis
4.4 | Anatomical Endoscopic Enucleation of the Prostate (AEEP)
4.4.1 | Efficacy and durability
4.4.2 | Periprocedural safety
4.4.3 | Functional complications
4.4.4 | Special situations
------------*Median lobe
------------*Acute urinary retention
------------*Anticoagulants
6 | CONCLUSION
Over the last 10 years, several new treatments have been introduced to the market to treat voiding LUTS due to BPE causing BOO. These mainly consist of minimally invasive treatment trying to reduce the hospital stay and postoperative complications. To date, no treatment has withstood the test of time compared to TURP in terms of long-term efficacy, except HoLEP; nonetheless, it is important to counsel patients appropriately regarding all available treatment options as patients may favor reduced efficacy in association with reduced side effects.
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