Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy.

OBJECTIVE: To evaluate the relationship between enlarged prostate, bulky median lobe (BML) or prior benign prostatic hyperplasia (BPH) surgery and perioperative functional, and oncological outcomes in high-risk (HR) prostate cancer (PCa) patients treated with Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). METHODS: 320 HR-PCa patients treated with RS-RARP between 2011 and 2020 at a single high-volume center. The relationship between prostate volume, BML, prior BPH surgery and perioperative outcomes, Clavien-Dindo (CD) grade ≥ 2 90-day postoperative complications, positive surgical margins (PSMs), and urinary continence (UC) recovery was evaluated respectively in multivariable linear, logistic and Cox regression models. Complications were collected according to the standardized methodology proposed by EAU guidelines. UC recovery was defined as the use of zero or one safety pad. RESULTS: Overall, 5.9% and 5.6% had respectively a BML or prior BPH surgery. Median PV was 45 g (range: 14-300). The rate of focal and non-focal PSMs was 8.4% and 17.8%. 53% and 10.9% patients had immediate UC recovery and CD ≥ 2. The 1- and 2-yr UC recovery was 84 and 85%. PV (p = 0.03) and prior BPH surgery (p = 0.02) was associated with longer operative time. BML was independent predictor of time to bladder catheter removal (p = 0.001). PV was independent predictor of PSMs (OR: 1.02; p = 0.009). Prior BPH surgery was associated with lower UC recovery (HR: 0.5; p = 0.03). CONCLUSION: HR-PCa patients with enlarged prostate have higher risk of PSMs, while patients with prior BPH surgery have suboptimal UC recovery. These findings should help physicians for accurate preoperative counseling and to improve surgical planning in case of HR-PCa patients with challenging features.

Comparison of holmium laser enucleation and transurethral resection of prostate in benign prostatic hyperplasia: a systematic review and meta-analysis.

Transurethral resection of the prostate (TURP) is the gold-standard classical method for the treatment of benign prostatic hyperplasia (BPH). In minimally invasive surgery, holmium laser enucleation of the prostate (HoLEP) is considered an alternative option. In this systematic review and meta-analysis, we aimed to comprehensively evaluate the advantages and disadvantages of TURP and HoLEP the treating BPH. We comprehensively searched PubMed, Cochrane Library, EMBASE, and Web of Science databases for all randomized controlled trials published before 1 December 2022 comparing HoLEP and TURP. The study protocol is registered on INPLASY (DOI: 10.37766/inplasy2023.5.0065). Compared with TURP, HoLEP required longer operation time but shorter catheter duration, hospital stay, and bladder irrigation time, as well as less postoperative irrigation. With HoLEP, maximum urinary flow rate at 12 and 24 months after surgery; post-void residual volume at 1, 6, and 12 months; and International Prostate Symptom Score at 12 months after surgery were superior to those with TURP. HoLEP was associated with significantly lower risk of hyponatremia, blood transfusion, and urethral stricture but greater risk of postoperative dysuria. Compared with TURP, HoLEP had better curative efficacy at 6, 12, and 24 months after operation and lower incidence of adverse events in patients with BPH.

In-hospital cost analysis of aquablation compared with transurethral resection of the prostate in the treatment of benign prostatic enlargement.

PURPOSE: To compare in-hospital treatment costs of aquablation and transurethral resection of the prostate (TURP) in the treatment of benign prostatic enlargement. PATIENTS AND METHODS: Patient data and procedural details were derived from a prospective database. In-hospital costs were calculated using detailed expenditure reports provided by the hospital accounts department. Total costs including those arising from surgical procedures, consumables, personnel and accommodation were analysed for 24 consecutive patients undergoing aquablation and compared with 24 patients undergoing TURP during the same period. Mean total costs and mean costs for individual expense items were compared between treatment groups with t-tests. RESULTS: Mean total costs per patient (± standard deviation) were higher for aquablation at EUR 10,994 ± 2478 than for TURP at EUR 7445 ± 2354. The mean difference of EUR 3549 was statistically significant (p <0.001). Although the mean procedural costs were significantly higher for aquablation (mean difference EUR 3032; p <0.001), costs apart from the procedure were also lower for TURP, but the mean difference of EUR 1627 was not significant (p <0.327). Medical supplies were mainly responsible (mean difference EUR 2057; p <0.001) for the difference in procedural costs. CONCLUSIONS: In-hospital costs are significantly higher for aquablation than for TURP, mainly due to higher costs of medical supplies for the procedure. This difference should be taken into consideration, at least in patients for whom the different side effect profiles of both treatments are irrelevant.

Permanent interstitial brachytherapy for prostate cancer implementing neoadjuvant prostatic artery embolization.

PURPOSE: Indication for permanent interstitial brachytherapy (PIB) can be limited by prostate volume, commonly decreased using neoadjuvant hormonal therapy. Volume changes and initial clinical results focusing on patients treated with prostatic artery embolization (PAE) were evaluated in this study. METHODS AND MATERIALS: A group of 102 consecutive patients were treated with permanent interstitial brachytherapy (PIB), 13 patients received a neoadjuvant PAE (median 12 weeks before PIB) in case of large prostate volume >60 cm³, and moderate to severe urinary problems. RESULTS: Patients after PAE were treated with significantly larger prostate volumes (52 ± 11 cm³ vs. 39 ± 11 cm³; p < 0.01; 66 ± 17 cm³ before PAE), but larger volume reductions to 44 ± 10 cm³ versus 35 ± 10 cm³ was found at day 30 (p < 0.05). International Prostate Symptom Score (IPSS) decreased significantly from 13 ± 5 before PAE to 7 ± 4 after PAE; p < 0.01. Initial PSA and first PSA after PIB were similar for patients with versus without PAE (5.9 ± 2.9 ng/mL vs. 6.2 ± 2.8 ng/mL and 1.5 ± 0.8 ng/mL vs. 1.9 ± 1.5 ng/mL). However, PSA 12 months after PIB was significantly lower after PAE (0.4 ± 0.3 ng/mL vs. 0.8 ± 0.6 ng/mL; p = 0.03). Four patients without prior PAE needed an intervention after urinary retention - transurethral resection of the prostate (TURP) in three cases and PAE in a single case. Urinary incontinence resulted in two cases after TURP. CONCLUSIONS: PAE could be successfully applied to decrease prostate volume and reduce urinary symptoms before PIB or as a treatment for urinary retention after PIB. A significantly lower PSA is promising for improved long-term cancer control.

Benign prostate hyperplasia: a review of the year's progress from bench to clinic.

PURPOSE OF REVIEW: Therapeutic tools for classic benign prostate hyperplasia (BPH) have focused on the dynamic component of obstruction and/or elimination of the static component via surgical or pharmaceutical therapies. Unfortunately, an exact cause for this disease process has not been identified, but additional insight has been achieved. This article presents an update of the BPH literature with a special focus on basic science or translational studies concerned with the cause of clinically significant BPH with lower urinary tract symptoms (LUTS). RECENT FINDINGS: Investigators are exploring connections between BPH with clinically significant LUTS, the metabolic syndrome, inflammation, alterations in cell signaling, and genetics which in turn has provided additional information concerning the pathogenesis, medical therapies as well as surgical therapies. SUMMARY: BPH is a chronic, progressive disease with important care implications and financial risks to the healthcare system. Continued improvements in length of life will demand that we unlock the cause of LUTS secondary to BPH with the goal of prevention as the ideal therapy. Studies reported in the last year contributed to our understanding of the disease process and provide insight for additional studies.

[Influence of blood pressure lowering treatment on IPSS, Qmax in old and middle-aged male patients with essential hypertension].

OBJECTIVE: To explore the influence of blood pressure lowering treatment on the International Prostate Syndrome Score (IPSS) and maximum flow rate (Qmax) in old and middle-aged male patients with essential hypertension. METHODS: We enrolled 193 hypertensive male patients aged 50-75 years from the rural area of Anqing, Anhui, treated them with Amlodipine for 4 weeks, and then analyzed the correlation of their baseline blood pressure and reduced blood pressure with the changes of IPSS and Qmax. RESULTS: After 4 weeks of medication, the systolic blood pressure (SBP) and diastolic blood pressure (DBP) of the subjects dropped by 16.8 +/- 16.7 and 8.1 +/- 7.7 mmHg respectively (P < 0.01), IPSS decreased by 2.5 +/- 5.5 points (P < 0.01) and Qmax increased by 0.2 +/- 4.7 ml/s (P = 0.46). Changes of Qmax were not significantly correlated with either the baseline or decreased blood pressure, while changes of IPSS had a significant linear correlation with the former but not with the latter. CONCLUSION: Lowering blood pressure in old and middle-aged male patients with essential hypertension can prevent or alleviate the subjective symptoms of benign prostatic hyperplasia, and it reduces IPSS more significantly in those with higher baseline blood pressure.

On the prevention and therapy of prostate cancer by androgen administration.

It has been widely suggested that elevated androgen levels may be critically involved in the genesis of prostate cancer. Despite the dependency of the normal prostate and of most prostatic cancers upon androgens and the fact that tumors can be produced in some rodent models by androgen administration, I will argue that, contrary to prevalent opinion, declining rather than high levels of androgens probably contribute more to human prostate carcinogenesis and that androgen supplementation would probably lower the incidence of the disease. I will also consider the possibility that the growth of androgen-independent prostate cancers might be reduced by the administration of androgens.

Morbidity and mortality after surgery for lower urinary tract symptoms: a study of 95 577 cases from a nationwide German health insurance database.

BACKGROUND: Little real-world data is available on the comparison of different methods in surgery for lower urinary tract symptoms due to benign prostatic obstruction in terms of complications. The objective was to evaluate the proportions of TURP, open prostatectomy (OP) and laser-based surgical approaches over time and to analyse the effect of approach on complication rates. METHODS: Using data of the German local healthcare funds (Allgemeine Ortskrankenkassen (AOK)), we identified 95 577 cases with a primary diagnosis of hyperplasia of prostate who received TURP, laser vaporisation (LVP), laser enucleation (LEP) of the prostate or OP between 2008 and 2013. Univariable logistic regression was used to analyse proportions of surgical approach over time, and the effect of surgical method on outcomes was analysed by means of multivariable logistic regression. RESULTS: The proportion of TURP decreased from 83.4% in 2008 to 78.7% in 2013 (P<0.001). Relative to TURP and adjusting for age, co-morbidities, AOK hospital volume, year of surgery and antithrombotic medication, OP had increased mortality (odds ratio (OR) 1.47, P<0.05), transfusions (OR 5.20, P<0.001) and adverse events (OR 2.17, P<0.001), and lower re-interventions for bleeding (OR 0.75, P<0.001) and long-term re-interventions (OR 0.55, P<0.001). LVP carried a lower risk of transfusions (OR 0.57, P<0.001) and re-interventions for bleeding (OR 0.76, P<0.001), but a higher risk of long-term re-interventions (OR 1.43, P<0.001). LEP had increased re-interventions for bleeding (OR 1.35, P<0.01). Complications were also dependent on age and co-morbidity. Limitations include the lack of clinical information and functional results. CONCLUSIONS: OP has the greatest risks of complication despite a low re-intervention rate. LVP demonstrated favourable results for transfusion and bleeding, but increased long-term re-interventions compared with TURP, while LEP showed increased re-interventions for bleeding. Findings support a careful indication and choice of method for surgery for LUTS, taking age and co-morbidities into account.

Lifestyle changes to prevent BPH: heart healthy = prostate healthy.

Benign prostatic hyperplasia (BPH) is one of the most prevalent conditions found in men, and increases with age. Drug, surgical, and phytotherapy tend to dominate the medical literature when discussing potential treatments for this condition. These treatments have demonstrated remarkable effectiveness for the various degrees of BPH. However, the potential for lifestyle changes to actually prevent this disease or reduce the severity of this condition when used as an adjunct to conventional treatment is not only intriguing but is strongly supported by past limited studies. More research is needed, but the time is ripe to discuss with patients the potential lifestyle changes that could influence risk. Obesity, a lack of physical activity, dyslipidemia, diabetes, hypertension, a heart unhealthy diet, and other factors may significantly increase the risk of BPH. Patients should be told that factors that increase the risk of cardiovascular disease seem to be associated with an increased risk of BPH or a greater severity of BPH.

Associations between diabetes and clinical markers of benign prostatic hyperplasia among community-dwelling Black and White men.

OBJECTIVE: The aim of this study was to examine associations between diabetes and clinical markers of benign prostatic hyperplasia (BPH) in community-dwelling white and black men aged 40-79 years. RESEARCH DESIGN AND METHODS: Data from the Olmsted County Study of Urinary Symptoms and Health Status and the Flint Men's Health Study were combined for a total study sample of 2,484 men. Severity of lower urinary tract symptoms (LUTS), peak urinary flow rates, prostate volume, and serum prostate-specific antigen (PSA) levels were examined by self-reported physician-diagnosed diabetes. RESULTS: Overall, 170 men (6.8%) reported a history of diabetes. Increased irritative LUTS and specifically nocturia were positively associated with diabetes. These patterns were consistent across race and persisted after adjustment for age, BMI, and various indicators of socioeconomic status. Furthermore, the relationship between irritative LUTS and diabetes was greater in black men. No significant associations were observed between diabetes and prostate volume, PSA level, and peak urinary flow rate. CONCLUSIONS: Our multiethnic community-based study demonstrates positive associations between diabetes and irritative LUTS and nocturia. Moreover, the association between irritative LUTS and diabetes is increased in black men. There was no strong evidence for an association between diabetes and BPH across measures more specific to BPH (i.e., prostate volume, PSA, and peak urinary flow rate). Taken together, our findings suggest that the presence of diabetes may be less related to prostate growth and more related to the dynamic components of lower urinary tract function. Further evaluations of the association between diabetes and BPH and related racial variations are warranted.

[Current drug therapy of benign prostatic hyperplasia]. / Aktuelle medikamentöse Therapie der benignen Prostatahyperplasie.

Almost 60% of elderly men suffer from symptoms of BPH, which have significant impact on their daily lives. Transurethral resection of the prostate (TURP) is currently the most effective therapy for relieve of obstruction and obstructive symptoms. Morbidity of TURP and disappointing results in patients with mild or moderate symptoms make surgery not suitable for all patients. 2 groups of drugs were currently developed, and showed efficacy in double-blinded placebo-controlled studies: alpha-blocking agents and 5 alpha-reductase inhibitors. Inhibition of alpha-adrenoreceptors significantly increases urinary flow rates and improves symptoms of BPH. Long-acting drugs, who selectively block alpha 1-adrenoreceptors (terazosin, doxazosin, tamsulosin) have the advantage, when compared with non-selective-alpha-blockers, that they have generally less adrenergic side effects. After intake alpha-adrenorceptor antagonists develop almost immediate action. 5 alpha-reductase inhibitors (finasteride) reduce prostatic size by 27%, they increase urinary flow rates and improve prostatic symptom scores, whilst adverse effects are extremely low. Full medical action is after 4 to 6 weeks. Both, alpha-Blockers and 5 alpha-reductase inhibitors need permanent administration for maintenance of action. Yet, synergistic effects, using their different modes of action have not been demonstrated after application of both drugs. Herbal products have not proved efficacious inspite of singular surprising results in clinical trials, their efficacy to treat BPH related symptoms was classified as placebo alike. Prior to therapy urological diagnosis and exclusion of prostate cancer is mandatory. Pharmacotherapy with alpha 1-adrenoreceptor antagonists and 5 alpha-reductase inhibitors have a place in the management of BPH patients with mild to moderate disease, who are bothered by their symptoms, or for those awaiting or wishing to delay surgery.