Paying the price for standing tall: Fluid mechanics of prostate pathology.

BACKGROUND: Age-dependent increase in the incidence of benign prostatic hyperplasia (BPH) and prostate cancer (PCa) are both related to cell proliferation and survival controlled by intraprostatic free testosterone (FT) concentration. Paradoxically, BPH and PCa occur as circulating testosterone levels decrease, so any possible relationship between testosterone levels and development of BPH and PCa remains obscure. RESULTS: In BPH the enlarging prostate is exposed to high testosterone levels arriving directly from the testes at concentrations about hundredfold higher than systemic FT. This occurs because venous blood from the testes is diverted into the prostate due to the elevated hydrostatic pressure of blood in the internal spermatic veins (ISVs). Elevated pressure is caused by the destruction of one-way valves (clinically detected as varicocele), a unique phenomenon related to human erect posture. While standing, human males are ISVs vertically oriented, resulting in high intraluminal hydrostatic pressures-a phenomenon not found in quadrupeds. In this communication, we demonstrate the fluid mechanics' phenomena at the basis of varicocele leading to prostate pathology. CONCLUSIONS: So far, varicocele has been studied mostly for its etiologic role in male infertility and, thus, for its effects on the testes. It is becoming clear that varicocele is a major etiologic factor in BPH and likely also in PCa. Restoring normal testicular venous pressure by treatment of the abnormal ISV's in varicocele has been shown to avert the flow from the prostate with the effect of reducing prostate volume, alleviating symptoms of BPH, and increasing concentrations of circulating FT.

[Interest of a systematic assessment of the treatment of the lower urinary tract symptoms in the management of benign prostatic hypertrophy in general practice (1380 patients) - Study EVALURO]. / Intérêt d'une évaluation systématique du traitement des symptômes du bas appareil urinaire dans la prise en charge d'une hypertrophie bénigne de la prostate en médecine générale (1380 patients) ­ Étude EVALURO.

OBJECTIVE: To evaluate the efficacy of a modification or initiation of treatment by a α-blocker in patients already medically treated for BPH-related LUTS, with persistent urinary symptoms. METHODS: This is a prospective observational study among general practitioners in France. Included patients were over 60 years of age with BPH-related LUTS who had been medically treated for at least 6 months. A treatment by an α-blocker was initiated or modified if the PGI-I (Patient Global Impression of Improvement) did not objective any improvement under treatment and the IPSS (International Prostate Symptom Score) was≥8. Patients were followed up between 1 and 3 months after inclusion. The primary endpoint was the frequency of unsatisfactory progression of patients, assessed by persistence of urinary symptoms under treatment (IPSS≥8 and PGI-I unchanged or worsened). Progress of LUTS (IPSS and PGI-I) following modification of treatment with α-blocker was also assessed at the follow-up visit. RESULTS: Three hundred and fifty-three physicians included 1449 patients between February 2, 2016 and March 9, 2017 (1380 patients were analyzed): the average age was 70.0±6.9 years ; the duration of the LUTS was 4.1±4.2 years; at inclusion, they received mainly plants (n=744; 53.9%) and α-blockers (n=463; 33.6%); the mean IPSS score was 16.4±6.7, it was not correlated with duration of SBAU; the mean PGi-I was 2.6±1.2. In total, 48.8% (612/1255) of patients had a non-satisfactory evaluation of the LUTS; 42.8% (591/1380) of patients had a modification of treatment according to the protocol: 385 (65.6%) had an initiation of a α-blocker, 202 (34.4%) had a modification of treatment by α-blocker (4 missing data). The α-blocker was monotherapy for 484 (81.9%) patients. At the follow-up visit (1 to 3 months), the average IPSS score was 7.7±4.8, significantly lower (18.7±6.1 at inclusion); the average PGI-I of 1.2±0.7 was significantly lower (3.5±0.8 at inclusion); the quality of life (Q8-IPSS) was significantly improved. For the 345 patients under plant extracts having changed for one α-blocker, as well as for the 67 patients under α-blocker having changed for another α-blocker, the 3 scores had decreased significantly. CONCLUSION: A systematic evaluation of medical treatment for BPH showed that 48.8% of patients medically treated for at least 6 months were not improved. A modification of treatment by an α-blocker (initiation or modification) can then significantly improve the LUTS.

Statistical analysis plan for the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM).

BACKGROUND: Current management for men with lower urinary tract symptoms (LUTS) is a pathway that results in prostate surgery in a significant proportion. While helpful in relieving benign prostatic obstruction (BPO), surgery may be ineffective for men suffering from difficulties not relating to BPO. The UPSTREAM trial started recruitment in October 2014 with the aim of establishing whether a care pathway including urodynamics (a diagnostic tool for BPO and thus an indication of whether surgery is needed) is no worse for men, in terms of symptomatic outcome, than one without (routine care). METHODS/DESIGN: This analysis plan outlines the main outcomes of the study and specific design choices, such as non-inferiority margins. The trial is currently recruiting in 26 hospitals across the UK, randomising men to either urodynamics or routine care, with recruitment set to end on the 31 December 2016. All outcomes will be measured 18 months after randomisation to allow sufficient time for surgical procedures and recovery. The primary outcome is based on a non-inferiority design with a margin of 1 point on the International Prostate Symptom Score (IPSS) scale. The key secondary outcome for this trial is surgery rate per arm, which is estimated to be at least 18% lower in the urodynamics arm. Surgery rates, adverse events, flow rate, urinary symptoms and sexual symptoms are secondary outcomes to be assessed for superiority. This is an update to the UPSTREAM protocol, which has already been published in this journal. DISCUSSION: This a priori statistical analysis plan aims to reduce reporting bias by allowing access to the trial's objectives and plans in advance of recruitment end. The results of the trial are expected to be published soon after the trial end date of 30 September 2018. TRIAL REGISTRATION: ISRCTN registry, ISRCTN56164274 . Registered on 8 April 2014.

A randomised controlled trial to determine the clinical and cost effectiveness of thulium laser transurethral vaporesection of the prostate (ThuVARP) versus transurethral resection of the prostate (TURP) in the National Health Service (NHS) - the UNBLOCS trial: a study protocol for a randomised controlled trial.

BACKGROUND: Transurethral resection of the prostate (TURP) has been the standard operation for benign prostatic obstruction (BPO) for 40 years, with approximately 25,000 procedures performed annually, and has remained largely unchanged. It is generally a successful operation, but has well-documented risks for the patient. Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a surgical technique similar to TURP. The small amount of study data currently available suggests that ThuVARP may have certain advantages over TURP, including reduced blood loss and shorter hospital stay, earlier return to normal activities, and shorter duration of catheterisation. DESIGN: A multicentre, pragmatic, randomised, controlled, parallel-group trial of ThuVARP versus standard TURP in men with BPO. Four hundred and ten men suitable for prostate surgery were randomised to receive either ThuVARP or TURP at four university teaching hospitals, and three district general hospitals. The key aim of the trial is to determine whether ThuVARP is equivalent to TURP judged on both the patient-reported International Prostate Symptom Score (IPSS) and the maximum urine flow rate (Qmax) at 12 months post-surgery. DISCUSSION: The general population has an increased life expectancy. As men get older their prostates enlarge, potentially causing BPO, which often requires surgery. Therefore, as the population ages, more prostate operations are needed to relieve obstruction. There is hence sustained interest in the condition and increasing need to find safer techniques than TURP. Various laser techniques have become available but none are widely used in the NHS because of lengthy training required for surgeons or inferior performance on clinical outcomes. Promising initial evidence from one RCT shows that ThuVARP has equivalent clinical effectiveness when compared to TURP, as well as other potential advantages. As ThuVARP uses a technique similar to that used in TURP, the learning curve is short, potentially making it also very quickly generalisable. This randomised study is designed to provide the high-quality evidence, in an NHS setting, with a range of patient-reported, clinical and cost-effectiveness outcomes, which will underpin and inform future NICE guidance. TRIAL REGISTRATION: ISRCTN registry, ISRCTN00788389 . Registered on 20 September 2013.

Preliminary assessment of neck circumference in benign prostatic hyperplasia in patients with metabolic syndrome

ABSTRACT Objectives To investigate the impact of neck circumference (NC) in the treatment of bening prostatic hyperplasia (BPH) patients with metabolic syndrome (MtS). Additionally, we determined dose response to alpha-blockers and cut-off values for NC and waist circumference (WC), in these patients. Materials and Methods Non-randomized, open-labelled, and multi-centre study was conducted between March 2014 and September 2015. The BPH patients were enrolled and were divided into 2 groups: with MtS (Group 1; n=94) and without MtS (Group 2; n=103). Demographic data, anthropometric measurements, blood analyses, uroflowmetric parameters, post voiding residual urine (PVR), prostate volume, quality of life (QoL) index, NC and WC were recorded. Both groups were administered oral alpha-blockers and response to treatment was evaluated. Receiver-operating characteristic (ROC) curves were obtained and significant p was p<0.05 . Results In total, 197 patients were enrolled with mean age of 60.5±8.1 years. Mean NC and WC were higher in MtS patients (p<0.001). Uroflowmetry parameters and QoL indexes were comparable between groups before treatment. International prostate symptom score, uroflowmetry parameters, and QoL significant improved in Group 2 than Group 1, at 1 st and 6 th months of treatment with alpha-blockers. Success rate of treatment was significant higher in Group 2 than Group 1 (p<0.001). Cut-off values were 42.5cm and 113.5cm for NC and WC respectively, for response to alpha-blockers in BPH patients with MtS. Conclusions MtS can be related with BPH and can negatively affect the response to alpha-blocker treatment. NC can be used for predicting response to alpha-blocker treatment in BPH patients with MtS.

Preliminary assessment of Neck Circumference in Benign Prostatic Hyperplasia in Patients with Metabolic Syndrome.

OBJECTIVES: To investigate the impact of neck circumference (NC) in the treatment of bening prostatic hyperplasia (BPH) patients with metabolic syndrome (MtS). Additionally, we determined dose response to alpha-blockers and cut-off values for NC and waist circumference (WC), in these patients. MATERIALS AND METHODS: Non-randomized, open-labelled, and multi-centre study was conducted between March 2014 and September 2015. The BPH patients were enrolled and were divided into 2 groups: with MtS (Group 1; n=94) and without MtS (Group 2; n=103). Demographic data, anthropometric measurements, blood analyses, uroflowmetric parameters, post voiding residual urine (PVR), prostate volume, quality of life (QoL) index, NC and WC were recorded. Both groups were administered oral alphablockers and response to treatment was evaluated. Receiver-operating characteristic (ROC) curves were obtained and significant p was p<0.05. RESULTS: In total, 197 patients were enrolled with mean age of 60.5±8.1 years. Mean NC and WC were higher in MtS patients (p<0.001). Uroflowmetry parameters and QoL indexes were comparable between groups before treatment. International prostate symptom score, uroflowmetry parameters, and QoL significant improved in Group 2 than Group 1, at 1st and 6th months of treatment with alpha-blockers. Success rate of treatment was significant higher in Group 2 than Group 1 (p<0.001). Cut-off values were 42.5cm and 113.5cm for NC and WC respectively, for response to alpha-blockers in BPH patients with MtS. CONCLUSIONS: MtS can be related with BPH and can negatively affect the response to alpha-blocker treatment. NC can be used for predicting response to alpha-blocker treatment in BPH patients with MtS.

Is multichannel urodynamic assessment necessary before considering a surgical treatment of BPH? Pros and cons.

PURPOSE: Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS. METHODS: The debate was presented with a "pro and con" structure. The "pro" side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The "con" side successively refuted the "pro" side arguments. RESULTS: The "pro" side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The "con" side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context. CONCLUSIONS: Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial.

BACKGROUND: Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. DESIGN: A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. DISCUSSION: The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. TRIAL REGISTRATION: Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Bladder function in obstructed men - does age matter?

AIM: The high prevalence of diseases and disabilities in the elderly will therefore impose major future challenges for governments, particularly in social security, health system and social care. METHODS: Nine hundred and seventy-one men, 40 years or older referred for low urinary tract symptoms (LUTS) evaluation who underwent full urodynamic investigation, were reviewed. Urodynamic parameters were obtained, such as Uroflowmetry, those of Filling Cystometry and those of pressure flow study (PFS). RESULTS: Mean age was of 66.1 years old. Most the patients included in the analysis were categorized as Schafer score 2-4. Correlation analysis of uroflowmetry parameters revealed statistically significant decrease in voided volume (p = 0.013), Qmax (p = 0.023) with aging. Cystometric parameters revealed significant age-related decrease in bladder capacity (p < 0.001) and bladder compliance (p = 0.004). PFS revealed significant decrease in voiding efficiency (p = 0.029), voided volume (p < 0.001), Qave (p = 0.008) and Qmax (p = 0.048) with progressing age. Age subgroup analyses showed significant differences in voiding efficiency (KW, p = 0.032), voided volume (KW, p < 0.001) and Qave (KW, p = 0.036). CONCLUSIONS: Age-related changes in voiding function might not be a result of impaired detrusor contractility or increased outflow obstruction, intrinsic causes must be suspected. Changes in the storage function of the bladder represent specific pathophysiological mechanisms influenced by aging.

Burden of male lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) - focus on the UK.

KEY MESSAGES: Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) can be bothersome and negatively impact on a patient's quality of life (QoL). As the prevalence of LUTS/BPH increases with age, the burden on the healthcare system and society may increase due to the ageing population. This review unifies literature on the burden of LUTS/BPH on patients and society, particularly in the UK. LUTS/BPH is associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning, and through its negative impact on QoL for patients and partners. LUTS/BPH is often underdiagnosed and undertreated. Men should be encouraged to seek medical advice for this condition and should not accept it as part of ageing, while clinicians should be more active in the identification and treatment of LUTS/BPH. To assess the burden of illness and unmet need arising from lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH) from an individual patient and societal perspective with a focus on the UK. Embase, PubMed, the World Health Organization, the Cochrane Database of Systematic Reviews and the York Centre for Reviews and Dissemination were searched to identify studies on the epidemiological, humanistic or economic burden of LUTS/BPH published in English between October 2001 and January 2013. Data were extracted and the quality of the studies was assessed for inclusion. UK data were reported; in the absence of UK data, European and USA data were provided. In all, 374 abstracts were identified, 104 full papers were assessed and 33 papers met the inclusion criteria and were included in the review. An additional paper was included in the review upon a revision in 2014. The papers show that LUTS are common in the UK, affecting ≈3% of men aged 45-49 years, rising to >30% in men aged ≥85 years. European and USA studies have reported the major impact of LUTS on quality of life of the patient and their partner. LUTS are associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning. While treatment costs in the UK are relatively low compared with other countries, the burden on health services is still substantial. LUTS associated with BPH is a highly impactful condition that is often undertreated. LUTS/BPH have a major impact on men, their families, health services and society. Men with LUTS secondary to BPH should not simply accept their symptoms as part of ageing, but should be encouraged to consult their physicians if they have bothersome symptoms.

Free uroflowmetry versus "Do-It-Yourself" uroflowmetry in the assessment of patients with lower urinary tract symptoms.

INTRODUCTION: We investigated the possibility that patients could carry out a urine flow assessment at home by themselves, in comfort, without expense and without the use of equipment. We compared this strategy of "Do-It-Yourself" (DIY) uroflowmetry with traditional, hospital uroflowmetry. MATERIALS AND METHODS: One hundred and twenty patients were enrolled. The patients underwent conventional, free uroflowmetry in hospital. Subsequently, the patients were asked to carry out the following procedure at home: urinate into a graduated container to quantify the total voided volume and determine the flow time by measuring the duration of miction with a stopwatch or simply with the second hand of a clock. This procedure had to be performed three times without preparation. RESULTS: Hundred patients completed the study. The mean age of the patients analysed was 64.12 years. Their free uroflowmetry values were as follows: the mean voiding time was 44.28 s, the mean voided volume was 290.92 ml, the mean Qmax was 15.17 ml/s, the mean Qmean was 7.87 ml/s, and the mean post-void residual volume was 78.44 ml. The mean Qmean measured by the "DIY-uroflowmetry" was 8.33 ml/s, which was not statistically significantly different (P = 0.12). Assuming that pathological hospital uroflowmetry values are equivalent to a DIY-Qmean ≤10 ml/s and that normal hospital values are equivalent to a DIY-Qmean >10 ml/s, the concordance was 100 %. CONCLUSIONS: Our proposed DIY evaluation of urine flow, together with the International Prostatic Symptom Score (IPSS), provides a good estimate of the results of free uroflowmetry, enabling unnecessary hospital investigations to be avoided.

[Results of treatment of patients with prostatic adenoma using silodosin based on an assessment of the phenotype of male sexuality].

The article presents the results of treatment of 40 patients with prostatic adenoma using silodosin (urorec) at a dose of 8 mg per day. Patients were divided into three groups according to the phenotype of male sexuality based on author's questionnaire. Evaluation of treatment results was performed after 24-week follow-up period. There was a high therapeutic effect of silodosin in all groups of patients with prostatic adenoma, but the greatest effect in terms of reduction of urination disorders and increases of maximum urinary flow rate was achieved in men with normo- and hyposexuality compared with hypersexual men. The development of ejaculation disorders during treatment with silodosin in patients with prostatic adenoma is less typical for the patients with hypersexual phenotype.

Establishing the clinical and economic benefits of adherence to 5-alpha reductase inhibitors in benign prostatic hyperplasia: an assessment of Medicare and Medicaid patients.

OBJECTIVE: The primary objective of this study was to evaluate the length of 5-alpha reductase inhibitor (5ARI) therapy on the likelihood of acute urinary retention (AUR) and prostate surgery in patients diagnosed with benign prostatic hyperplasia (BPH). Additionally, this study attempted to quantify the relationship between length of 5ARI therapy and monthly BPH-related medical costs. STUDY DESIGN: This study used MarketScan® claims data from January 1, 2003, to December 31, 2008. Male Medicare patients ≥ 65 years and Medicaid patients ≥ 50 years who received a diagnosis of BPH and at least one claim for a 5ARI during the study period were included. Cox proportional hazards models were used to evaluate the effect of length of therapy on AUR and surgery, whereas generalized linear models were used to assess the effect on costs. RESULTS: In 28,903 patients, every additional 30 days of 5ARI therapy reduced the likelihood of AUR and prostate surgery by 14 and 11%, respectively, while each 30-day increment of 5ARI therapy reduced BPH-related costs by 15%. CONCLUSION: For patients remaining on 5ARI therapy, significant clinical and economic benefits may be realized, including reductions in AUR and prostate surgery rates and reduced medical costs for these clinical events.

Uroflowmetric assessment of acute effects of sildenafil on the voiding of men with erectile dysfunction and symptomatic benign prostatic hyperplasia.

PURPOSE: To evaluate the acute effects of sildenafil (50 mg) on the micturation of men with erectile dysfunction (ED) and concomitant benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) using uroflowmetric parameters. MATERIALS AND METHODS: A total of 68 male patients randomized into two groups (36 treatment, 32 control groups) with International Prostate Symptom Score (IPSS) greater than 7 and International Index of Erectile Dysfunction-erectile function domain score lower than 26 were enrolled in the study. Patients in the treatment group received a single dose of 50 mg of oral sildenafil. Patients in the control group received no treatment. Prevoiding urine volumes determined ultrasonographically and voided urine volumes were also recorded. Statistical comparisons were made with the use of analysis of variance (ANOVA). RESULTS: Mean ages were similar between treatment and control groups (60.4 +/- 9.8 and 58.6 +/- 8.3 years, respectively, P = 0.430). In the treatment group the maximum and average flow rates increased significantly (Q (max) from 15.6 +/- 6.8 cc/s to 19.3 +/- 7.2 cc/s, P < 0.0001; Q (avg) from 7.3 +/- 3.0 cc/s to 9.1 +/- 3.0 cc/s, P < 0.0001) with sildenafil administration, while other parameters studied remained unchanged. CONCLUSION: Despite the limitations of variations of uroflowmetry, this study showed that sildenafil improves Q (max) and Q (avg) in patients suffering from ED with concomitant BPH-LUTS. Long-term studies are needed to evaluate the effects on IPSS, side effects, and drug interactions.

Positioning invasive versus noninvasive urodynamics in the assessment of bladder outlet obstruction.

PURPOSE OF REVIEW: To provide evidence of promising tests to noninvasively diagnose bladder outlet obstruction (BOO) in men with benign prostatic hyperplasia. RECENT FINDINGS: Pressure-flow studies are usually performed to prove BOO prior to prostatectomy. However, pressure-flow studies are invasive, expensive, time consuming, and potentially harmful to the patient due to unwarranted side-effects. In the last decade, attempts were made to diagnose BOO noninvasively. Ultrasound-derived measurements such as bladder or detrusor wall thickness or intravesical prostatic protrusion and urodynamic-derived measurements such as isovolumetric bladder pressure by the condom catheter or penile cuff tests show promising results. Likelihood ratios of all tests were calculated for this study and indicated a good ability to detect BOO. CONCLUSION: Noninvasive measurements of bladder/detrusor wall thickness, intravesical prostatic protrusion, or isovolumetric bladder pressure might replace invasive pressure-flow studies in the future if only information about BOO is needed. These tests are applicable for the majority of patients with lower urinary tract symptoms and suspected BOO. However, urodynamic investigations are still indicated in patients requiring detailed information about the bladder filling and voiding phases and to assess the precise cause of lower urinary tract symptoms.

Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement.

OBJECTIVES: To determine the clinical effectiveness and cost utility of procedures alternative to TURP (transurethral resection of the prostate) for benign prostatic enlargement (BPE) unresponsive to expectant, non-surgical treatments. DATA SOURCES: Electronic searches of 13 databases to identify relevant randomised controlled trials (RCTs). REVIEW METHODS: Two reviewers independently assessed study quality and extracted data. The International Prostate Symptom Score/American Urological Association (IPSS/AUA) symptom score was the primary outcome; others included quality of life, peak urine flow rate and adverse effects. Cost-effectiveness was assessed using a Markov model reflecting likely care pathways. RESULTS: 156 reports describing 88 RCTs were included. Most had fewer than 100 participants (range 12-234). TURP provided consistent, high-level, long-term symptomatic improvement. Minimally invasive procedures resulted in less marked improvement. Ablative procedures gave improvements equivalent to TURP. Holmium laser enucleation of the prostate (HoLEP) additionally resulted in greater improvement in flow rate. HoLEP is unique amongst the newer technologies in offering an advantage in urodynamic outcomes over TURP, although long-term follow-up data are lacking. Severe blood loss was more common following TURP. Rates of incontinence were similar across all interventions other than transurethral needle ablation (TUNA) and laser coagulation, for which lower rates were reported. Acute retention and reoperation were commoner with newer technologies, especially minimally invasive interventions. The economic model suggested that minimally invasive procedures were unlikely to be cost-effective compared with TURP. Transurethral vaporisation of the prostate (TUVP) was both less costly and less effective than TURP. HoLEP was estimated to be more cost-effective than a single TURP but less effective than a strategy involving repeat TURP if necessary. The base-case analysis suggested an 80% chance that TUVP, followed by HoLEP if required, would be cost-effective at a threshold of 20,000 pounds per quality-adjusted life-year. At a 50,000 pounds threshold, TUVP, followed by TURP as required, would be cost-effective, although considerable uncertainty surrounds this finding. The main limitations are the quantity and quality of the data available, in the context of multiple comparisons. CONCLUSIONS: In the absence of strong evidence in favour of newer methods, the standard--TURP--remains both clinically effective and cost-effective. There is a need for further research to establish (i) how many years of medical treatment are necessary to offset the cost of treatment with a minimally invasive or ablative intervention; (ii) more cost-effective alternatives to TURP; and (iii) strategies to improve outcomes after TURP.