Voiding urethrocystoscopy: A new concept for benign prostatic obstruction characterization.

AIM: To assess the feasibility of voiding urethrocystoscopy (VUC) in males and describe the characteristics of dynamic movements of the prostatic lobes during micturition. MATERIAL AND METHODS: Patients scheduled for benign prostatic obstruction relief in a tertiary reference center were included in this prospective evaluation. During urethrocystoscopy with a small diameter flexible endoscope, the bladder was filled until desire to void. The patient was asked to void with endoscope in place facing the veru montanum. Movements of the prostatic lobes during micturition were characterized, video-recorded, and categorized based on the dynamics of the lateral lobes, the posterior lobe and the bladder neck. RESULTS: In all, 192 evaluations were conducted. In 161 cases (84%), the patient was able to void. Among these patients, 126 cases were stated as "closed" (coalescent), without opening of the initial part of the urethra and the bladder neck. In 38 cases, there was no opening of the lateral lobes (type 1A), and in 47 cases a partial opening of the distal parts of the lateral lobes was seen (type 1B). In 31 cases, a fixed posterior bladder neck was seen (type 2A) and in 10 cases a mobile median lobe, with a rolling ball effect, was seen (type 2B). In 25 cases, the lumen was completely open and equivocal in 10 cases. CONCLUSIONS: This study demonstrates the feasibility of VUC and describes for the first time the dynamics of prostatic lobes during micturition. This evaluation may lead to a new approach for understanding the mechanical aspects of benign prostatic obstruction. LEVEL OF EVIDENCE: 3.

Phenotypic plasticity as a clue for invasion success of the submerged aquatic plant Elodea nuttallii.

Two closely related alien submerged aquatic plants were introduced into Europe. The new invader (Elodea nuttallii) gradually displaced E. canadensis even at sites where the latter was well established. The aim of the study was to evaluate the combined effects of environmental factors on several phenotypic characteristics of the two Elodea species, and to relate these phenotypic characteristics to the invasion success of E. nuttallii over E. canadensis. In a factorial design, Elodea plants were grown in aquaria containing five different nitrogen concentrations and incubated at five different light intensities. We used six functional traits (apical shoot RGR), total shoot RGR, relative elongation, root length, lateral spread, branching degree) to measure the environmental response of the species. We calculated plasticity indices to express the phenotypic differences between species. Light and nitrogen jointly triggered the development of phenotypic characteristics that make E. nuttallii a more successful invader in eutrophic waters than E. canadensis. The stronger invader showed a wider range of phenotypic plasticity. The apical elongation was the main difference between the two species, with E. nuttallii being more than two times longer than E. canadensis. E. canadensis formed dense side shoots even under high shade and low nitrogen levels, whereas E. nuttallii required higher light and nitrogen levels. We found that under more eutrophic conditions, E. nuttallii reach the water surface sooner than E. canadensis and through intensive branching outcompetes all other plants including E. canadensis. Our findings support the theory that more successful invaders have wider phenotypic plasticity.

Perioperative and economic analysis of surgical treatments for benign prostatic hyperplasia: A study of the French committee on LUT.

PURPOSE: To evaluate perioperative cost related to surgical treatments of benign prostatic obstruction (BPO): photoselective vaporization of the prostate (pvp), holmium/thullium laser enucleation (HoLEP/ThuLEP), transurethral resection of the prostate (TURP) and open prostatectomy (OP). MATERIAL AND METHODS: We retrospectively collected data from 237 patients who consecutively underwent a surgical treatment for BPH between January 2012 and June 2013 at nine institutions in France. An economic simulation model was constructed to estimate the cost of hospitalization related to surgical procedure from the hospital perspective and a cost minimization analysis was performed. RESULTS: TURP, OP, HoLEP/ThuLEP and PVP were performed in 99 (42%), 23 (10%), 64 (27%) and 51 (21%) patients, respectively. For men with prostate size<80mL: mean operative time was shorter with mTURP and PVP than HoLEP/thuLEP (P<0.001); Mean postoperative length of stay were 1.9, 3 vs. 3.4 days, for HoLEP/Thulep, PVP and TURP respectively (P=0.006); Costs of first hospitalization were comparable between HoLEP/ThuLEP and TURP but higher with PVP (P<0.001). For men with prostate size≥80mL: Compared to PVP and HoLEP/ThuLEP, OP was associated with shorter operative time (P<0.001) but longer length of stay (2.4, 4.2 vs. 7.8 days, respectively, P<0.0001); Costs of first hospitalization were significantly higher with OP than HoLEP/ThuLEP or PVP (P<0.001). CONCLUSIONS: PVP and HoLEP/ThuLEP were associated with a shorter LOS than TURP and OP. This benefit suggests these procedures could be more cost effective than OP, but still not cheaper alternatives to TURP. LEVEL OF EVIDENCE: 5.

[Evaluation of postoperative symptoms after Greenlight™ photovaporization of the prostate through a dedicated questionnaire]. / Évaluation précoce des troubles postopératoires après photovaporisation de la prostate Greenlight™ grâce à un questionnaire dédié.

AIMS: To evaluate postoperative symptoms after Greenlight™ photovaporisation of the prostate (PVP), through a dedicated questionnaire. METHODS: A retrospective study has been conducted between 2008 and 2014. The questionnaire had 5 sections about pain while voiding, hematuria, urgency, incontinence and urinary stream, and was filled at one-month postoperative. The main outcome criterion was pain while voiding. Descriptive statistical analyses were done to identify predictive factors for pain while voiding. RESULTS: Out of 169 patients, 22% had no pain while voiding, 37% had moderate pain, 30% acceptable pain and 11% intense pain. Patients with pain were significantly older, (P=0.012), had more urgency (P=0.01) and more often hematuria (P=0.0001). Only 7% of patients had no symptoms of urgency, and urgency was painful or bothering in 57% of cases. Hematuria was frequent, with clots in 21% of cases. Ninety three percent felt improvement of urinary stream. CONCLUSIONS: Systematic evaluation of symptoms through a dedicated questionnaire one month after PVP has shown that 41% of patients felt pain while voiding, 57% had urgency and 39% significant hematuria. These results should encourage a more accurate patient information and further studies to better understand postoperative healing after PVP.

[Medicoeconomic aspects of benign prostatic hyperplasia medical treatment]. / Aspects médicoéconomiques des traitements médicamenteux de l'hypertrophie bénigne de la prostate : une revue de la littérature du Comité des troubles mictionnels de l'homme de l'Association française d'urologie.

INTRODUCTION: The medicoeconomic issues of drug management of benign prostatic hyperplasia (BPH) are essential due to the aging population and the increasing number of therapeutic options. It is thus essential to assess the cost-effectiveness in order to define the most appropriate therapeutic strategies economically. The objective of this work was to conduct a literature review on the medicoeconomic studies on the drug therapy of BPH. METHOD: After analyzing the literature, 43 articles were found and 9 were selected for their relevance. RESULTS: Based on Markov models, we observed that: combination therapy and combined treatments (alphablockers and inhibitors of 5-alpha reductase [5ARI]) seemed to have the best cost-effectiveness. Then came the alphablockers, less expensive but exposing to a greater risk of progression and to the necessity of surgical treatments. Then came the 5ARI monotherapy and finally simple monitoring. CONCLUSION: The Markov models are imperfect tools, and resources invested in care depend on both the economic model and the value that individuals and society give to efficiency and cost.

[Serious and unexpected complications of benign prostatic obstruction surgery: Results of the LUTS Committee survey from urologists of the French Urological Association]. / Complications graves et inattendues de la chirurgie de l'hyperplasie bénigne de prostate : résultats de l'enquête du CTMH auprès des urologues de l'AFU.

PURPOSE: Rare and severe complications of benign prostatic hyperplasia (BPH) surgery are poorly documented in the literature. Our purpose was to make an inventory of severe and unexpected complications of BPH faced by urologists of the French Association of Urology (AFU). MATERIAL AND METHODS: A declarative 13-question survey was sent by e-mail 2 months before the 108th French Congress of Urology to the urologist's members of the AFU. Complications were split in complications due to material and complications directly related to the surgery. RESULTS: Overall, 216 (16.2%) urologists surveyed but only 85 forms were usable. Complications related to the material was divided into: excessive temperature of the serum irrigation leading to urethral and bladder burns (n=5), material default leading to interruption of the procedure (n=1) or incomplete hemostasis (n=2) and endoscope rupture (n=1). Peroperative complications related to surgery were divided into surgical complications: haemorrhage (n=7), urethral wounds (n=6), perforation and/or explosion (n=16), rectal wounds (n=11), obstructive renal failure (n=1); and medical complications: TURP syndrome (n=2), cardiovascular (n=5) and septic shock (n=6). CONCLUSION: This is the first French declarative study having allowed the identification of severe and unexpected complications of BPH surgery. The recorded occurred complications were very eclectic and secondary to all types of techniques used.

[Evaluation of the impact of CTMH guidelines on the management of benign prostatic hyperplasia]. / Évaluation de l'impact des recommandations du Comité des troubles mictionnels de l'homme sur la prise en charge de l'hypertrophie bénigne de prostate.

INTRODUCTION: The French guidelines on the management of benign prostatic hyperplasia (BPH) have been published in 2012 by the LUTS committee of the French Urological Association. The aim of this study was to evaluate the impact of these guidelines on the BPH management by French urologists. MATERIAL AND METHODS: A questionnaire has been distributed by email to 1141 urologists members of the French Association of Urologists in November 2013. RESULTS: We collected 222 responses (response rate: 19%). The guidelines have been read by 73% of the urologists. The guidelines were followed most of the time by 76% of them, 11% followed them systematically and 4.5% did not follow them. The new terminology was used by 28 to 52% according to the items. The symptoms were evaluated by the IPSS score (33%), by interrogatory alone (64%) or by neither of them (3%). Prostate volume was not systematically taken for account in the treatment strategy by 57% of the urologists. Sexual function was assessed systematically by 28% of the urologists, 11% used a questionnaire (IIEF: 92%). PSA was tested respectively by 70 and 51% of the urologists at the initial evaluation and the follow-up. After introduction of a monotherapy, 56% of the urologists evaluated the efficacy at 3 months. CONCLUSION: The French guidelines for the management of benign prostatic hyperplasia (BPH) by the LUTS committee of the French Urological Association were well known and used by French urologists. Some improvements can be expected for the use of the IPSS score, the evaluation of the sexual function, and the use of the new terminology. LEVEL OF EVIDENCE: 4.

[Conservative treatment of male non-neurologic urinary incontinence: a review by the LUTS committee of the French Urological Association]. / Traitements palliatifs et conservateurs de l'incontinence urinaire masculine non neurologique: une revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the conservative treatment of male non-neurologic urinary incontinence. METHOD: A systematic review was conducted using PubMed/MEDLINE with the following keywords: "incontinence", "male stress urinary incontinence", "pelvic floor training", "biofeedback", "absorbant products", "life style", "penile clamp". RESULTS: Palliative devices like penile clamps, penile sheaths and absorbent products were transitory options that were poorly evaluated. Life style modifications (scheduled voiding, controlled hydric absorption, decreased caffeine and spice intake) were useful in complement of other treatments especially in case of overactive bladder. Pelvic floor training (PFT) was useful after radical prostatectomy but remained optional for other types of incontinence. It accelerated the continence recovery postoperatively but it results at 1 year were uncertain. These results were maintained 1 year. Conservative treatments were useful postoperatively especially early supervised PFT. The benefit of biofeedback and perineal stimulation was controversial. Balder catheterization was a last resort option. Penile sheaths were better than urethral catheterization if there were no post-voiding residual urines. CONCLUSIONS: Palliative options have a limited efficacy but are mini-invasive and might be helpful complementary options.

[PSA testing, biopsy and cancer and benign prostate hyperplasia in France]. / Dosage du PSA, biopsie, cancer et hypertrophie bénigne de la prostate en France.

INTRODUCTION: Prostate-specific antigen (PSA) testing is high in France. The aim of this study was to estimate their frequency and those of biopsy and newly diagnosed cancer (PCa) according to the presence or absence of treated benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: This study concerned men 40 years and older covered by the main French national health insurance scheme (73 % of all men of this age). Data were collected from the national health insurance information system (SNIIRAM). This database comprehensively records all of the outpatient prescriptions and healthcare services reimbursed. This information are linked to data collected during hospitalisations. RESULTS: The frequency of men without diagnosed PCa (10.9 millions) with at least one PSA test was very high in 2011 (men aged 40 years and older: 30 %, 70-74 years: 56 %, 85 years and older: 33 % and without HBP: 25 %, 41 % and 19 %). Men with treated BPH totalized 9 % of the study population, but 18 % of the men with at least one PSA test, 44 % of those with at least one prostate biopsy and 40 % of those with newly managed PCa. Over a 3-year period, excluding men with PCa, 88 % of men with BPH had at least one PSA test and 52 % had three or more PSA tests versus 52 % and 15 % for men without BPH. One year after PSA testing, men of 55-69 years with BPH more frequently underwent prostate biopsy than those without BPH (5.4 % vs 1.8 %) and presented PCa (1.9 % vs 0.9 %). CONCLUSIONS: PSA testing frequencies in France are very high even after exclusion of men with BPH, who can be a group with more frequent managed PCa. LEVEL OF EVIDENCE: 4.

[Treatment of non-neurogenic masculine urinary incontinence due to overactive bladder: a review by the LUTS committee of the French Urological Association]. / Traitement de l'incontinence urinaire masculine non neurologique par hyperactivité vésicale : une revue de la littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the treatment of masculine urinary incontinence due to idiopathic overactive bladder. METHOD: A systematic review was conducted using PubMed/MEDLINE with the following keywords: "overactive bladder", "male urinary incontinence", "urgency", "antimuscarinic", "onabotulinumtoxinA", "neurostimulation", "cystoplasty". RESULTS: Antimuscarinic treatments were the first line option for overactive bladder incontinence (decreased incontinence under tolterodine versus placebo respectively -71% vs. -40%, P < 0.05). Their main side effects were dry mouth (16-29.6%) and constipation (4%), which might decrease the observance. In case of failure, neuromostimulation could be prosed with a 67% efficacy rate. Intra-detrusorian injections of onabotulinumtoxinA were an option, however there were still not validated for this indication and their efficacy decreases with time and after repeated injections. The ultimate option in case of refractory major over-activity was cystoplasty, which involves major morbidity for inconstant efficacy. CONCLUSIONS: The same treatments are available for non-neurologic urinary incontinence by bladder over-activity for men and women: antimuscarinic drugs, neurostimulation, onabotulinumtoxinA. However, only few data is available for masculine population exclusively.

[Initial assessment of male non-neurogenic incontinence: systematic review of the literature by the LUTS committee of the French Urological Association]. / Bilan initial d'une incontinence urinaire masculine (non neurologique): revue de la littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the initial evaluation of male urinary incontinence (MUI). METHOD: A systematic review was conducted using Pubmed/Medline from 1995 to 2013. RESULTS: Definition of MUI and its prevalence is variable according its definition and the population. Tools for its evaluation have been mainly studied in female population or only in patients with UI after radical prostatectomy. Objectives of the initial evaluation are to assess the type of incontinence, to evaluate its severity and the bother associated, and define the choice of treatment. Medical history, clinical assessment, and urine analysis are the first steps of the evaluation. Bladder diary, questionnaires and pad test can be useful to evaluate MUI. Post-void residual volume assessment is necessary if lower urinary tract symptoms are associated. Imaging is not routinely used in MUI. A specialist referral and further investigations such as urethrocystoscopy and urodynamics should be considered in case of invasive treatment, recurrent incontinence and specific situations. CONCLUSIONS: Initial assessment of MUI should be sequential with systematic investigations and optional ones.

[Initial assessment, follow-up and treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: guidelines of the LUTS committee of the French Urological Association]. / Bilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l'AFU.

AIM: To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH). METHOD: A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique. RESULTS: Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate. CONCLUSION: Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

[Predictive value of the penile cuff-test for the assessment of bladder outlet obstruction in men]. / Valeur prédictive du cuff-test dans le diagnostic de l'obstruction sous-vésicale chez l'homme.

PURPOSE: To assess the diagnostic performances and the acceptability of the penile cuff test (PCT) which is a non invasive method for the evaluation of bladder outlet obstruction (BOO), in comparison with the pressure flow study (PFS), the actual gold-standard. MATERIAL: Monocentric prospective study comparing the following subsets: "obstructed", "not obstructed" or "equivocal", deduced from PFS vs PCT, in 30 consecutive patients presenting with lower urinary tract symptoms. For the PCT, a cuff placed around the penis inflated automatically during the micturition, until flow rate interruption. The interruption cuff pressure revealed the isovolumetric bladder pressure (Pcuff-int). The data collected - Pcuff-int and maximum flow rate - were automatically reported on ICS modified nomogram. RESULTS: With the PFS, 11 patients (39%) were classified "obstructed", six patients (22%) "non-obstructed" and 11 patients (39%) "equivocal". In 61% cases, the patient was classified in the same category by both techniques. The "obstructed positive predictive value" of the PCT was 82% and the "non-obstructed-equivocal negative predictive value" was 88%. The median acceptability visual analogic scale score was 1/10 (0-3) for the PCT whereas it was 5/10 (2-10) for the PFS. This difference was statistically significant (p=0.004). CONCLUSION: The PCT was a reliable non-invasive tool for the diagnosis of BOO in male, in comparison with PFS. The predictive values of the PCT were relevant and its tolerance was better than PFS.

[Surgical management of benign prostatic hyperplasia by endoscopic techniques using electricity and open prostatectomy: A review of the literature by the LUTS committee of the French Urological Association]. / Traitement de l'hyperplasie bénigne de prostate par techniques endoscopiques électriques et adénomectomie voie haute : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the surgical treatment of benign prostatic hyperplasia (BPH) by endoscopic electric resection and vaporization, and by open prostatectomy. METHOD: A systematic review of recent literature was performed. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Both monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Endoscopic electric alternatives are monopolar and bipolar prostate vaporisation as well as bipolar resection. These techniques seem to show similar functional results than TURP and open prostatectomy, as well as an advantage in terms of bleeding.

[Surgical management of BPH by laser therapies: A review of the literature by the LUTS committee of the French urological association]. / Traitement chirurgical de l'hyperplasie bénigne de la prostate par laser : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the surgical treatment of benign prostatic hyperplasia (BPH) by laser. METHOD: A systematic review of recent literature was performed. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Alternative endoscopic options are laser photoselective vaporisation, holmium enucleation and thulium resection. These techniques seem to show functional results similar to those obtained after TURP and open prostatectomy, as well as an advantage in terms of bleeding.

[Surgical management of benign prostatic hyperplasia by thermotherapy and other emerging techniques: A review of the literature by the LUTS committee of the French Urological Association]. / Traitement chirurgical de l'hyperplasie bénigne de la prostate par thermothérapie et autres techniques émergentes : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on mini-invasive surgical treatment of benign prostatic hyperplasia (BPH) by thermotherapy and other emerging techniques. METHOD: A systematic review of literature was performed in Pubmed database for the period running from 1980 to 2011. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Thermotherapy using transurethral microwaves or needle ablation is an alternative to medical management. Urethral stents should only be proposed in exceptional cases of surgical contra-indication, because of their related complications. Botulinium toxin and ethanol intra-prostatic injections are currently under evaluation.

[Initial assessment and follow-up of benign prostatic hyperplasia: systematic review of the literature by the LUTS committee of the French Urological Association]. / Bilan initial et suivi de l'hyperplasie bénigne de prostate: revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the initial evaluation and follow-up of benign prostatic hyperplasia (BPH). METHOD: A systematic review of recent literature was performed. Level of evidence of publications was evaluated. RESULTS AND CONCLUSIONS: Objectives of the initial evaluation are to assess the link between low urinary tract symptoms (LUTS) and BPH, to evaluate the bother associated to LUTS, assess a complicated bladder outlet obstruction (BOO), diagnose an adenocarcinoma of the prostate if it modifies the therapeutic strategy, and establish an evolutive profile of the disease. Clinical assessment with digital rectal examination, evaluation of symptoms by a dedicated questionnaire and urine analysis are the first steps of BPH evaluation. Bladder diary is useful to objective storage symptoms. Uroflowmetry and post-void residual volume assessment are useful if BOO is suspected. Measure of serum creatinine and ultrasound exam of the urinary tract are second line explorations. Urine cytology, neurological evaluation, urethrocystoscopy, urodynamics with pressure-flow studies are useful if the link between LUTS and BPH is unclear. PSA dosage is used for prostate cancer screening or as a prognostic marker of BPH evolution.

[Benign prostatic hyperplasia medical treatment: systematic review of the literature by the CTMH/AFU]. / Traitement médical de l'hyperplasie bénigne de la prostate: revue de littérature par le CTMH/AFU.

INTRODUCTION AND OBJECTIVES: The medical treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (LUTS-BPH) has dramatically evolved within the last years: new drugs have been commercialized and others that used to be contra-indicated may now be prescribed. Our objective was to provide with an updated review of the scientific literature on the medical treatment of LUTS-BPH. PATIENT AND METHOD: A systematic review of the most recent scientific literature was performed. The query was addressed to the PubMed database using the following keywords: "benign prostatic hyperplasia" and "medical treatment". A very large amount of publications, from year 1990 until 2011, were reviewed to select the publications with level of evidence 1 and 2. These publications were analysed and the 30 most relevant were selected to serve as references for this article. RESULTS: There are many randomized clinical trials in the field of LUTS-BPH medical treatment. Recently, anti-muscarinic agents have been assessed and have proven their efficacy and tolerance as long as the storage symptoms are predominant over the voiding symptoms. Combination therapies using alpha-blockers and 5-alpha reductase (5-ARI) inhibitors, but also anti-muscarinic agents and PDEF-5 inhibitors may also be prescribed depending on the patient' complaint. CONCLUSION: The publication of recent randomized clinical trials allows the urologists to use new drugs and new combination therapies in the medical treatment of LUTS-BPH. In 2011, the medical treatment decision-making may better integrate the patient' complaint and medical history.