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World Journal of Urology Apr 2018Prostatic artery embolization (PAE) has seen a recent increase in interest as a treatment for men with benign prostatic obstruction (BPO). The appeal of this... (Review)
Review
PURPOSE
Prostatic artery embolization (PAE) has seen a recent increase in interest as a treatment for men with benign prostatic obstruction (BPO). The appeal of this intervention lies in reported reduction in morbidity and its minimally invasive nature. The purpose of this review is to assess the safety and efficacy of PAE as a new treatment in BPO and explore risks surrounding its performance.
METHODS
A review of the literature was performed. Medical databases searched included PubMed, EMBASE, and Cochrane databases, limited to English, peer-reviewed articles. Search terms included prostatic artery embolization, lower urinary tracts symptoms, minimally invasive therapies, interventional radiology prostate, and benign prostatic hyperplasia. Articles were screened by two independent reviewers for content on development, methods, outcomes, and complications of PAE.
RESULTS
Suitability of patients to undergo PAE depends on review of patient history, pre-procedure visualisation of appropriate vascular anatomy and clinical parameters. Despite this selection of candidates favourable for procedural success, PAE is not without risk of complications, some of which can significantly affect patient quality of life.
CONCLUSIONS
Although initial findings show promise regarding safety and efficacy of PAE in improving symptom and quality-of-life scores, further investigation is required to establish durability of effect and the appropriate use of this experimental modality. There is currently limited robust evidence for the beneficial outcomes of PAE. Long-term follow-up studies will add to the evidence base to help further assess the feasibility of this procedure as an alternative to TURP.
Topics: Arteries; Embolization, Therapeutic; Humans; Male; Prostate; Prostatic Hyperplasia; Prostatism; Risk Adjustment; Treatment Outcome
PubMed: 29445846
DOI: 10.1007/s00345-018-2220-z -
Cardiovascular and Interventional... Apr 2022A 66-years old male patient presents with lower urinary tract symptoms, mostly due to obstructive symptoms, and an enlarged prostate with 80 cm, with a broad-based... (Review)
Review
Minimally Invasive Therapies for Benign Prostatic Obstruction: A Review of Currently Available Techniques Including Prostatic Artery Embolization, Water Vapor Thermal Therapy, Prostatic Urethral Lift, Temporary Implantable Nitinol Device and Aquablation.
A 66-years old male patient presents with lower urinary tract symptoms, mostly due to obstructive symptoms, and an enlarged prostate with 80 cm, with a broad-based median lobe, suggestive of benign prostatic obstruction (BPO). Trans-urethral resection of the prostate (TURP) was proposed. However, the patient desired to preserve ejaculatory function and was afraid of a potential negative impact on erectile function. Thus, the patient inquired about minimally invasive therapies (MITs) as alternatives to TURP. In this review, currently available MITs for BPO are described including prostatic artery embolization, water vapor thermal therapy (Rezum®), prostatic urethral lift, iTIND® (temporary implantable device) and aquablation (Aquabeam®). Focus is given on the description of the technique, level of evidence and advantages over conventional surgical options.
Topics: Aged; Alloys; Arteries; Embolization, Therapeutic; Humans; Lower Urinary Tract Symptoms; Male; Minimally Invasive Surgical Procedures; Prostate; Prostatic Hyperplasia; Steam
PubMed: 35043243
DOI: 10.1007/s00270-021-03052-4 -
Current Opinion in Urology May 2018Benign prostatic obstruction (BPO) is a common cause of lower urinary tract symptoms (LUTS) in elderly men. However, such symptoms are often caused by primary detrusor... (Review)
Review
PURPOSE OF REVIEW
Benign prostatic obstruction (BPO) is a common cause of lower urinary tract symptoms (LUTS) in elderly men. However, such symptoms are often caused by primary detrusor overactivity or underactivity. Surgical management where BPO is absent or merely incidental has a lower chance of success, and exposes the patient to the potential complications of surgery. This review discusses the diagnostic challenges facing this common presentation.
RECENT FINDINGS
Most evidence comes from small, historical prospective cohort studies. A Cochrane review found only two studies that met the prespecified inclusion criteria. It concluded that urodynamics changed decision-making regarding surgery for LUTS but it was not possible to determine whether this impacted upon outcome. A systematic review of several noninvasive alternatives to urodynamics could not recommend any of them over urodynamic pressure-flow study assessment. Further research is currently in progress, the 'UPSTREAM' study, which is a randomized, multicentre trial. Men are randomized to undergo investigation with clinical evaluation and uroflowmetry, or to additionally receive urodynamics. The primary aim is to determine the impact of urodynamics on the assessment pathway.
SUMMARY
Assessment of BPO involves determining whether it has a contributory role in individual patients. This is a crucial factor in outcome, as surgery can give poor results if the symptoms are principally caused by detrusor dysfunction (overactivity or underactivity). Urodynamics can help determine this if undertaken to a suitable standard. Further research will identify the precise role of this test modality.
Topics: Diagnosis, Differential; Humans; Male; Prostatic Hyperplasia; Prostatism; Urinary Bladder, Overactive; Urinary Bladder, Underactive; Urodynamics
PubMed: 29528972
DOI: 10.1097/MOU.0000000000000496 -
Prostate Cancer and Prostatic Diseases Jun 2018The purpose of this narrative review is to evaluate the role of prostatic inflammation as a treatment target for lower urinary tract symptoms (LUTS) due to benign... (Review)
Review
BACKGROUND
The purpose of this narrative review is to evaluate the role of prostatic inflammation as a treatment target for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and provide an update on the available therapies.
METHODS
An extensive literature search was conducted for studies on established and investigational treatments with anti-inflammatory mechanism of action that has been assessed for the management of male LUTS due to BPO.
RESULTS
Data on phosphodiesterase 5 inhibitors, nonsteroidal anti-inflammatory drugs, vitamin D3 receptor analogs, phytotherapy, statins, and lifestyle changes have been reviewed and analyzed. Preclinical evidence has shown the anti-inflammatory effect of these treatments on prostate. However, there is a wide variation in the degree of mature of each therapy. In addition, there are significant differences between the studies in terms of design, number of patients, and duration of follow-up.
CONCLUSIONS
Several drugs classes have been investigated for their impact on prostatic inflammation and improvement of male LUTS. The reviewed data support the rationale for use of agents that may alter and improve the inflammatory environment in the prostate in men with LUTS, but further high-quality long-term studies are required for the exact positioning of the new drugs in daily practice.
Topics: Humans; Inflammation; Lower Urinary Tract Symptoms; Male; Prognosis; Prostatic Neoplasms; Prostatism
PubMed: 29686417
DOI: 10.1038/s41391-018-0039-8 -
European Urology Focus Jul 2022Urodynamic study (UDS) provides the most objective assessment of bladder outlet obstruction (BOO) but is impractical to be recommended routinely in outpatient services.... (Meta-Analysis)
Meta-Analysis Review
A Systemic Review and Meta-analysis of Transabdominal Intravesical Prostatic Protrusion Assessment in Determining Bladder Outlet Obstruction and Unsuccessful Trial Without Catheter.
CONTEXT
Urodynamic study (UDS) provides the most objective assessment of bladder outlet obstruction (BOO) but is impractical to be recommended routinely in outpatient services. Intravesical prostatic protrusion (IPP) had been described to obstruct urinary flow by creating an anatomical ball-valve effect, but there remains a lack of pooled evidence that can objectively correlate with BOO in benign prostatic hyperplasia.
OBJECTIVE
To update the current evidence on the predictive role of IPP in determining BOO and unsuccessful trial without catheter (TWOC).
EVIDENCE ACQUISITION
A comprehensive literature search was performed to identify studies that evaluated IPP in diagnosing UDS-determined BOO and TWOC. The search included the PubMed/MEDLINE, EMBASE, and Cochrane Library up to January 2021. An updated systemic review and meta-analysis was performed.
EVIDENCE SYNTHESIS
A total of 18 studies with 4128 patients were examined. Eleven studies with 1478 patients examined the role of IPP in UDS-determined BOO. The pooled area under the curve (AUC) was 0.83 (95% confidence interval [CI]: 0.79-0.86), and at a cut-off of >10 mm, the sensitivity (Sn) and specificity (Sp) were 0.71 (95% CI: 0.61-0.78) and 0.77 (95% CI: 0.68-0.84), respectively. The probability-modifying plot revealed positive and negative likelihood ratios of 3.34 (95% CI: 2.56-4.36) and 0.35 (95% CI: 0.26-0.45), respectively. Seven studies with 2650 patients examined IPP in predicting unsuccessful TWOC, with a pooled AUC of 0.74 (95% CI: 0.70-0.84), with Sn of 0.51 (95% CI: 0.43-0.60) and Sp of 0.79 (95% CI: 0.73-0.84) at an IPP cut-off of >10 mm. Five studies compared prostate volume (PV) and IPP and revealed a lower AUC of PV at 0.71 (95% CI: 0.67-0.75), which was an inferior parameter in diagnosing BOO (p < 0.001).
CONCLUSIONS
This systemic review provided evidence that IPP is a reliable clinical parameter that correlates strongly with underlying BOO and unsuccessful TWOC.
PATIENT SUMMARY
In this review, we comprehensively reviewed all the literature to date on evaluating the clinical utility of intravesical prostatic protrusion (IPP). We have demonstrated that IPP correlates strongly with urodynamic study (UDS)-determined bladder outlet obstruction and failure of trial without catheter (TWOC). Outpatient IPP measurement is a quick, inexpensive, and reproducible clinical parameter that can determine the severity of benign prostatic hyperplasia. The clinical role of IPP in predicting failure of TWOC selects patients who are best treated with aggressive surgical approaches rather than conservative medical therapies. More importantly, IPP can facilitate the discriminatory use of invasive UDS, reserved for patients with a strong suspicion of concomitant detrusor abnormalities.
Topics: Catheters; Humans; Male; Prostate; Prostatic Hyperplasia; Ultrasonography; Urinary Bladder Neck Obstruction
PubMed: 34561198
DOI: 10.1016/j.euf.2021.09.016 -
European Urology Jun 2016The urodynamic outcomes for α1-blockers (ABs) treatment in patients with lower urinary tract symptoms related to benign prostatic enlargement (LUTS/BPE) is a matter of... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
The urodynamic outcomes for α1-blockers (ABs) treatment in patients with lower urinary tract symptoms related to benign prostatic enlargement (LUTS/BPE) is a matter of debate.
OBJECTIVE
To perform a systematic review and meta-analysis of studies evaluating the ABs urodynamic outcomes in patients with LUTS/BPE. The primary endpoint was variation in bladder outlet obstruction index (BOOI). Secondary endpoints were the maximum urinary flow rate (Qmax) and detrusor pressure at Qmax (PdetQmax). A meta-analysis of placebo-controlled randomized clinical trials (RCTs) was performed to compare ABs with placebo.
EVIDENCE ACQUISITION
A systematic review of PubMed/Medline, ISI Web of Knowledge, and Scopus databases was performed in May 2015. Seventeen studies were selected for inclusion.
EVIDENCE SYNTHESIS
The overall pooled data showed a mean BOOI change of -14.19 (p<0.0001), a mean PdetQmax change of -11. 39cm H2O (p<0.0001), and a mean Qmax improvement of 2.27ml/s (p<0.0001). Subgroup analysis showed a mean BOOI change of -14.88 (p=0.01) for alfuzosin, -19.41 (p=0.01) for doxazosin, -16.47 (p<0.0001) for naftopidil, -30.45 (p<0.0001) for silodosin, -14.27 (p=0.002) for tamsulosin, and -6.69 (p=0.005) for terazosin. Subanalysis of RCTs containing a placebo arm showed a significant improvement in BOOI in patients undergoing ABs treatment. Meta-regression revealed a significant positive association between the percentage of patients with obstruction at baseline and the improvement in BOOI after treatment with ABs.
CONCLUSION
ABs improve BOOI in patients with LUTS/BPE mainly by reducing PdetQmax, and this effect is higher in patients presenting with urodynamic obstruction at baseline. The free Qmax variation underestimates the real effect of ABs on benign prostatic obstruction.
PATIENT SUMMARY
Results of this meta-analysis suggest that α1-blockers objectively improve urinary voiding function in patients with benign prostatic obstruction.
Topics: Adrenergic alpha-1 Receptor Antagonists; Clinical Trials as Topic; Doxazosin; Humans; Indoles; Male; Naphthalenes; Piperazines; Prazosin; Prostatism; Quinazolines; Severity of Illness Index; Sulfonamides; Tamsulosin; Urodynamics
PubMed: 26831507
DOI: 10.1016/j.eururo.2015.12.034 -
Prostate Cancer and Prostatic Diseases Dec 2023Anatomical endoscopic enucleation of the prostate (AEEP) is recommended for first line surgical treatment of benign prostatic obstruction (BPO) caused by moderate and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anatomical endoscopic enucleation of the prostate (AEEP) is recommended for first line surgical treatment of benign prostatic obstruction (BPO) caused by moderate and large prostatic adenoma. However, its role in the retreatment setting after failed previous surgical treatment for BPO remains uncaptured. In this scope, we performed a systematic review and meta-analysis aiming to assess the safety and efficacy of AEEP in the retreatment setting.
METHODS
We searched PubMed, Cochrane Library and Embase databases from inception to March 2022 for prospective or retrospective studies involving patients undergoing prostatic enucleation for recurrent or residual BPO after previous standard or minimally invasive surgical treatments for BPO. Based on data availability, we performed a meta-analysis comparing AEEP in patients with recurrent or residual BPO versus AEEP for primary BPO.
PROSPERO
CRD42022308941).
RESULTS
We included 15 studies in the systematic review and 10 in the meta-analysis (6553 patients, 841 with recurrent or residual BPO and 5712 with primary BPO). All included studies involved patients undergoing HoLEP or ThuLEP. In terms of Qmax, post-void residual, International Prostate Symptom Score, removed adenoma, operative time, duration of catheterization and hospital stay, as well as complications, HoLEP for recurrent or residual BPO was equally effective compared to HoLEP for primary BPO up to 1 year postoperatively. Importantly, the beneficial effect of HoLEP on the retreatment setting was observed after previous standard or minimally invasive surgical treatments for BPO. The overall strength of evidence for all outcomes was deemed very low.
CONCLUSIONS
HoLEP may be safely and effectively used in experienced hands for the surgical treatment of recurrent or residual BPO in patients with large or moderate prostates following previous open, endoscopic or minimally invasive surgical treatment for BPO.
Topics: Humans; Male; Prospective Studies; Prostate; Prostatic Hyperplasia; Prostatic Neoplasms; Retreatment; Retrospective Studies; Treatment Outcome; Endoscopy
PubMed: 37193777
DOI: 10.1038/s41391-023-00677-z -
Expert Opinion on Emerging Drugs Jun 2010Benign prostatic enlargement (BPE) leading to benign prostatic obstruction (BPO) affects an increasing number of men as they grow older. They can affect quality of life... (Review)
Review
IMPORTANCE OF THE FIELD
Benign prostatic enlargement (BPE) leading to benign prostatic obstruction (BPO) affects an increasing number of men as they grow older. They can affect quality of life and cause lower urinary tract symptoms (LUTS) including urinary retention. The currently available pharmacotherapies are alpha-blockers and 5-alpha reductase inhibitors which may be effective but can have adverse effects and long-term compliance problems. Therefore, it is important to find new medical treatments for LUTS/BPO and this review aims to identify the potential future drugs undergoing clinical trials in this field.
AREAS COVERED IN THIS REVIEW
Articles were identified by means of a computerized Google, PubMed and Cochrane Library search over the last 10 years (using the following keywords: benign prostate hyperplasia, enlargement and obstruction) and a search of the PharmaProjects database.
WHAT THE READER WILL GAIN
An insight into the currently available and future potential treatments for benign prostatic obstruction.
TAKE HOME MESSAGE
The exact etiology of benign prostatic hyperplasia (BPH) and its consequences, BPE and BPO, are not known; however, ageing and functioning testes have been implicated. Several classes of drugs are currently undergoing clinical trials such as phosphodiesterase inhibitors and leutenizing hormone-releasing hormone antagonists. Others include phytoestrogens, progestogens, NX1207 and PRX302. Some of these work by affecting testosterone level and, therefore, on the static component of BPO, while it is not known how the rest work. Until the exact etiology of BPH/BPE/BPO is known, we are unlikely to have the cure for this ageing male phenomenon.
Topics: Age Factors; Animals; Clinical Trials as Topic; Drug Design; Drug Therapy, Combination; Drugs, Investigational; Humans; Male; Prostatic Hyperplasia; Prostatism; Treatment Outcome
PubMed: 20446824
DOI: 10.1517/14728211003716459 -
The Canadian Journal of Urology Jun 2017To report the five year results of a prospective, multi-center, randomized, blinded sham control trial of the Prostatic Urethral Lift (PUL) in men with bothersome lower... (Randomized Controlled Trial)
Randomized Controlled Trial
INTRODUCTION
To report the five year results of a prospective, multi-center, randomized, blinded sham control trial of the Prostatic Urethral Lift (PUL) in men with bothersome lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).
MATERIALS AND METHODS
At 19 centers in North America and Australia, 206 subjects ≥ 50 years old with International Prostate Symptom Score (IPSS ) > 12, peak flow rate (Qmax) ≤ 12 mL/s, and prostate volume 30 cc-80 cc were randomized 2:1 to the PUL procedure or blinded sham control. In PUL permanent UroLift implants are placed to hold open the lateral lobes of the prostate to reduce urinary obstruction. After randomized comparison at 3 months and the only opportunity to add more PUL implants, PUL patients were followed to 5 years. LUTS severity (IPSS), quality of life (QOL), BPH Impact Index (BPHII), Qmax, sexual function, and adverse events were assessed throughout follow up.
RESULTS
IPSS improvement after PUL was 88% greater than that of sham at 3 months. LUTS and QOL were significantly improved by 2 weeks with return to preoperative physical activity within 8.6 days. Improvement in IPSS, QOL, BPHII, and Qmax were durable through 5 years with improvements of 36%, 50%, 52%, and 44% respectively. No difference was seen between Intent to Treat and Per Protocol populations. Surgical retreatment was 13.6% over 5 years. Adverse events were mild to moderate and transient. Sexual function was stable over 5 years with no de novo, sustained erectile or ejaculatory dysfunction.
CONCLUSIONS
PUL offers rapid improvement in symptoms, QOL and flow rate that is durable to 5 years. These improvements were achieved with minimal use of a postoperative urinary catheter, rapid return to normal, and preservation of both erectile and ejaculatory function. Symptom improvement was commensurate with patient satisfaction. PUL offers a minimally invasive option in the treatment of LUTS due to BPH.
Topics: Double-Blind Method; Ejaculation; Follow-Up Studies; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Penile Erection; Prospective Studies; Prostatic Hyperplasia; Prostatism; Prostheses and Implants; Quality of Life; Reoperation; Severity of Illness Index; Sexuality; Treatment Outcome; Urodynamics
PubMed: 28646935
DOI: No ID Found -
Archivio Italiano Di Urologia,... Sep 2022Surgery is the treatment for male lower urinary tract symptoms (LUTS) relat-ed to benign prostatic obstruction (BPO) refractory to pharma-cological treatment or with...
OBJECTIVE
Surgery is the treatment for male lower urinary tract symptoms (LUTS) relat-ed to benign prostatic obstruction (BPO) refractory to pharma-cological treatment or with complications. This study aimed to assess factors associated with the need for surgical reinterven-tion and/or continuation of pharmacological treatment.
MATERIALS AND METHODS
A retrospective analysis of patients who underwent prostatic surgery for male LUTS associated with BPO between 1 May 2015 and 1 May 2016, with a minimum follow-up of five years, in an academic tertiary hospital. The type of surgery, preoperative, postoperative and follow-up analysis were collected in a database.
RESULTS
A total of 212 patients were included with a mean age of 70 ± 8.66 years at five years follow-up. At 5 years, a total of 86.9% of patients do not need pharmacological treatment and 12% required surgical reintervention. Of the preoperative parameters, it was found a relationship between prior prostatitis and the need for second surgery with an odds ratio of 4.6.
CONCLUSIONS
Patients should be informed of the potential need for pharmacological treatment following surgery, or even of the need for reintervention. History of prostatitis seems to be a risk factor for reintervention.
Topics: Aged; Humans; Lower Urinary Tract Symptoms; Male; Middle Aged; Prostatic Hyperplasia; Prostatitis; Retrospective Studies; Urethral Obstruction
PubMed: 36165472
DOI: 10.4081/aiua.2022.3.295