Decreased semen volume and decreased or absent libido were also higher in men on dutasteride compared to placebo.124 Ejaculation failure was found to be higher in men on combination dutasteride and 0.2mg tamsulosin compared to 0.2mg tamsulosin, alone (2.6% versus 0.3%; ARD: 2.3%; 95%CI: 0.4, 4.2).133, The multinational 4-year REDUCE trial131 found an increased incidence of gynecomastia (1.9% versus 1.0%; ARD: 0.8; 95%CI: 0.3, 1.3) with a larger between group difference in the post hoc analysis of a subset of 1,617 men (2.4% versus 0.7%; ARD: 1.7; 95%CI: 0.5, 2.9).124 During the 2-year observational extension phase conducted in 2,751 participants, no new cases of gynecomastia were reported.132 Conversely, a 2-year study conducted in Asia did not demonstrate any increased risk of gynecomastia in men on dutasteride.133 One observational study reported a greater incidence of gynecomastia in men who used finasteride or dutasteride, alone or with an alpha blocker, when compared to non-exposure to LUTS/BPH medications.138 A meta-analysis looking at 14 studies found increased risks of gynecomastia and breast tenderness for men on 5-ARI when compared to placebo.139, In observational studies, two studies reported on potential risk associated with 5-ARI use.140,141 One study compared the use of finasteride or dutasteride to men not using either drug.141 Dementia was greater in the finasteride and dutasteride groups as compared to the placebo group in analyses less than 27 months; however, rates were similar after 27 months.141 In the second study, use of 5-ARI was compared to tamsulosin over 20 months with higher rates of dementia seen in the tamsulosin group with a dose-dependent risk noted.124, Two observational studies reported on risks of depression. 19. Combination tadalafil and finasteride resulted in improvement in IIEF-EF scores compared to finasteride alone in sexually active men (RR: 4.7; 95%CI: 3.04, 6.38). 65. Urology 2013; Lucas MG, Stephenson TP, Nargund V: Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia. The authors reported the occurrence of medical failure at 36 months follow-up, defined as needing to start alpha blockers or 5-ARI anew, in 9% of participants after RWT and 14% of participants after TURP.80, 41. The trial included men with a baseline IPSS of more than 8 with a mean of 20 points, indicating severe LUTS. However, increasing amounts of residual urine with worsening voiding efficiency over time may indicate the need for more frequent follow-up visits and prompt additional investigations such as pressure flow studies, cystoscopy and prostate volume assessment, and/or a change in therapy. Differences in ROB can help explain heterogeneity in the results of studies included in a systematic review. This should include studies of specific hypotheses of how LUTS/BPH is impacted by obesity and related diseases; new and enhanced collaborative efforts between urologists, clinical trialists, exercise physiologists and dietary experts; and assessments of the relationship between the various manifestations of metabolic syndrome and LUTS/BPH. Rapid and durable relief of symptoms, 3. Journal of Clinical Urology 2014; Ahyai S, Lehrich K, Kuntz R: Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. This, in turn, leads to a reduction in the overall androgenic growth stimulus in the prostate, an increase in apoptosis and atrophy, and ultimately a shrinkage of the organ ranging from 15-25% measured at six months. This may lead to one of the following scenarios: A perfect concordance between the IPSS and global assessment should not be expected. Three-year results showed sustained improvements for the IPSS IPSS-QoL, and Qmax, with scores remaining significantly improved from baseline;70 Qmax improvement was > 50% from 3 to 24 months and 39% at 36 months.13 At 36 months in the intent-to-treat population of the original 136 participants, mean change from baseline in IPSS was -11.0 points and the mean score was 10.4 points, representing a 50% improvement from baseline. Compared to finasteride alone, overall withdrawals were less in the combined tadalafil and finasteride group, 11.6% versus 18.3% (RR: 0.63; 95%CI: 0.44, 0.91). Comparison of HoLEP and TURP in terms of efficacy in the early postoperative period and perioperative morbidity. Urologists should inform identified patients with planned cataract surgery of IFIS risk and delay initiation of alpha blocker therapy until after the procedure. East Afr Med J 2002; 79: 65. Prostate imaging and other novel tests are areas of potentially beneficial and significant research. Conversely, tadalafil resulted in little to no difference compared to placebo in the IPSS change from baseline compared to placebo across the 10 trials, -5.4 points versus -3.6 points ([MD: -1.7 points; 95%CI: -2.14, -1.35]; high quality of evidence) (Figure 3), and IPSS-QoL ([MD: -0.3 points; 95%CI: -0.35, -0.17]; high quality of evidence) compared to placebo.170-179 The minimal detectable difference of 3 points was not achieved for either measure. The study excluded men with prostate volume < 30g and > 80g and did not exclude men with obstructing middle lobes or median bars. The mean age was 63 years (61-66), and baseline IPSS was 16 points (16-22), indicating moderate symptom severity. J Urol 2020; Taylor BL, Jaffe WI: Electrosurgical transurethral resection of the prostate and transurethral incision of the prostate (monopolar techniques). These chosen topics illustrate the pressing need for improved methods to diagnose and measure disease symptoms, severity and progression; development of new drug therapies, derived from both synthetic and naturally occurring compounds; and identification and clinical testing of prevention strategies; and for further development of intervention therapies based on non- or minimally invasive approaches. It has long been understood that alpha-adrenergic receptor blockade may induce EjD. Proscar Long-term Efficacy and Safety Study. Overall withdrawal from participation was 7% in the mirabegron group and 3% in the placebo group (RR: 2.41; 95%CI: 0.54, 10.67). 82. Practitioners should also consider delaying a voiding trial in patients with an active UTI until the infection has resolved. (Expert Opinion), After exclusion of other causes of hematuria, 5-ARIs may be an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding. Eur Urol 2014; Thomas JA, Tubaro A, Barber N et al: A multicenter randomized noninferiority trial comparing GreenLight-XPS laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: two-yr outcomes of the GOLIATH Study. There was a significant (p<0.001) decrease in the mean IPSS, with a 3.3 fold reduction in the finasteride group and a 1.3 reduction in the placebo group. (Expert Opinion). (Moderate Recommendation; Evidence Level: Grade B), PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe. The PLESS study suggests that long-term medical therapy could impact the natural history of BPH as manifested by AUR and surgery. J Urol 2002; Sandfeldt L, Bailey DM, Hahn RG: Blood loss during transurethral resection of the prostate after 3 months of treatment with finasteride. Di Silverio F, Gentile V, Pastore A et al: Benign prostatic hyperplasia: what about a campaign for prevention? While the impact of tadafil on LUTS/BPH symptoms has been described, the use of this drug does not appear to improve urodynamic profiles.180 During a multicenter, randomized, double-blind, placebo controlled clinical trial comparing once daily tadalafil 20 mg versus placebo over 12 weeks in men with LUTS/BPH, investigators assessed change in detrusor pressure at maximum urinary flow rate. AUA-SI improved significantly in both treatment groups (p<0.001), with significantly greater improvement with dutasteride (-4.5) compared with placebo (-2.3) (p<0.001). Affordability. 13 The diagnostic guidelines by Abrams et al (2009) are revisited in Appendix A7. Prostate Cancer Prostatic Dis 2011; Chang D, Campbell J: Intraoperative floppy iris syndrome associated with tamsulosin. The resection of the prostate is performed using a water jet from a transurethrally placed robotic handpiece. J Urol 2018; Gilling P, Barber N, Bidair M et al: Randomized controlled trial of Aquablation vs. transurethral resection of the prostate in benign prostatic hyperplasia: one-year outcomes. The current literature on the standard surgical options as well as on minimally invasive procedures was similarly reviewed. In men with LUTS predominantly due to BPH, the reason for failure may be related to medication efficacy; as such, procedural or surgical options may be considered. Uroflowmetry is a simple and risk-free, office-based procedure that can be an important adjunct in the evaluation of LUTS. For example, intravesical protrusion (e.g., intravesical lobe, ball-valving middle lobe) has been recognized to predict poor outcomes from watchful waiting and most medical therapies.29Some of the available MISTs are indicated for prostates between specific sizes (i.e. More specifically, computational biology and genomic factors should be aimed toward understanding drivers of BPH and prostate growth and therapeutic targets. J Sex Med 2012; Agrawal MS, Yadav A, Yadav H et al: A prospective randomized study comparing alfuzosin and tamsulosin in the management of patients suffering from acute urinary retention caused by benign prostatic hyperplasia. In 2018, the draft Guideline focusing on surgical management was distributed to 130 peer reviewers of which 58 returned comments. Patients newly treated for AUR with alpha blockers should complete at least three days of medical therapy prior to attempting trial without a catheter (TWOC). Ottawa, Canada: Evidence Partners. From subjective feeling to objective data. RWT surgery utilizes a robotic handpiece, console, and conformal planning unit (CPU). Regarding the comparative efficacy, effectiveness, and safety of monopolar versus bipolar TURP, there are five systematic reviews and meta-analyses published between 2009 and 2015 that compared bipolar TURP to monopolar TURP.229-233 None of the authors found significant differences in terms of improvement in IPSS and peak urinary flow rates at 12 months, the main efficacy parameters of interest. 67. Finasteride Long-Term Efficacy and Safety Study Group. Following initial publication in 2018, this Guideline underwent an amendment in 2019 that included literature published through January 2019. For IPSS and IPSS-QoL, reviewers determined the statistical significance of the effect of interventions versus control but defined clinical efficacy based on whether the mean or median effect between intervention and control exceeded thresholds for clinical significance (i.e., the MDD). Las ratas se distribuyeron en 6 grupos: control negativo y positivo . After production, testosterone is circulated via the bloodstream to the prostate gland, and then enters into the cells by simple diffusion. (Moderate Recommendation; Evidence Level: Grade C). What Urologists Need to Know about Telehealth, Benign Prostatic Hyperplasia (BPH) Guideline, Confederacion Americana de Urologia (CAU), Volunteer Opportunities for Residents and Young Urologists, Residents and Fellows Committee Activities, Residents and Fellows Committee Essay Contest, Frequently Asked Questions about the Residents Forum, The AUA Residents and Fellows Committee Teaching Award, Young Urologists of the Year Award Winners, Young Urologists Podcasts & Webcast Series, Practice Guideline for Urologic Ultrasound, Urologic Ultrasound Practice Accreditation, Training Guidelines for Urologic Ultrasound, Request a Hands-on Urologic Ultrasound Course, BLUS Handbook of Laparoscopic and Robotic Fundamentals, Accredited Listing of U.S. Urology Residency Programs, Additional Fellowships for Internationals, Continuing Medical Education & Accreditation, AUA Continuing Education (CE) Mission Statement, Section Meeting Request for Course of Choice, Confidentiality Statement for Online Education, Sexual Activity and Cardiovascular Disease, Engage with Quality Improvement and Patient Safety (E-QIPS), Clinical Consensus Statement and Quality Improvement Issue Brief (CCS & QIIB), Improving Advanced Prostate Cancer Patient Management and Care Coordination, Activities for the AUA Leadership Program, Urology Scientific Mentoring and Research Training (USMART), Brandeis University’s Executive MBA for Physicians, Resources for Coding and Reimbursement Process, Holtgrewe Legislative Fellowship Program Application, 2023-2024 AUA Science & Quality Fellow Program Application, 2020-2021 AUA Science & Quality Fellow Program Application, Quality Payment Program Improvement Activities, Boston Scientific Medical Student Innovation Fellowship, Physician Scientist Residency Training Awards, Drug Development in NMIBC from Scientific, Regulatory, Clinician, and Patient Perspectives, NIDDK/AUA Congenital Anomalies of External Genitalia Workshop, Methods in Clinical Urology Research Workshop, Surgical Mangement Algorithm associated with this guideline, Trial of Medical Therapy Algorithm associated with this guideline, Basic Management Algorithm associated with this guideline, AQUA 12: Benign Prostate Hyperplasia: IPSS improvement after diagnosis, AQUA 26: Benign Prostate Hyperplasia Care: Benign Prostate Hyperplasia, https://www.fda.gov/drugs/information-drug-class/5-alpha-reductase-inhibitor-information, https://www.urologix.com/clinicians/cooled-thermotherapy.php, Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) is substantial Applies to most patients in most circumstances and future research is unlikely to change confidence, Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) is substantial Applies to most patients in most circumstances but better evidence could change confidence, Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) appears substantial Applies to most patients in most circumstances but better evidence is likely to change confidence (rarely used to support a Strong Recommendation), Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) is moderate Applies to most patients in most circumstances and future research is unlikely to change confidence, Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) is moderate Applies to most patients in most circumstances but better evidence could change confidence, Benefits > Risks/Burdens (or vice versa) Net benefit (or net harm) appears moderate Applies to most patients in most circumstances but better evidence is likely to change confidence, Benefits = Risks/Burdens Best action depends on individual patient circumstances Future research unlikely to change confidence, Benefits = Risks/Burdens Best action appears to depend on individual patient circumstances Better evidence could change confidence, Balance between Benefits & Risks/Burdens unclear Alternative strategies may be equally reasonable Better evidence likely to change confidence, A statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. IPSS-QoL was reported in two trials.19,20 At 24 months, median QoL was 2 in both arms in one trial,20 and mean IPSS-QoL was 0.9 and 1.4 in the other trial.54 Comparable to the overall analysis, need for blood transfusion (peri- and post-operative) and incontinence were similar in the HoLEP and TURP groups. Pooled results showed successful TWOC may be greatly increased with alfuzosin compared to placebo, 60% versus 39% (OR: 2.28; 95%CI: 1.55, 3.36). 81. The review team worked closely with the Panel to refine the scope, key questions, and inclusion/exclusion criteria. Cent European J Urol 2017; Prieto L, Romero J, Lopez C et al: Efficacy of doxazosin in the treatment of acute urinary retention due to benign prostate hyperplasia. J Urol 2011; Naspro R, Gomez Sancha F, Manica M et al: From "gold standard" resection to reproducible "future standard" endoscopic enucleation of the prostate: what we know about anatomical enucleation. After review of the recommendations for diagnosis published by the 2005 International Consultation of Urologic Diseases12 and reiterated in 2009 in an article by Abrams et al (2009), the Panel unanimously agreed that the contents were valid and reflected "best practices". In addition, this could provide more uniform approaches to treatment success and failure and gateways to both minimally-invasive and surgical therapies. Certain treatment modalities recommended in the Guideline may be unavailable to some clinicians, for example due to lack of access to the necessary equipment/technology or a lack of expertise in the use of such modalities. Diode lasers used in urology have variable wavelengths and several have been utilized for enucleation, but only by a handful of surgeons with few studies. (Expert Opinion), Pressure flow studies are the most complete means to determine the presence of BOO.36 Non-invasive tools provide useful information, but only pressure flow studies can document detrusor contractility, or lack thereof. 62. Although not a primary outcome, symptom and flow rate improvement were superior in the combination therapy arm compared to both monotherapies. One large (n=222) low ROB, 12-week trial comparing solifenacin 6 and 9 mg to placebo in men with moderate-severe LUTS (IPSS≥13) showed no significant difference in IPSS (-6.3 placebo, -6.0 solifenacin 6 mg, -6.3 solifenacin 9 mg). Histopathologic analysis of tissue obtained after PUL demonstrates a benign response to the implant. J Urol 2005; 173: 1256. Urology 2010; Gilling P, Barber N, Bidair M et al: Water: A double-blind, randomized, controlled trial of aquablation(®) vs transurethral resection of the prostate in benign prostatic hyperplasia. (Conditional Recommendation; Evidence Level: Grade C). World J Urol 2020; Mondaini N, Gontero P, Giubilei G et al: Finasteride 5 mg and sexual side effects: how many of these are related to a nocebo phenomenon? Mean IPSS-QoL was improved from baseline by 49% at 3 years. Colon Patologia Benigna April 2021 0. A unique search strategy was used for each of the three topics. 47. (Conditional Recommendation; Evidence Level: Grade C), Compared to many other surgical interventions, PUL has a higher likelihood of preserving sexual function.302 Woo et al. Incontinence through long-term follow-up was significantly lower with TUMT (0.7%) compared to TURP (3.9%). Turk J Urol 2014; Nuhoglu B, Balci MB, Aydin M et al: The role of bipolar transurethral vaporization in the management of benign prostatic hyperplasia. J Endourol 2002; Helke C, Manseck A, Hakenberg OW et al: Is transurethral vaporesection of the prostate better than standard transurethral resection? 77. Laser treatment of benign prostatic hyperplasia in patients on oral anticoagulant therapy: a review. DHT forms a complex with androgen receptors that is then transported to the nucleus. Safety and QoL issues can be treated with bladder drainage such as intermittent catheterization while the patient is being evaluated for BOO. Regarding the combination of vardenafil with, one tamsulosin, one small trial (n=60) conducted in Italy205 compared vardenafil 10 mg plus tamsulosin 0.4 mg to tamsulosin 0.4 mg alone. Histological BPH is common and may lead to BPE. Superiority of dutasteride 0.5 mg and tamsulosin 0.2 mg for the treatment of moderate-to-severe benign prostatic hyperplasia in Asian men. Hill A, Njoroge P: Suprapubic transvesical prostatectomy in a rural Kenyan hospital. At 12 weeks, combined mirabegron and silodosin resulted in little to no difference in IPSS (MD: 0.30; 95%CI: -1.27, 1.87; moderate quality of evidence) and IPSS-QoL (MD: 0.40; 95%CI: -0.40, 0.81; moderate quality of evidence) compared to combined fesoterodine and silodosin. Response to treatment through 3 months, based on an improvement in IPSS of ≥30% or ≥8 points, was significantly greater in the WVTT group (74%) compared to the SHAM group (31%) (RR: 2.4; 95%CI: 1.6, 3.5). Although the Index Patient defined in the 2003 Guideline was aged 50 or older, the Panel has lowered the age for inclusion in this Guideline, as this lower age group can present with LUTS. TUMT was one of the earliest office-based MISTs available and several iterations have been modified since it was first described over 25 years ago. Independent.245-247 Independent of specific technique, laparoscopic and robotic simple prostatectomy are effective and safe procedures for large to very large glands.248, Finally, the introduction of the single port I robot has prompted some to use this technology for simple prostatectomy as well. A "standard" has the least flexibility as a treatment policy; a "recommendation" has significantly more flexibility; and an "option" is even more flexible. 30. Zhonghua Nan Ke Xue 2002; McConnell J, Wilson J, Goerge F et al: Finasteride, and inhibitor of 5α-Reductase, suppresses prostatic dihydrotestosterone in men with benign prostatic hyperplasia. The responses were then correlated to the changes in the IPSS score at the same follow-up visit and analyzed.27,28. McConnell J, Wilson J, Goerge F et al: Finasteride, and inhibitor of 5α-Reductase, suppresses prostatic dihydrotestosterone in men with benign prostatic hyperplasia. 8. When body of evidence strength Grade B is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances, and better evidence could change confidence. However, both TURP and PVP had statistically higher retreatment rates than men who underwent HoLEP (5%, p=0.03). This conversion is enabled by the enzyme 5AR, of which there are two isoenzymes, known as type I and type II. J Urol 2003; 169: 20. Originalul nou. J Urol 2003; Zhang SY, Hu H, Zhang XP et al: Efficacy and safety of bipolar plasma vaporization of the prostate with "button-type" electrode compared with transurethral resection of prostate for benign prostatic hyperplasia. Hiprplasia Prostática Benigna - Gpc.pdf [3no76pqw85ld]. 84. Surgical interventions for symptomatic BPH are often used and have been described in the management approach.345 However, surgical intervention may not be desired depending on the ability to hold anticoagulation and/or the frailty of the patient. What are the predictors of beneficial effects from treatments? Euro Urol 2012; Porst H, Kim ED, Casabe AR, et al: Efficacy and safety of tadalafil once daily in the treatment of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: results of an international randomized, double-blind, placebo-controlled trial. Urol J 2010; Xie JB, Tan YA, Wang FL et al: Extraperitoneal laparoscopic adenomectomy (Madigan) versus bipolar transurethral resection of the prostate for benign prostatic hyperplasia greater than 80 ml: complications and functional outcomes after 3-year follow-up. 11. BJU Int 2011; Foley SJ, Soloman LZ, Wedderburn AW et al: A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. Overall withdrawals were 13% with combined mirabegron and silodosin and 17% with combined fesoterodine and silodosin (RR: 0.80; 95%CI: 0.34, 1.89). (Moderate Recommendation; Evidence Level: Grade C). Palabras Clave: Amplitud de distribucion eritrocitaria (ADE) - hiperplasia benigna de prostatica. From the urologist’s perspective, successful attributes might include: 1. In the phase III silodosin studies, it was noted that the number of men reporting EjD as an adverse event decreased from 46% to 11% for men in their 50s versus 70s, respectively, and the number of men discontinuing treatment due to the adverse events decreased from 4.7% to 0 %.91,92. Mean age of study participants was 63 years. 13. J Clin Psychiatry 2012; Irwig MS and Kolukula S: Persistent sexual side effects of finasteride for male pattern hair loss. A fast learning curve, 3. Significant heterogeneity between most identified studies limits confidence of outcomes in pooled analysis of ThuLEP versus TURP. BJU Int 2017; Anticoagulation and Antiplatelet Therapy in Urologic Practice: ICUD and AUA Review Paper 2014. http://www.auanet.org/guidelines/anticoagulation-and-antiplatelet-therapy. LUTS may be due to structural or functional abnormalities in one or more parts of the lower urinary tract that comprises the bladder, bladder neck, prostate, distal sphincter mechanism, and urethra. Flow rates of <10 mL/s have shown a specificity of 70%, a positive predictive value of 70%, and a sensitivity of 47% for BOO.24 If the patient's condition is not sufficiently suggestive of obstruction (e.g., peak urinary flow [Qmax] >10 mL/sec), pressure flow studies should be considered as treatment failure rates are somewhat higher in the absence of obstruction. Wurzel R, Ray P, Major-Walker K et al: The effect of dutasteride on intraprostatic dihydrotestosterone concentrations in men with benign prostatic hyperplasia. Short recovery time with rapid return to life activities, 4. In one study evaluating both IPSS and IIEF scores, sildenafil 25 mg with tamsulosin 0.4 mg resulted in significant changes in the IPSS. P Hiperplasia Prostática Benigna, I. de intervenção . Discrepancies were resolved by consensus. The procedure is generally performed with saline irrigation, eliminating the possibility of TUR syndrome that can occur with non-ionic irrigation. Since the main difference between monopolar and bipolar TURP is regarding TUR syndrome, which is unique to TURP and no other treatment, safety parameters other than TUR syndrome can also be compared between surgical interventions and monopolar and bipolar TURP. Hiperplasia Benigna De Prostata July 2021 0. Conditional Recommendations also can be supported by any evidence strength. J Endourol 2009; Garcia-Segui A, Gascon-Mir M: Comparative study between laparoscopic extraperitoneal and open adenomectomy. Barcelona: Doyma, 1989;1808-9. Libido does not appear to be affected significantly by surgical therapy, and some studies have even shown an improvement in erectile function (EF) after surgical treatment ((this improvement is controversial as other studies show a worsening of EF).20 Most importantly, sexual side effects from surgical treatments are more likely to be permanent than those from medical treatments, which can often be reversed by stopping medical treatment or switching to an alternative treatment. Six RCTs (n=601) compared effectiveness of TUVP and bipolar TURP.272-277 Mean age was 66 years (range 60 to 69), baseline IPSS was 21 (range 18 to 24), and mean prostate volume was 56mL (range 32 to 64). Transl Androl Urol 2016; Hueber PA, Ben-Zvi T, Liberman D et al: Mid term outcomes of initial 250 case experience with GreenLight 120W-HPS Photoselective vaporization prostatectomy for benign prostatic hyperplasia: comparison of prostate volumes <60 cc, 60 cc-100 cc and > 100cc. size versus morphological characteristics and their relative importance in producing symptoms, obstructive versus irritative symptoms relative to prostate morphology and size, and patient phenotypes relative to urologic symptom profiles). We expect these concerns to grow in importance with the aging of our nation and the obesity epidemic. (Expert Opinion). Study. BJU Int 2010; Horasanli K, Silay MS, Altay B et al: Photoselective potassium titanyl phosphate (KTP) laser vaporization versus transurethral resection of the prostate for prostates larger than 70 mL: a short-term prospective randomized trial. J Urol 2006; 175: 1691. One high-quality randomized trial conducted in the US with 369 subjects showed that at 12 weeks, sildenafil 50-100 mg improved the IPSS by 6.3 points compared to 1.9 for placebo.181 IPSS change was also greater in the sildenafil group with severe and moderate LUTS. It is the hope of this Panel that further data will be available in the peer reviewed literature on these therapies to allow incorporation into future iterations of this Guideline. (Strong Recommendation; Evidence Level: Grade A), Anticholinergic agents, alone or in combination with an alpha blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS. While there are several medical and surgical ways to reduce the influence of androgenic steroids on the growth of the prostate (e.g., medical or surgical castration), the only hormonal therapies with an acceptable benefit-to-RR are the 5-ARIs. (Expert Opinion), Clinicians should consider assessment of prostate size and shape via transrectal or abdominal ultrasound, cystoscopy, or cross-sectional imaging (i.e., magnetic resonance imaging [MRI]/ computed tomography [CT]) if such studies are available, prior to intervention for LUTS/BPH. Nocturia is often multifactorial in origin and symptomatic of other medical problems, further complicating effective management. RJM 2014; Lee SH, Chung BH, Kim SJ et al: Initial combined treatment with anticholinergics and α-blockers for men with lower urinary tract symptoms related to bph and overactive bladder: A prospective, randomized, multi-center, double-blind, placebo-controlled study. Four randomized, placebo-controlled, well-executed studies,160-163 two non-controlled studies,164,165 and one randomized study with poorly defined methods of measuring blood loss166 explored the ability of 5-ARIs prior to surgery to reduce blood loss associated with TURP. BJU Int 1999; 84: 972. In men concerned about new onset of ED and/or EjD, PUL likely does not pose additional risk. Table 4. The specificity of the outcome (the persistence or onset of new sexual dysfunction) is virtually non-existent given that sexual dysfunction occurs at background rates in all men and not just in men who use 5-ARI’s.135,157 As for biological gradient as one criteria of the Bradford-Hill criteria, it is difficult to understand how 1 mg of finasteride may cause persistence when the 5 mg dose of the same drug is much less likely.151,152 Additionally, the more broadly acting dutasteride (activity at Type I and II receptors) has been less implicated than the more specific finasteride (activity at Type II receptors only). In the first trial, combined tadalafil and alpha blocker resulted in little to no difference in IPSS compared to alpha blocker alone at 12 weeks (-2.3 versus -1.5 points; MD: -0.79 points; 95%CI: -2.00, 0.42; moderate quality of evidence).203 In the second trial, a combination of tadalafil 5 mg and tamsulosin 0.4 mg compared to tadalafil alone resulted in little to no difference in IPSS (-9.5 points versus -8.1 points; MD: -1.3 points; 95%CI: -2.54, -0.10; high quality of evidence) and IPSS-QoL (MD: -0.1 points; 95%CI: -0.39, 0.11; high quality of evidence).14 There was little to no difference in change in IIEF (9.2 points versus 9.5 points; MD: -0.3 points; 95%CI: -1.47, 0.83; moderate quality of evidence). All were low ROB randomized controlled 12-week trials. These procedures include monopolar and bipolar TURP, robotic simple prostatectomy (retropubic, suprapubic, and laparoscopic), TUIP, bipolar TUVP, PVP, PUL, thermal ablation using TUMT, WVTT, TUNA, enucleation using HoLEP or ThuLEP, RWT, and PAE. Caine M, Raz S, Zeigler M: Adrenergic and cholinergic receptors in the human prostate, prostatic capsule and bladder neck. Other psychological effects, such as increased suicidality and psychological adverse events, have also been examined.144, Two observation studies have examined the risk of diabetes to men on 5-ARI; however, these trials have yielded contradictory results.145,146, PFS is a controversial and poorly-defined constellation of chronic 5-ARI-induced sexual, physical, and psychological symptoms that putatively persist after discontinuation of the 5-ARI.147-150 Concerns regarding PFS prompted the FDA to amend the labels for 5-ARI with a warning of its risks. 2007; Salonia A, Gallina A, Briganti A et al: Remembered international index of erectile function domain scores are not accurate in assessing preoperative potency in candidates for bilateral nerve-sparing radical retropubic prostatectomy. This document was written by the Benign Prostatic Hyperplasia Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2016. Tamsulosin at a dose of 0.4 mg/day, however, does not appear to significantly potentiate the hypotensive effects of sildenafil.88 Regardless, patients utilizing both these medications should be counselled appropriately regarding the risk for drops in blood pressure and symptoms associated with this. Urology 2001; Fawzy A, Hendry A, Cook E et al: Long-term (4 year) efficacy and tolerability of doxazosin for the treatment of concurrent benign prostatic hyperplasia and hypertension. J Urol 2015; Unger JM TC, Thompson IM Jr, Tangen CM et al: Long-term consequences of finasteride vs placebo in the prostate cancer prevention trial. (Conditional Recommendation; Evidence Level: Grade B), PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH. J Urol 2009; 181: 963. Mean changes in IPSS from baseline through 3 months was greater with TUMT compared with SHAM (-10 and -5.8 points, respectively).57 Need for recatheterization for transitory urinary retention and gross hematuria was reported for 17% and 9% of the TUMT participants compared to none for the SHAM group. Sandfeldt L, Bailey D, Hahn R: Blood loss during transurethral resection of the prostate after 3 months of treatment with finasteride. The baseline IPSS score predicates the change in IPSS needed to achieve threshold improvements in IPSS and GSA: the greater the baseline IPSS score, the more of a drop is required to achieve improvements in GSA. Development of a Patient-Centered Approach to Improve Adherence and Compliance. The Surgical BPH Panel was created in 2016 by the American Urological Association Education and Research, Inc. J Xray Sci Technol 2013; Kumar A, Vasudeva P, Kumar N et al: A prospective randomized comparative study of monopolar and bipolar transurethral resection of the prostate and photoselective vaporization of the prostate in patients who present with benign prostatic obstruction: a single center experience. The one-year outcome data from the Gilling study revealed one participant in the TURP group (2%) and 3 in the RWT group (3%) required surgical retreatment for BPH (RR: 1.68; 95%CI: 0.17, 15.83).79 At 36 months, one participant in the TURP group (1.5%) and 5 in the RWT group (4.3%) required surgical retreatment for BPH (RR: 2.80; 95%CI: 0.33, 23.47). In appropriate patients for whom the physical size of the prostate cannot be addressed due to the expertise of the surgeon via a safe or efficacious transurethral approach, simple prostatectomy (i.e., adenoma enucleation) may be considered using an open, laparoscopic or robotic-assisted approach. Bleeding and drops in hemoglobin seem to favor bipolar TURP but with a relatively high degree of heterogeneity in both meta-analyses. J Endourol 2012; Lukacs B, Loeffler J, Bruyere F et al: Photoselective vaporization of the prostate with GreenLight 120-W laser compared with monopolar transurethral resection of the prostate: a multicenter randomized controlled trial. Urodynamic measures remained unchanged during the study with no statistically significant difference between tadalafil and placebo in change in any urodynamic parameter assessed including Qmax, maximum detrusor pressure, BOO index or bladder capacity (all measures p ≥0.13). Further study of this topic to address systemic biases in the LUTS/BPH care of these populations would substantially inform this Guideline and promote healthcare equity. PAE is a technically demanding procedure, averaging fluoroscopy times of up to 50 minutes and procedure times up to 2 hours.344 Attainment of proficiency involves a challenging learning curve for physicians who—while trained in the performance of endovascular interventions—may be less familiar with core concepts of BPH pathophysiology, diagnosis, treatment, and follow-up.344 It is thus the opinion of the Panel that PAE should only be performed in the context of a clinical trial or registry study until additional evidence is available to indicate definitive clinical benefit and define specific indications. Berkow R, Fletcher AJ, et al. La prevalencia de disfunción eréctil en conjunto con hiperplasia prostática benigna es del 5.2-40%, y los pacientes con hiperplasia prostática benigna es 1.33-6.24 veces más frecuente que tengan disfunción eréctil que aquellos sin hiperplasia prostática benigna. Br J Urol 1998; Brown CT, Yap T, Cromwel DA et al: Self management for men with lower urinary tract symptoms: randomised controlled trial. In a study focused only on Asian men and using a 0.2 mg tamsulosin dose, men with characteristics often associated with disease progression obtained better symptomatic benefit from combination therapy compared to monotherapy with tamsulosin. In all instances, patients should be provided with the risk/benefit profile for all treatment options in light of their circumstances to allow them to make informed decisions regarding their treatment plans. Benign Prostatic Hyperplasia (BPH) Guideline Management of Benign Prostatic Hyperplasia/ Lower Urinary Tract Symptoms (2021) The goal of this revised guideline is to provide a useful reference on the effective evidence-based surgical management of male lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). Dutasteride is the second 5-ARI approved by the U.S. Food and Drug Administration (FDA) for the use in men with LUTS and BPH.119 Initial phase-3 randomized studies demonstrated the efficacy of dutasteride and were reviewed along with the 2 year CombAT trial data.120-122 Roehrborn and colleagues (2002) randomized 4,325 men with BPH and moderate to severe symptoms to dutasteride 0.5 mg daily or to placebo and followed them for 24 months.123 These data are pooled from three identical phase-three clinical trials, encompassing 400 sites in the United States and 19 other countries. J Cataract Refracr Surg 2006; 32: 1336. The Panel noted that PVP may be less efficacious for larger volume prostates and that patient expectations should be aligned accordingly. High-grade cancer was more frequent in the finasteride group (6.4% versus 5.1%).126, The REDUCE trial enrolled 8,000 men with a PSA 2.5-10, negative biopsy within 6 months of enrollment, and a planned per protocol biopsy at years 2 and 4. On the 5 mg dose at 6 weeks, the proportion of participants on the 5 mg dose of tadalafil was also significantly greater than participants on placebo 49% versus 36%. The mean change in Qmax at 3 months was higher for those who underwent PUL (4.3mL/s) compared to SHAM (2.0mL/s), P=.005. Long standing BOO from BPH can progress to incomplete bladder emptying, bilateral hydroureteronephrosis, and, ultimately, acute and/or chronic renal insufficiency. Cantrell M, Bream-Rouwenhorst H, Steffensmeir A et al: Intraoperative floppy iris syndrome associated with alph-adrenergic receptor antagonists. 28. Gacci M, Bartoletti R, Figlioli S et al: Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study. Urology 1995; 45: 768. J Urol 2013; Fayad AS, Elsheikh MG, Zakaria T et al: Holmium laser enucleation of the prostate versus bipolar resection of the prostate: a prospective randomized study. When assessing for absolute risk reduction for men on dutasteride compared to placebo, there were noticeable differences both with AUR (6% risk reduction) and BPH-related surgery (3.8%).124. Two trials reported significant differences in maximum urine flow at 12 months favoring OSP, while one trial found no difference between the groups. 66. Minerva Urol Nefrol 2017; Habib EI, ElSheemy MS, Hossam A et al: Holmium laser enucleation versus bipolar plasmakinetic resection for management of lower urinary tract symptoms in patients with large-volume benign prostatic hyperplasia: Randomized-controlled trial. Reynard J: Does anticholinergic medication have a role for men with lower urinary tract symptoms/benign prostatic hyperplasia either alone or in combination with other agents? Less frequently, LUTS/BPH has been associated with other comorbidities including AUR, renal insufficiency, and the development of gross hematuria, bladder calculi, urinary incontinence and recurrent urinary tract infection (UTI).8, 9. Physicians should prescribe an oral alpha blocker prior to a voiding trial to treat patients with AUR related to BPH. Hiperplasia Prostatica Benigna July 2021 0. Miller M, Puchner P: Effects of finasteride on hematuria associated with benign prostatic hyperplasia: long-term follow-up. BJU Int 2010; Karaman MI, Kaya C, Ozturk M et al: Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-yearfollow-up. Funding of the Guideline was provided by the AUA; panel members received no remuneration for their work. Semmens J, Wisniewski Z, Bass A et al: Trends in repeat prostatectomy after surgery for benign prostate disease: application of record linkage to healthcare outcomes. Urology 2002; Roehrborn CG, Lukkarinen O, Mark S et al: Long-term sustained improvement in symptoms of benign prostatic hyperplasia with the dual 5alpha-reductase inhibitor dutasteride: results of 4- year studies. PVP is a transurethral form of treatment that utilizes a 600-micron side firing laser fiber in a noncontact mode. Urology 2003; Roehrborn CG, Boyle P, Gould AL et al: Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. Curr Opin Urol 2004; Bent S, Kane C, Shinohara K et al: Saw palmetto for benign prostatic hyperplasia. J Urol 2009; 181: 1779. TURP remains the historical standard by which all other subsequent surgical approaches to treatment of BPH are compared and serves as the reference group for all other techniques in this Guideline. 2011; van Melick HH, van Venrooij GE, Boon TA: Long-term follow-up after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization. Impacto del brote de COVID-19 en las listas de espera de. Compared to traditional resection loops, the various TUVP designs aspire to improve upon tissue visualization, blood loss, resection speed and patient morbidity. For IPSS this is a difference of >3 points. Actas Urological Espanolas 2017; Chang CH, Lin TP, Chang YH et al: Vapoenucleation of the prostate using a high-power thulium laser: a one-year follow-up study. 2006; Gupta NP, Doddamani D, Aron M et al: Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc. Public Health Nutr 2000; 3: 459. Guideline summaries as they appear in The Journal of Urology® (2021) Part I, Part II, Unabridged version of this guideline [pdf] Surgical Mangement Algorithm associated with this guideline [pdf] Trial of Medical Therapy Algorithm associated with this guideline [pdf] Basic Management Algorithm associated with this guideline [pdf]Español translated guideline and translated algorithm courtesy of Confederacion Americana de Urologia (CAU) [pdf], J. Kellogg Parsons, MD; Lori B. Lerner, MD; Michael J. Barry, MD; Anurag Kumar Das, MD; Manhar C. Gandhi, MD; Steven A. Kaplan, MD; Tobias S. Kohler, MD; Leslie Martin, MD; Claus G. Roehrborn, MD; John T. Stoffel, MD; Charles Welliver, MD; Kevin T. McVary, MD. World J Urol 2014; Peng B, Wang G, Zheng J et al: A comparative study of thulium laser resection of the prostate and bipolar transurethral plasmakinetic prostatectomy for treating benign prostatic hyperplasia. Malek R, Kuntzman R, Barrett D: High power potassium-titanyl-phosphate laser vaporization prostatectomy. Hiperplasia Prostática Benigna September 2021 Publisher: Editora Atheneu Authors: Guilherme Andrade Peixoto Hospital Israelita Albert Einstein Download full-text PDF Read full-text Discover. Of the participants randomized to PUL, five-year follow-up data demonstrated slight decreases in mean IPSS and QoL scores; however, both remained significantly improved from baseline. JU 2008; Takeda M, Nishizawa O, Imaoka T et al: Tadalafil for the treatment of lower urinary tract symptoms in japanese men with benign prostatic hyperplasia: results from a 12-week placebo-controlled dose-finding study with a 42-week open-label extension. First, there are no properly designed studies (e.g., using appropriate controls and addressing the issues described above with respect to the study of sexual function) that report a significant association between discontinuation of finasteride and persistence of sexual dysfunction. Eur Urol 1996; 29: 439. Transurethral surgery. Int Urol Nephrol 2006; 38: 275. (Clinical Principle). Unfortunately, either return to or de novo use of medication is difficult to report and varies considerably by study. 6. BMJ 2019; Lee S, Yang Y, Tsai T et al: 5-alpha-reductase inhibitors and the risk of diabetes mellitus: a nationwide population-based study. The Panel agreed that it is important to share the following observations regarding the use of 5-ARIs and prostate cancer prevention, risk reduction, the risk of high-grade disease, and the danger of not paying attention to the expected 50% reduction in PSA under 5-ARI treatment. Reductions in the risk of AUR and BPH related surgery were also seen. Like Nd:YAG, the depth of penetration is deeper than PVP. 42. Mean IIEF-EF score was 14.4, indicative of mild-moderate ED. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burdens is unclear. In addition, a better definition of potential long-term complications of medical therapy needs to be delineated in the quest for enhancing both prescriber and patient choice. J Endourol 2014; Omar MI, Lam TB, Alexander CE et al: Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (turp). BPH and ensuing LUTS is a significant health issue affecting millions of men. Since there are no differences in efficacy, it is reasonable to compare surgical interventions in this Guideline document with either monopolar or bipolar TURP series regarding efficacy measures. J Urol 2004; Russell D, Wilson J: Steroid 5alpha-reductase: two genes/two enzymes. La obstrucción del tracto de salida ha sido asociada con la hiperplasia prostática benigna (HPB), dado el crecimiento progresivo del adenoma, lo cual lleva a un incremento en la resistencia al flujo urinario, junto con un efecto deletéreo en la función renal. The presence of moderate-to-severe LUTS was also associated with the development of AUR as a symptom of BPH progression, increasing from an incidence of 6.8 episodes per 1,000 patient years of follow-up in the overall population to a high of 34.7 episodes in men aged 70 and older with moderate-to-severe LUTS. In reviewing the need for blood transfusion, either peri- or post-operatively, likelihood was significantly lower compared to TURP for both HoLEP (RR: 0.18; 95%CI: 0.08, 0.40) and ThuLEP (RR: 0.4; 95%CI: 0.2, 0.8). Relative risk reduction of the period prevalence of prostate cancer was 23%, with 25.1% in control group versus 19.9% in dutasteride group being diagnosed. The AUA-SI and the International Prostate Symptom Score (I-PSS) (Appendix A6)10, 11 are nearly identical, validated short, self-administered questionnaires, used to assess the severity of three storage symptoms (frequency, nocturia, urgency) and four voiding symptoms (feeling of incomplete emptying, intermittency, straining, and a weak stream). While anticholinergics alone have been used for OAB symptoms in men and women, there has been some reluctance on the part of clinicians to use them alone in patients with LUTS/BPH due to the potential risk of worsening bladder residuals or retention. J Endourol 2005; Kaya C, Ilktac A, Gokmen E et al: The long-term results of transurethral vaporization of the prostate using plasmakinetic energy. Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of change in medical management or surgical intervention. The majority of studies address the impact of PDE5s on LUTS/BPH used tadalafil. Incidence of urinary retention did not differ between mirabegron 100 mg and placebo (2%). BJU Int 2018; Hagberg K, Divan HA, Fang SC et al: Risk of gynecomastia and breast cancer associated with the use of 5-alpha reductase inhibitors for benign prostatic hyperplasia. Urology 2003; Bautista OM, Kusek JW, Nyberg LM et al: Study design of the Medical Therapy of Prostatic Symptoms (MTOPS) trial. Scand J Urol Nephrol 2005; Hahn RG, Fagerstrom, T., Tammela, T. L., Van Vierssen Trip, O., Beisland, H. O., Duggan, A. and Morrill, B.: Blood loss and postoperative complications associated with transurethral resection of the prostate after pretreatment with dutasteride. JSM 2017; Gacci M, Vittori G, Tosi N et al: A randomized, placebo-controlled study to assess safety and efficacy of vardenafil 10 mg and tamsulosin 0.4 mg vs. tamsulosin 0.4 mg alone in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. The Panel concluded that substantial issues remain in recommending PAE for the routine treatment of bothersome LUTS attributable to BPH. Systematic reviews and meta-analyses were searched to identify additional eligible studies. Sexually-related adverse events have been examined in a variety of randomized studies with dutasteride groups.124,131-134 ED rates from the REDUCE trial were 9% versus 5.7% in the placebo group (ARD: 3.2%; 95%CI: 2.1, 4.4).131 At 2-years, the CONDUCT trial reported that the incidence of ED was greater with dutasteride combined with tamsulosin compared with tamsulosin monotherapy at 8% versus 0% (ARD: 8%; 95%CI: 5, 10.7).
Marketing Digital Para Restaurantes Pdf, Resultados Encuesta Nacional De Hogares, La Bonbonniere Restaurante, Alimentación En Lactantes De 0 A 6 Meses Pdf, Prácticas Pre Profesionales Economía,