SUFU 2019: The Impact of the New Guidelines on the Management of BPH in 2019

Miami, FL ( Dr. Foster leads the audience through the AUA BPH Guidelines briefly emphasizing the new changes /updates that will be seen in the new updated BPH guidelines.  Why talk about new guidelines now? Several BPH therapies have emerged and will be getting incorporated into the guidelines.  Aquablation, urethral prostatic lift, prostate artery embolization, water thermal therapy, etc. Medical management is also being looked at and will be updated in the new guidelines.

His talk started with the basic evaluation of the patient along with preoperative testing. Each point is listed below.

  1. AUASI and shared decision-making approach should be used as a guide. Pros and cons of each therapy should be discussed with the patient and provider.
  2. Prostate imaging was not necessary before these new guidelines, however, with the new emerging therapies, prostate size and anatomy characteristics are necessary. 
  3. Post-void residual (PVR) can give some indication of lower urinary tract function but still a clinical principle.
  4. Non-invasive uroflowmetry is also an indicator of lower urinary tract function but also a clinical principle. 
  5. Clinicians should consider pressure/flow studies (Urodynamics) before surgery for lower urinary tract symptoms. This is the most accurate to determine the presence of bladder outlet obstruction. This is considered an expert opinion since no randomized prospective trials have been done. 
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  1. Surgery is recommended for patients who have renal insufficiency, refractory urinary retention, recurrent UTI, recurrent bladder stones or gross hematuria due to BPH. These patients are usually older and have more co morbidities.
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The imaging modalities can be abdominal or transrectal ultrasoumd, pelvic MRIs or even cystoscopy. DRE and PSA are rough indicators for prostate size and less accurate.  

  1. Operating for asymptomatic bladder diverticuale is not recommended, this is new in the guidelines.  
  2. Transurethral resection of the prostate (TURP) is still considered the gold standard. Most of the studies comparing other methods are compared to TURP in clinical trials.
  3. Monopolar and bipolar TURPs have the same outcome
  4. Simple prostatectomy can be offered to the patient and can be done by different techniques. The choice of the technique (open, laparoscopic, robotic) all depends on clinical expertise. There is no size cutoff for when to perform the procedure.  With the availability of bipolar TURP that allows for longer resection, many patients may not need a prostatectomy.
  5. Transurethral incision of the prostate can be offered to patients with small glands. This technique has less bleeding and less retrograde ejaculation.
  6. Transurethral vaporization of the prostate can be offered.
  7. Photvaporization can be offered to patients but should be used at120W or 180W. The higher wattage is more superior and efficacious. The similar outcome as TURP but caution should be used as there can be a higher rate of bleeding with larger prostates.
  8. Prostate urethral lift needs assessment of prostate size and anatomy. Prostate size should be < 80 g and absence of obstructing middle lobe as determined by the surgeon. The incontinence rates can be better. 
  9. Sexual and ejaculatory function can be preserved with prostate urethral lift
  10. Transurethral microwave therapy can be offered but patients should be warned that there are higher surgical retreatment rates.
  11. Water vapor thermal therapy can be offered but the prostate size cutoff is < 80 g. When compared to sham treatment maintained at 3 years. Serious adverse events were the same in the sham and therapy group. Non serious adverse events were higher in the treatment group.  
  12. Sexual and ejaculatory function preserved in water vapor thermal therapy
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  1. Transurethral needle ablation should not be used. There are no recent peer-reviewed publications.
  2. Holep and Thulep depends on surgeon expertise and the prostate size is independent of outcome. Once the learning curve is met by the surgeon, these are reasonable options.
  3. Prostate artery embolization is not recommended for the treatment of lower urinary tract symptoms outside of clinical trial for index patients. It is important to note that Dr. Foster reiterated this several times. If a patient is to undergo the procedure it should involve a multidisciplinary team. There is concern that patients are going to interventional radiology with evaluation by a urologist.  
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Lastly, 22. Medically complicated patients, or patients at higher risk of bleeding, or cannot come off anticoagulation, Holep, thulep, and PVP are reasonable options. In the new update, there will be more information about Aquablation. One of the issues is the risk of bleeding that may need foley traction or cauterization for hemostasis. There are lower rates of retrograde ejaculation. Studies are limited 
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Presented by: Harris Emilio Foster, MD, Professor of Urology, Yale School of Medicine

Written by: M Lira Chowdhury, DO, Fellow, Female Urology, Pelvic Reconstructive Surgery & Voiding Dysfunction, The University of California Irvine, Department of Urology, @lirachowdhury at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting, SUFU 2019, February 26 - March 2, 2019, Miami, Florida
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