The impact of changing trends in medical therapy on surgery for benign prostatic hyperplasia over two decades, "Beyond the Abstract," by In Ho Chang, MD, et al

BERKELEY, CA (UroToday.com) - Our design of this abstract was to know how new medication therapy changed management of benign prostatic hyperplasia (BPH).

The development of alpha-blockers in the early 1990s made a medical breakthrough for BPH.[1] After the early 2000s, combination therapy with 5-alpha reductase inhibitors (5ARI) has resulted in changes in the management of lower urinary tract symptoms (LUTS) secondary to BPH.[2] In the Proscar Long-Term Efficacy and Safety (PLESS) and Medical Therapy of Prostate Symptoms (MTOPS) studies, medical therapy reduced the incidence of urinary retention and the need for invasive surgery.[3] Now medical therapy has become first line treatment for BPH. Nevertheless, surgery for BPH is still performed, and some patients suffer from symptomatic deterioration despite long-term medical therapy.

bta ho changThe aim of this study was to compare the outcome in patients who underwent surgery between the period 1985-1989 before the widespread use of medical therapy for BPH, to that in the period 1995-1999, when medical therapy was developed and began to be prescribed as alternative treatment to surgery, and to that in 2005-2009, when medical therapy became the primary treatment over surgical intervention and when combination therapy had become commonly adopted.

We investigated age, comorbidity, body mass index (BMI), PSA level, prostate volume, prostate transitional zone volume, maximum urinary flow rate, post-void residual urine volume, international prostate symptom score (IPSS), QoL score, BPH medication, and chief complaint as the preoperative status. The weight of the resected tissue and transfusion were evaluated as operative parameters. The postoperative course was evaluated as follows: length of hospital stay, the post-operative day on which the catheter was removed, and postoperative complications. Postoperative complications were defined as any event requiring an additional treatment within 1 year of BHP surgery, and were defined as: secondary hemorrhage that required transfusion or hospital admission within 4 postoperative weeks, impaired detrusor contractility that required suprapubic cystostomy due to recurrent acute urinary retention (AUR) or failure to void, repeat surgery for BPH, urethral stricture that required operations of urethra, long-term stress incontinence, and irritative LUTS that required medications until postoperative 1 year.

The medical records of 952 men were included in this study. The mean age and BMI of patients had increased through the past two decades (p<0.001). Hypertension, operation history, and other comorbidities also increased significantly (p<0.001, p=0.005, p<0.001). The indications for surgery in 1985-1989/1995-1999/2005-2009 were respectively AUR in 34.7/20.2/15.1% of patients, and symptomatic deterioration in 61.1/72.3/73.0%. The prostate volume and resected tissue weight were respectively increased from 34.4±14.5 cc to 61.3±32.4 cc and from 7.2±6.4 g to 10.8±7.6 g over two decades. Patients operated in 2005-2009 had theirs removed earlier (p<0.001). Secondary hemorrhage within four postoperative weeks and repeat TURP within one year was significantly reduced (p=0.03, p=0.003). There was no statistical significance in impaired detrusor contractility (p=0.523).

Over the last two decades, medical therapy has been the standard first-line therapy for BPH.[3,4] Our results showed an increasing trend of alpha-blocker monotherapy and combination therapy with 5-alpha reductase inhibitors after the 1990s. However, surgery for BPH was still required and TURP became the main stay of surgical intervention for BPH. Although medical therapy is appropriate for patients with symptomatic BPH, it has obvious limitations. Failure of medical therapy results in worsening LUTS and recurrent AUR. In this study, the most common chief complaint was symptomatic deterioration and the next was AUR.

Our hypothesis was that medical therapy for BPH delayed surgical intervention. Patients who finally required surgery inevitably emerged older, with worse health conditions, and more advanced disease. Therefore, late surgical intervention could result in poorer outcomes associated with worse postoperative complications. In this study, the mean age of patients who underwent surgery was older in the 1990s compared to the 1980s, and the rise was greater after 10 years. A considerable number of patients had hypertension, previous surgical, and other medical history in the 2000s. We thought that increasing comorbidity was due to aging and advancement in diagnostic technique and increasing health concern. Higher BMI means higher risk of comorbidity.[5, 6] In addition, the mean prostate volume and resected weight increased during the 20-year period in patients who underwent surgical intervention for BPH. Reich et alevaluated 10,654 patients who underwent TURP and demonstrated that the mortality and morbidity were closely associated with the weight of tissue resected.[7] According to Mebust et alincreased morbidity was seen in patients with gland size beyond 45 g and age greater than 80 years.[8] However, according to our survey of perioperative and postoperative variables, the numerical value of transfusion, secondary hemorrhage, repeat TURP, length of hospital stay, and days to catheter removal reduced with time. On the other hand, we thought that critical outcomes such as impaired detrusor contractility would be poor. We hypothesized that long-term bladder outlet obstruction would impaire bladder detrusor contractility. Saito et alexperimented with rat bladder after long-term outflow obstruction and found the whole bladder pressure was left significantly lower than controls.[9] However, the number of patients who required suprapubic cystostomy after TURP did not increase significantly. This is because new techniques and equipment also reduced complications and overcame the risks associated with aging.[10, 11] In addition, combination therapy resolved bladder outlet obstruction and protected against progression to impaired detrusor contractility.[12, 13] The result shows us that despite old age and large prostate volume, surgical intervention confers benefits to patients.

Age, comorbidity and prostate volume of patients who underwent surgery for BPH have increased during the two decades studied. This trend explains the increased weight of resected tissue as well as morbidity and mortality rates. However, advances in surgical technique widen the indications of surgery for BPH and reduces complications. Appropriate selection of therapy for the management of BPH will benefit patients.

References: 

  1. Chung BH, Yang KM, Hong SJ. Meta-analysis of Alpha Receptor Antagosist for Benign Prostatic Hyperplasia from Papers that were Published in Korea. Korean J Urol 2005;46:252-8.
  2. Lepor H, Auerbach S, Puras-Baez A, Narayan P, Soloway M, Lowe F, et al A randomized, placebo-controlled multicenter study of the efficacy and safety of terazosin in the treatment of benign prostatic hyperplasia. J Urol 1992;148:1467-74.
  3. McConnell JD, Roehrborn CG, Bautista OM, Andriole GL, Jr., Dixon CM, Kusek JW, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003;349:2387-98.
  4. Clifford GM, Farmer RD. Medical therapy for benign prostatic hyperplasia: a review of the literature. Eur Urol 2000;38:2-19.
  5. Kuczmarski RJ, Carroll MD, Flegal KM, Troiano RP. Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994). Obes Res 1997;5:542-8.
  6. Barreto SM, Passos VM, Firmo JO, Guerra HL, Vidigal PG, Lima-Costa MF. Hypertension and clustering of cardiovascular risk factors in a community in Southeast Brazil--The Bambui Health and Ageing Study. Arq Bras Cardiol 2001;77:576-81.
  7. Reich O, Gratzke C, Bachmann A, Seitz M, Schlenker B, Hermanek P, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol 2008;180:246-9.
  8. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141:243-7.
  9. Saito M, Ohmura M, Kondo A. Restoration of rat bladder function following release of short- and long-term partial outflow obstruction. Urol Res 1997;25:193-7.
  10. Shin YS, Park JK. Changes in Surgical Strategy for Patients with Benign Prostatic Hyperplasia: 12-Year Single-Center Experience. Korean J Urol 2011;52:189.
  11. Starkman JS, Santucci RA. Comparison of bipolar transurethral resection of the prostate with standard transurethral prostatectomy: shorter stay, earlier catheter removal and fewer complications. BJU Int 2005;95:69-71.
  12. Boyle P, Roehrborn C, Harkaway R, Logie J, de la Rosette J, Emberton M. 5-Alpha reductase inhibition provides superior benefits to alpha blockade by preventing AUR and BPH-related surgery. Eur Urol 2004;45:620-6; discussion 6-7.
  13. Chang HS, Park CH, Kim CI. Comparison of the Long Term Effect of Alpha-Blocker Only and 5-Alpha Reductase Inhibitor Combination Treatment on Acute Urinary Retention and Prostatic Surgery for Patients with Benign Prostatic Hyperplasia. Korean J Urol 2006;47:7-12.

Written by:

In Ho Chang, MD,a Se Young Choi, MD,a Young Sun Kim, MD,b Tae-Hyoung Kim,a MD, Soon Chul Myung, MD,b Young Tae Moon, MD,b and Kyung Do Kim, MDb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

a Department of Urology, Chung-Ang University College of Medicine, Seoul, South Korea
bDepartment of Urology, College of Medicine, Chung-Ang University, Seoul, South Korea 


 

The impact of changing trends in medical therapy on surgery for benign prostatic hyperplasia over two decades - Abstract

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