PL 04. Current management of BPH

Benign prostatic hyperplasia (BPH) is a histological diagnosis that includes stromal and smooth muscle cell proliferation in the prostatic transitional zone. Lower urinary tract symptoms (LUTSs) are medical syndrome that can be caused by multiple conditions that include BPH as the most important and frequent cause. During the past decade, many changes in the diagnosis, medical and surgical management of LUTS have evolved and come to our treatment armamentarium. There is a wide range of options that include pharmacological therapies, mechanical devices and new surgical interventions have emerged and have become available for the treatment of BPH.

DIAGNOSTIC EVALUATION

A basic evaluation should be performed on every patient with LUTS. This includes medical history, assessment of symptoms and bother, physical exam including digital rectal examination (DRE), urinalysis, serum prostate specific antigen (PSA) levels. The routine measurement of creatinine levels is no longer recommended in the initial evaluation of LUTS. Urodynamic studies are considered optional and they can be used in counseling patients regarding the outcome of surgical therapies for BPH.

TREATMENT ALTERNATIVES

Medical management

Patients with mild symptoms or patients with moderate or severe symptoms not bothered by their LUTS should be managed with watchful waiting (standard). The combination of an alphablocker and 5-alpha reductase inhibitors (5-ARIs) is an effective treatment for patients with LUTS and prostaticenlargement based on volume, PSA levels and or enlargement on DRE. Anticholinergic agents are appropriate and effective treatment alternatives for the management of LUTS secondary to BPH in men without an elevated residual and when LUTS is predominantly irritative.

Minimally invasive therapies

Transurethral needle ablation (TUNA) and Transurethral microwave thermotherapy (TUMT) are considered appropriate and effective treatment alternative for moderate or severe LUTS. Surgical procedures.

The AUA guidelines recommended surgery for patients who have renal insufficiency secondary to BPH, who have recurrent urinary tract infections, bladder stones or gross hematuria due to BPH, and those who have LUTS refractory to other therapies.The TURP is considered as the surgical standard procedure for men with prostate sizes of 30-80 mL. This procedure is considered to be superior to medical and minimally invasive therapies in improving symptoms but the morbidity is higher. According to the AUA guidelines, transurethral laser enucleation with Holmium [HoLRP, HoLEP], transurethral ablation [HoLAP, and photoselective vaporization (PVP)] are considered effective treatment alternatives for TURP. The open prostatectomy is an appropriate and effective treatment alternative for men with large size prostate in the absence of Holmium lasers.

FOLLOW-UP

Follow-up after surgery should be at 4-6 weeks after removal of the catheter; at this visit an IPSS and an uroflowmetry are recommended.