Bertrand Lukacs

Photoselective Vaporization of the Prostate with GreenLight 120-W Laser Compared with Monopolar Transurethral Resection of the Prostate: A Multicenter Randomized Controlled Trial

BACKGROUND Evidence supporting the widespread use of GreenLight High Performance System (HPS) 120-W photoselective vaporization of the prostate (PVP) is lacking. OBJECTIVE To assess the noninferiority of PVP compared with transurethral resection of the prostate (TURP) on urinary symptoms and the superiority of PVP over TURP on length of hospital stay. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized controlled trial was conducted. INTERVENTION Patients underwent monopolar TURP or PVP with the GreenLight HPS 120-W laser. MEASUREMENTS International Prostate Symptom Score (IPSS), Euro-QOL questionnaire, uroflowmetry, Danish Prostate Symptom Score Sexual Function Questionnaire, sexual satisfaction, and adverse events were collected at 1, 3, 6, and 12 mo. The two groups were compared using the 95% confidence interval (CI) of median difference for testing noninferiority of the IPSS at 12 mo and the student t test for testing the difference in length of hospital stay. RESULTS AND LIMITATIONS A total of 139 patients (70 vs 69 men in each group) were randomized. Median IPSS scores at 12-mo follow-up were 5 (interquartile range [IQR]: 3-8) for TURP versus 6 (IQR: 3-9) for PVP, and the 95% CI of the difference of the median was equal to -2 to 3. Because the upper limit of the 95% CI was >2 (the noninferiority margin), the hypothesis of noninferiority could not be considered demonstrated. Median length of stay was significantly shorter in the PVP group than in the TURP group, with a median of 1 (IQR: 1-2) versus 2.5 (IQR: 2-3.5), respectively (p<0.0001). Uroflowmetry parameters and complications were comparable in both groups. Sexual outcomes were slightly better in the PVP group without reaching statistical significance. CONCLUSIONS The present study failed to demonstrate the noninferiority of 120-W GreenLight PVP versus TURP on prostate symptoms at 1 yr but showed that PVP was associated with a shorter length of stay in the hospital. TRIAL REGISTRATION NCT01043588.

Management of Symptomatic BPH in France: Who Is Treated and How?

Objective: To review the contemporary management of symptomatic benign prostatic hyperplasia (BPH) in France. Methods: Information was obtained from published scientific articles, IMS market analysis data and community-based surveys among older men. Results: The prevalence of symptomatic BPH in France is relatively high. About 15–20% of men over 50–60 years of age report moderate to severe lower urinary tract symptoms (LUTS: total I-PSS >7). If this is applied to the 5.7 million men aged 60 or over living in France, it seems that 855,000–1,140,000 men have symptomatic BPH. In the AFU-Synthélabo community-based survey, around half of these men (more than 10%) visited a physician because they were bothered by these symptoms interfering with performing daily life activities. This suggests that approximately 600,000 patients have a diagnosis of symptomatic BPH in France. These patients can contact both general practitioners (GPs) and urologists for the management of symptomatic BPH. Approximately one in every four to one in every three men with LUTS visits directly a urologist whereas the other 65–75% initially contacts a GP in France. GPs very often prescribe medical treatment for LUTS related to BPH. Of all medical prescriptions in France, 80% are made by GPs and only 12.5% by urologists. The total market for medical therapy increased substantially since 1994. Since 1998, it grew with 2–3%/year. A total of 640,000 patients received medical therapy for BPH in 1998. The growth in the medical treatment market was mainly due to an increase in the number of patients receiving α1-adrenoceptor antagonists. Today, this is the most frequently prescribed class of medical therapy (45.3%) followed by plant extracts (37.5%) who’s market share decreased slightly since 1996. The market share of finasteride is also still decreasing and represents today 17.2% of all prescriptions. The growth in the α1-adrenoceptor antagonist segment can mainly be attributed to the introduction of tamsulosin in 1996. The price for medical therapy in France is around 1 Euro/day and is estimated to be around 229 million Euro in 1998. All drugs are reimbursed for 35% by the Social Insurance. The number of prostatectomies has declined in France in the 1990s. A national database includes information from events taking place in all hospitals in France. It appears that a total of 66,431 surgical procedures for the prostate were done in 1997 of which 81% were performed transurethrally and 14% open. Total direct costs involved with these surgical procedures were 229 million Euro. Conclusions: The costs involved in the management of symptomatic BPH in France are very high. However, there still exist no official guidelines defining for GPs and urologists in a shared care environment how this condition should be diagnosed and in which situations which medical therapies should be prescribed or when surgery is indicated. The French urological association is playing a key role in improving treatment of BPH. Several initiatives are underway to observe real life practice by developing a national database for urology, promote studies to evaluate cost/effectiveness of each therapy, define national guidelines of good practice and develop the shared care concept with GPs.

Bilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l’AFU

AIM To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH). METHOD A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique. RESULTS Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate. CONCLUSION Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP)

To describe the step‐by‐step learning curve of the holmium laser enucleation of the prostate (HoLEP) surgical technique.

Management of Lower Urinary Tract Symptoms Related to Benign Prostatic Hyperplasia in Real-life Practice in France: A Comprehensive Population Study

BACKGROUND Male lower urinary tract symptoms (LUTS) are one of the most treated diseases, but little is known about patient trajectories in current clinical practice. OBJECTIVE To describe the dynamic treatment patterns of LUTS presumably due to benign prostatic obstruction (BPO). DESIGN, SETTINGS, AND PARTICIPANTS All prescriptions of α1-adrenergic receptor blocking agents (α1-blockers), 5α-reductase inhibitors (5-ARIs), and phytotherapy, and all surgeries related to BPO performed in France from 2004 to 2008 were identified using two distinct administrative claim databases maintained by the National Health Insurance system that covers the entire population. After linking the two data sets, all consecutive treatment events were analyzed for each patient. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Drug prescription details were assessed for each year, region, and prescriber qualification. Medical treatment initiation, interruption, evolution, and events after surgical management (hospital stay, reoperation, complication rates, and subsequent medical prescriptions) were also investigated. RESULTS AND LIMITATIONS Overall, 2 620 269 patients were treated within 5 yr, with important geographic variations. Medical treatment was interrupted for approximately 16% of patients. The α1-blockers were prescribed most frequently, but phytotherapy surprisingly accounted for 27% of all monotherapies and 54% of all combination therapies. General practitioners and urologists (92% and 3.7% of overall prescribers, respectively) exhibited a similar prescription profile. Treatment initiation was medical in 95.4% of cases, consisting primarily of monotherapy using α1-blockers (60.3%), phytotherapy (31.8%), or 5-ARIs (7.9%). Treatment was modified at extremely high rates within 12 mo of initiation (8.7%, 14.6%, and 12.9%, respectively). The median hospital stay for surgical management was far higher than in clinical trials. Long-term surgical complications and reoperation rates favored open prostatectomy. Incidence of pharmacologic treatment after surgery was as high as 13.8% at 12 mo. CONCLUSIONS This unique dynamic evaluation of clinical practice revealed unexpected results that contrast with previously published evidence from clinical trials. This approach may merit monitored and targeted measures to improve the level of care in the field.

RecommandationBilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l’AFUInitial assessment, follow-up and treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: Guidelines of the LUTS committee of the French Urological Association

AIM To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH). METHOD A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique. RESULTS Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate. CONCLUSION Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

Laser treatment of benign prostatic hyperplasia in patients on oral anticoagulant therapy : a review

We assessed the therapeutic efficacy and safety of laser prostatectomy (LP) for treating benign prostatic hyperplasia (BPH) in patients on oral anticoagulation. We systematically reviewed previous reports, using the Pubmed database and bibliographies of retrieved articles and reviews. The oral anticoagulation included coumarin derivatives and platelet‐aggregation inhibitors (PAI). Previous studies do not allow the establishment of definitive conclusions for managing patients on oral anticoagulation and who require BPH surgery. No randomized studies are available. Nevertheless, compared to transurethral resection of the prostate (TURP), LP seems to decrease the risk of haemorrhage in patients taking PAI or coumarin derivatives. Therefore, LP is a useful alternative to TURP for managing patients on oral anticoagulation, and could be proposed as the first intention for those patients. Continuing PAI during the procedure is feasible. A replacement of coumarin derivatives by low molecular weight heparin is preferable. No conclusion can be reached on the preferred type of laser technique to treat these patients, but data on laser enucleation is much less abundant and conclusive than that on laser vaporization.

Bilan initial et suivi de l’hyperplasie bénigne de prostate : revue de littérature du CTMH de l’AFU

PURPOSE To perform an update on the initial evaluation and follow-up of benign prostatic hyperplasia (BPH). METHOD A systematic review of recent literature was performed. Level of evidence of publications was evaluated. RESULTS AND CONCLUSIONS Objectives of the initial evaluation are to assess the link between low urinary tract symptoms (LUTS) and BPH, to evaluate the bother associated to LUTS, assess a complicated bladder outlet obstruction (BOO), diagnose an adenocarcinoma of the prostate if it modifies the therapeutic strategy, and establish an evolutive profile of the disease. Clinical assessment with digital rectal examination, evaluation of symptoms by a dedicated questionnaire and urine analysis are the first steps of BPH evaluation. Bladder diary is useful to objective storage symptoms. Uroflowmetry and post-void residual volume assessment are useful if BOO is suspected. Measure of serum creatinine and ultrasound exam of the urinary tract are second line explorations. Urine cytology, neurological evaluation, urethrocystoscopy, urodynamics with pressure-flow studies are useful if the link between LUTS and BPH is unclear. PSA dosage is used for prostate cancer screening or as a prognostic marker of BPH evolution.

Transurethral plasma vaporization of the prostate: 3-month functional outcome and complications

Study Type – Therapy (multi‐centre cohort)

Management of non-complicated BPH: proposition of a renewed decision tree.

Nowadays the management of benign prostatic hypertrophia (BPH) is undergoing striking changes. The standard medical treatments are represented by three families which are the phytotherapy, the alpha-blockers and the 5-alpha-reductase inhibitors. These treatments were deemed as symptomatic and used only as monotherapy. Recent numerous studies bring new assessments on BPH: the medical treatment is able to modify the natural history of BPH especially by reducing the risk of acute urinary retention. Furthermore the association of two different therapeutic classes seems to be more efficient than the use of a monotherapy in some cases. Similarly the place of two instrumental techniques, the thermotherapy by microwaves or by radiofrequencies, previously proposed as alternatives to the surgical treatment seems to find their way rather as alternatives to the medical treatment. These different elements allow building a renewed decision tree which decisions are shared with the patient at each stage. This decision tree of the management of patients having non-complicated BPH symptoms must include initial clinical characteristics of the patient and its disease and the evolution under treatment which has not been yet considered in the international recommendations. It also considers the possibilities of associations with other therapeutic classes.