Geraldo de Campos Freire

Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: a comparative, international overview

G within the healthcare system aim to rationalize the diagnosis, treatment, and monitoring of a particular disease and can be applicable on an international scale or may be country-specific. This information is directed at either the specialist or the general practitioner (GP). Guidelines have been produced by governmental agencies or professional organizations on various diseases in the urologic field, such as urolithiasis, erectile dysfunction, penile cancer, bladder cancer, prostate cancer, and benign prostatic hyperplasia (BPH). BPH is an increasingly common condition in the aging male. By the age of 60 years, more than 50% of men will have microscopic evidence of the disease,1 and more than 40% of men beyond this age will have lower urinary tract symptoms.2 This factor, together with the geographic variations in patterns of practice, high cost of treatment, and increasing number of treatment options, make BPH a suitable candidate for practice guidelines. In general, guideline development involves the participation of specialists who determine the clinical evidence for individual practices. Subsequently, a series of recommendations are proposed, the strength of which depends on the available evidence. This can be a lengthy procedure, as evidenced by the 3 years it took for the development of the U.S. guidelines on BPH by the Agency for Health Care Policy and Research (AHCPR) published in 1994.3 The process involved the review of the world literature on BPH diagnosis and treatment, and the draft guidelines were extensively reviewed by experts and practitioners in the fields of urology, internal medicine, and family practice before a final report was published. Another body, the International Consultation (IC), patronized by the World Health Organization, is an international group of experts in prostatic diseases who meet as individual committees to develop recommendations on the diagnosis and treatment of BPH using a “consensus approach,” again based on a detailed review of the published data. This review aims to compare and contrast the current guidelines available both internationally and within individual countries. The goals are to determine whether patients might receive similar care in different countries and whether guidelines are sufficiently up-to-date to keep up with the new developments in the targeted disease area.

URODYNAMIC PRESSURE FLOW STUDIES CAN PREDICT THE CLINICAL OUTCOME AFTER TRANSURETHRAL PROSTATIC RESECTION

PURPOSE We evaluate whether urodynamic evaluation can determine preoperatively the clinical prognosis of patients treated with transurethral prostatic resection as measured by urinary symptom score and quality of life index. MATERIALS AND METHODS A total of 253 patients who previously elected transurethral prostatic resection based on clinical symptoms completed the American Urological Association symptom score and quality of life index, and underwent urodynamic evaluation before and after operation. The patients were divided into 7 groups in accordance with detrusor pressure at maximum urinary flow rate. The preoperative and postoperative symptom score and quality of life index were analyzed in each group. RESULTS Of the patients 42% were not obstructed and could not be distinguished from those who were obstructed preoperatively based on total urinary symptoms (p = 0.95) or subjective impression measured by the quality of life index (p = 0.96). The entire obstructed group demonstrated marked improvement compared to the nonobstructed group (p = 0.018). Analysis of severity also revealed a clear relationship with clinical outcome and subjective satisfaction with obstruction grade, that is the more severely obstructed cases had greater clinical benefit compared to those with little or no obstruction. Furthermore, the nonobstructed subjects did not show any clinical or subjective improvement after transurethral prostatic resection (p = 0.24). CONCLUSIONS Urodynamic studies provide great predictive value of clinical improvement after prostatic relief but they also properly predict the poor clinical results in nonobstructed patients.

Midterm Follow-Up After Prostate Embolization in Two Patients with Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men [1, 2]. Transurethral resection of the prostate (TURP) is still the ‘‘gold standard’’ surgical treatment for prostates. Due to the relative morbidity of TURP, minimally invasive techniques have been developed as alternatives for treatment for BPH, such as transurethral microwave thermotherapy and other laser ablations, but surgery (accomplished by transurethral or open means) constitutes the traditional treatment for BPH. Taking into account the patients’ comorbidities, surgical intervention in this age group may be considered high risk [3]. We report the radiological and clinical midterm follow-up of PAE in two patients with acute urinary retention due to BPH. Two patients with acute urinary retention due to BPH were selected for the study. Both patients were been previously described in this same journal in 2010 [4]. Prostatic artery embolization was performed under local anesthesia in both patients. One underwent bilateral embolization and the other had a unilateral embolization procedure. After PAE procedure, ultrasonography (US) and magnetic resonance imaging (MRI) were used for evaluation of effectiveness at 1, 3, 6, and 18 months. International prostate symptom score (IPSS), quality of life score (QUOL), and international index of erectile function score (IIEF) were evaluated until the last 24 month follow-up.

Extravesical ureteral implantation in kidney transplantation

Abstract Eighty-eight cases of kidney transplantation and extravesical ureteral implantation are reviewed with long-term evaluation. The total complication rate was 18.14 per cent, and in only 3.4 per cent have these complications been responsible for the death of the patients. The technique has been shown to be safe and useful for reestablishing the urinary transit in kidney transplantation.

Transurethral resection of the prostate for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: how much should be resected?

OBJECTIVE To assess the impact of the percent of resected tissue on the improvement of urinary symptoms. MATERIALS AND METHODS The study included a prospective analysis of 88 men with benign prostatic hyperplasia. Patients were divided in three groups according to the percent of resected tissue: Group 1 < 30%; Group 2, 30% to 50%; and Group 3, > 50%. Each patient was re-evaluated 3 months after surgery. We assessed the international prostatic symptom score, nocturia and serum prostate specific antigen levels. RESULTS All patients presented a significant decrease on mean International Prostate System Score (IPSS) (23 to 5.9), Quality of Life (QoL) (4.9 to 1.0) and nocturia (3.2 to 1.9). Variation in the IPSS was 16.7, 16.6 and 18.4 for patients from Group 1, 2 and 3 respectively (P = 0.504). Although the three groups presented a significant decrease in QoL, patients in Group 3 presented a significantly greater decrease when compared to Group 1. Variation in QoL was 3.1, 3.9 and 4.2 for patients from Group 1, 2 and 3 respectively (p = 0.046). There was no significant difference in nocturia variation according to the percent of resected tissue (p = 0.504). Median pre and postoperative PSA value was 3.7 and 1.9 ng/mL respectively. Patients from Group 1 did not show a significant variation (p = 0.694). Blood transfusions were not required in any group. CONCLUSIONS Resection of less than 30% of prostatic tissue seems to be sufficient to alleviate lower urinary tract symptoms related to benign prostate hyperplasia. However, these patients may not show a significant decrease in serum PSA level.

Transplantation of a Horseshoe Kidney

Abstract Horseshoe kidneys generally have not been used for transplantation. Their use has been described in only 3 cases, and in these cases the kidney was divided and transplanted into 2 recipients. We present a case in which a horseshoe kidney was transplanted successfully en bloc by its aorta-caval vascular pedicle to overcome the obstacle of a multiple renal arterial supply.

Prostate specific antigen levels following transurethral resection of the prostate

OBJECTIVE Determine how serum prostate-specific antigen (t-PSA) levels and free PSA (f/t PSA) ratio change following transurethral resection of the prostate (TURP). MATERIALS AND METHODS Thirty men with a mean age of 67.0 +/- 4.2 years (range 46 to 84 years) underwent TURP for BPH between May 2005 and October 2005. Preoperative assessment included symptom evaluation with the International Prostate Symptom Score (I-PSS) and the prostate volume estimation by transrectal ultrasound. Total PSA and f/t PSA ratio were assessed before the procedure, as well as 30, 60 and 180 days after the TURP. RESULTS Clinical improvement after TURP, reflected by I-PSS score, was demonstrated as early as 30 days and remained stable until the end of the follow-up. Mean t-PSA declined 71% after TURP and 60 days after surgery the reduction reached its peak, stabilizing afterwards. It varied from 6.19 +/- 7.06 ng/mL before surgery to 1.75 +/- 1.66 ng/mL on day 60 (p < 0.001). The mean baseline f/t PSA ratio was 18.2% +/- 3.4% and was not significantly changed at any given time point in the postoperative period (p = 0.91). There were also no statistically significant differences in t-PSA or f/t PSA between patients with and without prostatitis at any time point (p = 0.23). Resected prostate fragments weighed 29.9 +/- 19.6 g, corresponding to 39.1% of the estimated preoperative prostate volume. Each gram of tissue resected decreased PSA by 0.15 +/- 0.11 ng/mL, while 1% prostate volume resected led to a reduction of 2.4% +/- 0.4% in serum PSA from baseline. CONCLUSIONS PSA decreases drastically in patients who undergo TURP. These low levels stabilize within 60 days after surgery. The f/t PSA ratio did not change, and the finding of chronic prostatitis did not affect the levels of these variables.

Analysis of the risk factors for incidental carcinoma of the prostate in patients with benign prostatic hyperplasia

PURPOSE To determine the occurrence of incidental carcinoma of the prostate, its characteristics, and the risk factors for this diagnosis in a group of patients surgically treated for benign prostatic hyperplasia. METHODS The study comprised a retrospective analysis of 218 patients. After surgical treatment, patients with the finding of incidental carcinoma of the prostate were compared to those without this finding. The preoperative variables analyzed were patient age, digital rectal examination, PSA, PSA density, prostate volume, and preoperative prostate biopsy. We also determined the sensitivity, specificity, positive predictive value, and negative predictive value of digital rectal examination and PSA for the finding of incidental carcinoma of the prostate at surgical specimen analysis. RESULTS Thirteen (6.2%) out of the 218 patients presented incidental carcinoma of the prostate. Eight (61.5%) of these tumors were classified as T1a and 5 (38.5%) as T1b. Only advanced age (P = 0.003) and the presence of a suspect digital rectal examination (P = 0. 016) were statistically related to the findings of the surgical specimen analysis. The sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of incidental carcinoma were 23.0%, 96.6%, 30.0%, and 95.2% for a suspect digital rectal examination and 85.0%, 34.1%, 7.5%, and 97.2% for a PSA greater than 4.0 ng/mL. The accuracy for these methods was 92.2% and 37.1%, respectively. CONCLUSIONS Advanced age and the presence of a suspect digital rectal examination represent the most important risk factors for the diagnosis of an incidental carcinoma of the prostate. However, the low positive predictive values reflect the weak correlations among these variables.

Incidence of histological prostatitis and its correlation with PSA density

OBJECTIVE The aim of this study was to determine the incidence of asymptomatic, histologically proven prostatitis in men with symptoms of benign prostate hyperplasia and to observe the correlation between asymptomatic prostatitis and prostate specific antigen (PSA) density. INTRODUCTION The incidence of type IV prostatitis is unknown. There is a tendency to correlate the presence of inflammatory prostatitis with an elevation of PSA. MATERIALS AND METHODS From August 2000 to January 2006, 183 patients who underwent surgical treatment for benign prostate hyperplasia as a result of obstructive or irritative symptoms were prospectively studied. In accordance with the histology findings, these patients were divided into two groups: group I included patients with the presence of histological prostatitis and group II included patients with the absence of histological prostatitis. The mean PSA densities were compared. RESULTS Histological evidence of prostatitis was observed in 145 patients. In this group, the mean PSA density was 0.136 ± 0.095. In 38 cases, there was no evidence of inflammation upon histological examination of the surgical samples. In these 38 cases, the mean PSA density was 0.126 ± 0.129. No statistically significant differences were detected between the two groups; the p-value is 0.124. CONCLUSION Abnormal PSA density should not be attributed to the inflammatory prostatitis process.

Botulinum toxin for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia

Botulinum toxin (BTX) is the most potent biological toxin used for the treatment of urologic conditions. During the last 3 years, the use of BTX has been extended to the treatment of symptomatic benign prostatic hyperplasia, however, the actual mechanism through which BTX can reduce prostate volume and infravesical resistance is not well understood. This article reviews the main effects of BTX in prostate tissues. A critical analysis of the outcomes of patients who were studied in clinical series that used this toxin to treat lower urinary tract symptoms related to benign prostatic hyperplasia is also presented.