Gerasimos Alivizatos

EAU Guidelines on Benign Prostatic Hyperplasia (BPH)

Objective: To establish guidelines for the diagnosis, treatment, and follow–up of BPH. Methods: A search of published work was conducted using Medline. In combination with expert opinions recommendations were made on the usefulness of tests for assessment and follow–up: mandatory, recommended, or optional. In addition, indications and outcomes for the different therapeutic options were reviewed. Results: A digital rectal examination is mandatory in the assessment for the diagnosis of BPH. Recommended tests are the International Prostate Symptom Score, creatinine measurement (or renal ultrasound), uroflowmetry, and postvoid residual urine volume. All other tests are optional. The aim of treatment is to improve patients’ quality of life, and it depends on the severity of the symptoms of BPH. The watchful waiting policy is recommended for patients with mild symptoms, medical treatment for patients with mild–moderate symptoms, and surgery for patients who failed medication or conservative management and who have moderate–severe symptoms, and/or complications of BPH which require surgery. Regarding non–surgical treatments, transurethral microwave thermotherapy is the most attractive option. These treatments should be reserved for patients who prefer to avoid surgery or who no longer respond favourably to medication. Finally, recommendations for follow–up tests and a recommended follow–up time schedule after BPH treatment are provided. Conclusions: Recommendations for assessment, possible therapeutic options, and follow–up of patients with BPH are made.

Oral estramustine and oral etoposide for hormone-refractory prostate cancer

OBJECTIVES Estramustine and etoposide have been shown to inhibit the growth of prostate cancer cells in experimental models. An in vivo synergism of the two agents, when administered to patients with metastatic prostate cancer refractory to hormone therapy, has been reported. To confirm these results, we administered this combination to a large number of patients with hormone-refractory prostate cancer (HRPC). METHODS Fifty-six patients with metastatic HRPC were treated with oral estramustine 140 mg three times a day and oral etoposide 50 mg/m2/day for 21 days. Therapy was discontinued for 7 days and the cycle was then repeated. Therapy was continued until evidence of disease progression or unacceptable toxicity occurred. To control for the possible interference of an antiandrogen withdrawal effect, all patients discontinued antiandrogen therapy and were not enrolled in the study unless there was evidence of disease progression. RESULTS Forty-five percent of 33 patients with measurable soft tissue disease demonstrated an objective response, which included five complete and ten partial responses. Among 52 patients with osseous disease 17% showed improvement and 50% showed stability of bone scan. Thirty patients (58%) demonstrated a decrease of more than 50% in pretreatment prostate-specific antigen (PSA) levels. The median survival of all patients was 13 months. Good pretreatment performance status, measurable disease response, improvement or stability of bone scan, and PSA response were important predictors of longer survival. CONCLUSIONS We conclude that the combination of estramustine and etoposide is an active and well-tolerated oral regimen in HRPC.

Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises in the early management of urinary incontinence after radical prostatectomy.

Objective To evaluate the comparative effectiveness of electromyographic (EMG) biofeedback with verbal instructions as learning tools of pelvic muscle exercises (PMEs) in the early management of urinary incontinence after radical prostatectomy.

Incontinence and erectile dysfunction following radical prostatectomy: a review.

Radical prostatectomy remains the treatment of choice for localized prostate cancer in age-appropriate and health-appropriate men. Although cancer control is the most important aspect of a radical prostatectomy, minimization of postoperative morbidity, especially urinary incontinence and erectile dysfunction, is becoming a greater concern. We reviewed recent data available on Medline regarding the incidence, pathophysiology, evaluation, and treatment of incontinence and sexual dysfunction after radical prostatectomy. Health-related quality of life issues have been specifically addressed. Although low incidences of incontinence and erectile dysfunction after radical prostatectomy have been reported in the hands of experienced surgeons, the literature review revealed a great variety, with incontinence rates ranging from 0.3–65.6% and potency rates ranging from 11–87%. Several factors contribute to this wide difference, the most important being the application of a meticulous surgical technique. General and cancer-specific health-related quality of life is not being affected after radical prostatectomy. The incidence of incontinence and erectile dysfunction is higher after radical prostatectomy when compared to the incidence observed when other therapies for localized prostate cancer are applied. However, the majority of the patients undergoing radical prostatectomy would vote for the operation again. Today, avoidance of major complications after radical prostatectomy depends mostly on a high-quality surgical technique. When incontinence or erectile dysfunction persists after radical prostatectomy, the majority of the treated patients can be managed effectively by various methods.

Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate: COMPARISON OF B-TURP VS M-TURP IN A MULTICENTRE RCT SETTING

Study Type – Therapy (RCT)

Is there still a role for open surgery in the management of renal stones

Purpose of review In the last few decades, with the improvement in endourological surgery and the invention and evolution of extracorporeal shock-wave lithotripsy, the indications for open surgery in stone disease have become rare, although open surgery still has a role in selected cases. In this review we discuss the current indications of open surgery for the elimination of urinary calculi. Recent findings A MEDLINE and MeSH search was performed to evaluate currently available guidelines on open stone surgery and identify the evidence-based medicine that support the role of open surgery in treating urinary lithiasis. The latest papers published on open stone surgery are reviewed and conclusions are drawn, based on their results. Summary Open stone surgery should be avoided in most cases, but should be considered for those patients in whom a reasonable number of less invasive procedures would not be useful. The most common indications for open stone surgery include complex stone burden, failure of extracorporeal shock-wave lithotripsy or endourological treatment and anatomical abnormalities (such as ureteropelvic junction obstruction and infundibular stenosis with or without renal caliceal diverticulum). The level of evidence for the currently available guidelines is not adequate, mainly because of lack of properly designed, large prospective randomized trials that compare different treatment options.

Results from an international multicentre double‐blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate

Sir, Voiding symptoms due to BPH are common, with endoscopic transurethral resection (TUR) of the obstructing tissue still considered the ‘ gold standard ’ with 20 000 procedures undertaken in the UK in 2007, at an average annual cost of ≈ £ 70 million [ 1 ] . The authors are correct that traditional monopolar TUR of the prostate (mTURP) does have historical disadvantages for blood loss and risk of electrolyte disturbance, and as such, alternative technologies have been developed to match the symptom improvement, whilst reducing morbidity and hospital stay. This well designed randomised controlled trial highlights data in accordance with the contemporary clinical impression that the rates of TUR syndrome (0.7%) and blood loss requiring transfusion (2.9%) for mTURP are low; and that the total complication rate is comparable with the newer bipolar TURP (bTURP) technology (31 vs 27%) [ 2 ] . Although the authors have compared catheterisation times between mTURP and bTURP (3.0 vs 3.1 days), the data is conspicuously lacking in not addressing the important question of hospital stay between the groups. This parameter is widely used as the economic driver for the introduction of laser or bipolar technology as a day case procedure. Health services across the globe are facing unprecedented reforms. With budget static in real terms, the UK ’ s NHS needs to fi nd effi ciencies worth £ 15 – 20 billon over the next 4 years to keep pace with rising demand. Increasing the relative amount of day-case and short-stay elective surgery is an obvious source of savings. However, the evidence for an economic benefi t with bTURP is limited, and often dependent on comparative mTURP hospital stays of > 2 days [ 1,3 – 5 ] . We would argue that a 23-h stay should be the preoperative intention in all patients undergoing mTURP, and routine in-patient stays in excess of this should be consigned to history. We audited 125 mTURP cases at our institution over 12 months, with the intention preoperatively of undertaking them as a short-stay procedure. The median hospital stay was < 23 h in all-comers. The mean weight of tissue resected was 23.4 g. The median time to trial without catheter (TWOC) was 4 days; with a successful TWOC rate of 94%. We have achieved this through a combination of improved patient and staff education and hence expectation; meticulous haemostasis; and the addition of postoperative diuresis with one dose of i.v. furosemide or mannitol. The patient is managed in a streamlined 23-h short-stay unit with bladder irrigation discontinued in recovery, and early mobilisation encouraged. This has maximised throughput of patients without compromising outcomes.

Midterm Results from an International Multicentre Randomised Controlled Trial Comparing Bipolar with Monopolar Transurethral Resection of the Prostate

BACKGROUND Pooled data from randomised controlled trials (RCTs) with short-term follow-up have shown a safety advantage for bipolar transurethral resection of the prostate (B-TURP) compared with monopolar TURP (M-TURP). However, RCTs with follow-up >12 mo are scarce. OBJECTIVE To compare the midterm safety/efficacy of B-TURP versus M-TURP. DESIGN, SETTING, AND PARTICIPANTS From July 2006 to June 2009, TURP candidates with benign prostatic obstruction were consecutively recruited in four centres, randomised 1:1 into the M-TURP or the B-TURP arm and regularly followed up to 36 mo postoperatively. A total of 295 patients were enrolled. INTERVENTION M-TURP or B-TURP using the AUTOCON II 400 electrosurgical unit. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Safety was estimated by complication rates with a special emphasis on urethral strictures (US) and bladder neck contractures (BNCs) recorded during the short-term (up to 12 mo) and midterm (up to 36 mo) follow-up. Efficacy quantified by changes in maximum urine flow rate, postvoid residual urine volume, and International Prostate Symptom Score was compared with baseline, and reintervention rates in each arm were also evaluated. RESULTS AND LIMITATIONS A total of 279 patients received treatment after allocation. Mean follow-up was 28.8 mo. A total of 186 of 279 patients (66.7%) completed the 36-mo follow-up. Posttreatment withdrawal rates did not differ significantly between arms. Safety was assessed in 230 patients (82.4%) at a mean follow-up of 33.4 mo. Ten US cases were seen in each arm (M-TURP vs B-TURP: 9.3% vs 8.2%; p=0.959); two versus eight BNC cases (M-TURP vs B-TURP: 1.9% vs 6.6%; p=0.108) were collectively detected at the midterm follow-up. Resection type was not a significant predictor of the risk of US/BNC formation. Efficacy was similar between arms and durable. A total of 10 of 230 patients (4.3%) experienced failure to cure and needed reintervention without significant differences between arms. High overall reintervention rates, withdrawal rates, and sample size determination not based on US/BNC rates represent potential limitations. CONCLUSIONS The midterm safety and efficacy of B-TURP and M-TURP are comparable. TRIAL REGISTRATION Netherlands Trial Register, NTR703 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=703).

Interstitial laser coagulation treatment of benign prostatic hyperplasia: Is it to be recommended?

PURPOSE To update the clinical data on the treatment of benign prostatic hyperplasia (BPH) by interstitial laser coagulation (ILC). MATERIAL AND METHODS In addition to recent review articles, original papers published during the last 2 years were surveyed. The focus was on prospective, particularly randomized, trials and on those with long-term follow-up. RESULTS Interstitial laser coagulation is feasible, although considerable variability is observed in the results. Operative complications are minimal, but the postoperative catheterization time is relatively long. Irritative symptoms can last for a long time, and the rate of urinary infections is as high as 35%. There also is significant variability in the urodynamic results. The technique seems to be more effective in patients with mild bladder outlet obstruction at baseline. The retreatment rate at 1 year is as high as 15%, and higher rates, as much as 40%, are described at 3 years. When compared in a randomized fashion with transurethral resection of the prostate (TURP), the postoperative period is shorter after TURP and the retreatment rate (early and late) is higher after ILC. CONCLUSIONS Interstitial laser coagulation is superior to TURP in terms of operative morbidity, but postoperative morbidity is higher after ILC. Long-term durability has not been properly documented, and randomized studies show a higher retreatment rate after ILC than after TURP. The technique is recommended for those patients with bleeding disorders necessitating an interventional therapy.

Bipolar vs monopolar transurethral resection of the prostate: evaluation of the impact on overall sexual function in an international randomized controlled trial setting

The effect of TURP on overall sexual function and particularly erectile function (EF) is controversial with conflicting results based on a low level of evidence. The effects of monopolar and bipolar TURP (M‐TURP and B‐TURP, respectively) on EF are similar, as has been shown in a few non‐focused randomized control trials (RCTs). For the first time, the present study offers focused results of a comparative evaluation of the effects of B‐TURP and M‐TURP on overall sexual function, as quantified with the International Index of Erectile Function Questionnaire (IIEF‐15) in an international, multicentre, double‐blind RCT setting.