Steven A. Kaplan, MD

	When health economists evaluate therapies and interventions, concepts such as burden of disease, health-related quality of life, and downstream economic factors are analyzed. While BPH is a big-ticket item for the field of urology, is it a big deal to the population at large? Does it have a substantial effect in a substantial group of men at risk?

 discussed in the September 2016 issue of 

, the authors evaluated the correlation with lower urinary tract symptoms (LUTS) and major adverse cardiac events (MACE). Employing an extensive literature search and meta-analysis, more than 25,000 men including 2,291 with MACE were evaluated. In this group of men (mean age, 52.5±5.5 years), moderate to severe LUTS was associated with a significantly increased incidence of MACE.

	What is the significance of these findings? The association between MACE and LUTS has been established in many populations. Is there a common etiologic factor? Various hypotheses have been proposed, including vascular, nerve and endothelial damage, an alteration of smooth muscle tone and an arterial insufficiency leading to reduced blood flow and hypoxia, and a downstream cascade of inflammatory factors.

	In a study of National Health and Wellness Survey data in 2011 and 2012, a significant health burden as well as correlation to cardiovascular disease was found. Much of this was related to nocturia (which was excluded from the MACE analysis).

	One limitation of this study is that the association between LUTS and cardiac events may be a self-fulfilling prophecy, i.e., men with moderate/severe LUTS and MACE are more likely to seek health care.

	Other confounding variables that were not analyzed include family history, diet, tobacco and drug use, and physical activity, as well pertinent comorbidities including depression.

	The bottom line is that LUTS is an important health care burden and that health care professionals should be screening for the presence of LUTS in men at risk.

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"LUTS is an important health care burden, and health care professionals should be screening for its presence in men at risk," writes Steven A. Kaplan, MD.

LUTS’ burden may extend to cardiac events

	The world has become increasingly fascinated with new technologies, toys, and gadgets. Urologists are no different. Many prospective resident candidates often cite the myriad technological advances in urology as a drawing force to our specialty. But have new technologies translated into more efficient, durable, and meaningful outcomes for our patients? 

Bipolar vaporization: Do benefits outweigh risks?

 has had an interesting roller coaster ride over the past 25 years with new medicines, minimally invasive surgical therapies (MIST), and a host of novel surgical technologies, including lasers and bipolar electrosurgery. The arena that has seen the most stops and starts is MIST and includes balloon dilation, urethral stents, transrectal and transurethral microwave thermotherapy, and needle ablation of the prostate.

	The past 2 to 3 years has seen a renaissance in MIST technologies, including the FDA-approved 

 (UroLift System) and two new exciting technologies using either 

(Aquablation). In a pivotal, single-blinded study of RezÅ«m versus control, there appears to be significant improvement in symptoms and uroflow. While we can debate whether there was an adequately blinded control arm, the impressive improvement in uroflow in the treatment versus the sham group suggests that the trial was well conducted. Sexual function was also preserved.

	Aquablation is one of the most promising technologies seen over the past decade. A large multicenter clinical trial will begin soon to ascertain its safety and efficacy versus transurethral surgery. The amount of tissue removed in a very short period of time is impressive. At this point, it appears the technology will need to be performed in the operating room and will compete with transurethral surgery.

	This is an exciting time in the management of BPH. Ultimately, ease of performance, reproducibility, efficacy and safety, reimbursement, and durability of results will determine the success of each technology. Moreover, urologists will have to be mindful of developing therapeutic algorithms for each of these technologies so that prostate size, presence of a middle lobe, sustainability of results, and ability to do a procedure in the office versus the operating room will help bring the greatest value of these therapies to our patients.

	It’s a fun time to be in the BPH space, but we should approach with caution and appropriate degrees of skepticism.

	For more on the technology Dr. Kaplan discusses above, please see:

Study: BPH procedure’s benefits sustained at 3 years

Convective transurethral therapy reduces LUTS

The management of BPH has had an interesting roller coaster ride over the past 25 years with new medicines, minimally invasive surgical therapies, and a host of novel surgical technologies, including lasers and bipolar electrosurgery.

Author | Steven A. Kaplan, MD

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LUTS’ burden may extend to cardiac events

New tech may bring exciting era in BPH