Best of AUA 2014: BPH/LUTS

July 10, 2014

Richard K. Lee, MD, MBA, presents the take home messages on BPH/LUTS from the AUA annual meeting in Orlando, FL.

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• A report on the 2-year outcomes of the UroLift prostatic urethral lift system (NeoTract, Pleasanton, CA) found significant improvements in IPSS, maximum flow rate, and PVR, with a low re-treatment rate of only 7% at 24 months. Sexual function was preserved in all patients.

• Body mass index positively correlated with prostate size but negatively correlated with age, International Prostate Symptom Score, and quality of life index. Separately, increased BMI correlated with methylation activity and absence of 5-alpha-reductase type 2 expression, which may have implications for response to medications such as finasteride (Proscar).

• Estrogen receptor-alpha knockout mice treated with testosterone and estradiol show smaller bladder volumes and masses compared to wild-type and estrogen receptor-beta knockout mice in a bladder outlet obstruction model, which may have implications for selective estrogen receptor modulator use in terms of modifying bladder behavior after treatment for prostate pathology.

• Higher risk cardiovascular events, diabetes, depression, and stress were associated with greater risk of moderate-to-severe lower urinary tract symptoms and erectile dysfunction. Separately, insulin resistance was found to predict severe LUTS and ED.

• LUTS patients with sympathetic hyperactivity demonstrated better IPSS response to treatment with alfuzosin (Uroxatral) compared with hypoactive men.

• Hypogonadal men with testosterone <300 ng/dL responded less well to treatment with 5 mg of daily tadalafil (Cialis) compared to eugonadal men.

• A multi-component behavioral therapy consisting of pelvic floor muscle training, delayed voiding, and urge suppression reduced nocturia by approximately one episode per evening and improved quality of life, sleep, and bother in a multicenter trial of 72 men.

• Researchers confirmed the 3-year long-term safety and efficacy of the alpha-1D antagonist naftopidil in 117 patients with an IPSS score of 7 or greater. Treatment failure was seen in approximately 29% of these patients.

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• Several studies evaluated the use of the GreenLight photoselective vaporization of the prostate laser (American Medical Systems, Minnetonka, MN). The GOLIATH study randomized 291 men to GreenLight XPS versus monopolar transurethral resection of the prostate, with no statistical difference between treatment arms in IPSS, maximum flow rate (Qmax), quality of life index, prostate volume, and PSA. A second study comparing GreenLight XPS with holmium laser enucleation of the prostate found equivalence between the modalities in Qmax, IPSS, and post-void residual at 12 months. In a global multicenter cohort of more than 1,000 men undergoing GreenLight XPS treatment, improvements were seen in all clinical outcomes.

• Prostatic arterial embolization (PAE) continues to evolve. In over 500 patients with moderate to severe LUTS who were treated with PAE, the authors reported a 72% success rate at 36 months, although two major complications were noted: bladder wall ischemia requiring surgical repair and perineal pain. In a trial comparing PAE with TURP in prostates ranging in size from 30 to 90 grams, TURP demonstrated superior improvements in Qmax, IPSS, bladder outlet indexing, and quality of life scores.

• The RezÅ«m transurethral convective steam ablation therapy system (NxThera, Inc., Maple Grove, MN) was reported in multiple abstracts. Researchers reported rapid procedure times ranging from 2 to 23 minutes, with significant improvements at the pilot study level seen in IPSS, Qmax, and PVR. Magnetic resonance imaging confirmed the anatomic safety profile of the vapor stream used with the system. Complications noted in these trials included transient urinary retention, mild dysuria, and hematuria.

• In 55 stress urinary incontinence patients undergoing treatment with the AdVance XP transobturator male sling (American Medical Systems), a 67% cure rate at 12 months was reported.

• A retrospective review of the Argus male sling (Promedon, Cordoba, Argentina) in 96 patients found that the sling was effective even after radiotherapy, although an overall complication rate of 64% was noted.

• Transperineal ultrasound may have a role in the evaluation of the failed male transobturator sling. Sling malposition was noted as the major fault for sling failure in male patients.

• Prior radiotherapy, urethral stent placement, and small cuffs are risk factors for artificial urinary sphincter (AUS) explantation.

• In a review of outcomes of AUS replacement for recurrent incontinence, most patients had no evidence of device abnormality, and device failure was secondary to changes in mechanical properties of their reservoir.

• AUS cuff downsizing for recurrent/persistent stress urinary incontinence was associated with a higher rate of mechanical failure compared to replacement of reservoir or tandem cuff placement.UT

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