Treatments for Benign Prostatic Hyperplasia. Part 4

Posted by admin on November 28th, 2009 No Comments

Transurethral prostatic resection

Efficacy. Lepor and Rigaud critically examined the efficacy of transurethral prostatectomy in men with moderate symptoms of prostatism. They assessed subjective outcome using a popular standardized symptom score formulated by Boyarsky and colleagues, as well as objective urinary flow rates. Urodynamic parameters alone cannot be used to assess efficacy, as it has been established that they do not correlate closely with symptoms.

Approximately 85% of patients reported that symptoms were markedly improved after prostatic resection. The mean obstructive and irritative symptoms scores decreased 88% and 65%, respectively. Those who failed to improve had predominantly irritative symptoms. Mean peak urinary flow rate increased 108%. Abrams had previously reported a mean increase of more than 200%. Conversely, most studies on adrenergic blockade report mean peak urinary flow increases of 40% to 60%.

The authors concluded that urinary flow rates and symptom scores improved more after transurethral prostatectomy than after any other therapeutic options available for Benign Prostatic Hyperplasia.

Complications. Mebust and associates reviewed mortality as well as intra-operative and postoperative complications in 3885 patients. The mortality from transurethral prostatic resection (TUPR) was 0.2%, with cardiovascular events being the predominant cause. The population at risk was elderly with multisystem disease. Intra-operative morbidity was reported at 7%. Hemorrhage, dilutional hyponatremia, arrhythmias, and extravasation were the most common complications. Eighteen percent of patients experienced postoperative complications, among which failure to void, hemorrhage, clot retention, and genitourinary infections were the most prominent.

Sexual function after prostatectomy

Sexual function after prostatectomy is an area of concern to many patients. The prevalence of postoperative impotence has been reported at between 5% and 31%. Retrograde ejaculation occurs in the majority of patients after transurethral prostatic resection. While this should not alter the sensation of orgasm and ejaculation, patients often find it distressing, and it can play a role in impotence.

Some studies suggest that there is no increase in sexual dysfunction when compared with other surgery in the elderly. The psychological affect of surgery involving the sexual organ, alteration of ejaculation, and the censure of sexual activity in the elderly may point to a cognitive, rather than a physiologic, event. The exact mechanism and incidence remain unknown.

Conclusion

Benign prostatic hyperplasia, both pathologically and clinically, increases with age. As the geriatric population expands, so will the medical and financial importance of this disease.

Transurethral prostatic resection is likely to remain the standard of care for the foreseeable future. It is a safe procedure, particularly when one considers the relatively high-risk population undergoing it. It is more effective than all other current and experimental forms of therapy by a wide margin. Efforts to reduce hospital stay will result in substantial savings and should be encouraged.

Alternative invasive therapies, such as balloon dilation and urethral stents, are currently unproven. The ideal techniques and optimal patient population have yet to be described. Current evidence would suggest a limited role for hormonal therapy, which is expensive and offers limited clinical benefit. More promising are the use of OC-adrenergic blockers to treat outlet obstruction and anticholinergics to treat irritative symptoms when obstruction is mild to moderate. ■

Management of Benign Prostatic Hyperplasia (BPH): Treatment Treatment for benign prostatic hyperplasia (BPH) must be patient specific and includes watchful waiting and monitoring, pharmacotherapy, minimally invasive therapy and surgery. Certain patients may benefit more from surgery than pharmacotherapy based upon results of the clinician’s evaluation and the patient’s subjective assessment of ...
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Long-Term Complications Untreated, benign prostatic hyperplasia may lead to complications such as acute or chronic urinary retention, renal failure, serious or recurrent urinary tract infections, bladder decompensation, hydronephrosis, and calculi, particularly bladder calculi. Few studies, however, have quantified the long-term risk of these complications. Several authors ...
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