BENIGN PROSTATIC HYPERPLASIA

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Suggested Reading Chen B and Yeh J: Alterations in connective tissue metabolism in stress incontinence and prolapse. J Urol 2011; 186: 1768.

Benign Prostatic Hyperplasia Re: Intravesical Prostatic Protrusion Can Be a Predicting Factor for the Treatment Outcome in Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction Treated with Tamsulosin A. A. Cumpanas, M. Botoca, R. Minciu and V. Bucuras Department of Urology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania Urology 2013; 81: 859e863.

Abstract available at http://jurology.com/ Editorial Comment: I had the pleasure of meeting Professor Foo in Singapore last year when I was a visiting professor there. As usual, I learned a lot! Most notably, Foo had been extensively evaluating the role of intravesical prostatic protrusion (IPP) as a method to predict the degree of bladder outlet obstruction and the response to surgical therapy. The data are quite compelling. Tan and Foo1 and other investigators have contributed a significant noninvasive proxy for bladder outlet obstruction and a potential predictor of medical and surgical success. Since that time, we have been using IPP as part of every transrectal ultrasound we perform and have found similar results. One can almost predict which patients will have urinary retention and which will have a good surgical outcome. To supplement this concept, the authors of this study use IPP as a predictor of which patients may fail alpha-blocker therapy. They report that response to tamsulosin using predetermined criteria (International Prostate Symptom Score decrease of 35% and 3 points, and peak flow rate increase of 25% and 1.6 ml per second) was significantly less in men with a baseline IPP of less than 10 mm. This finding makes intuitive sense, as men with middle lobe obstruction seem to be a different breed than those with simple bilobar hypertrophy. In general, men with IPP greater than 10 mm tend to have worse symptoms and worse bladder outlet obstruction and are more likely to go into urinary retention but most importantly seem to respond best to surgical intervention. Steven A. Kaplan, MD 1. Tan YH and Foo KT: Intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urinary retention. J Urol 2003; 170: 2339.

Re: Predictors of Successful First-Line Antimuscarinic Monotherapy in Men with Enlarged Prostate and Predominant Storage Symptoms C. H. Liao, Y. C. Kuo and H. C. Kuo Department of Urology, Cardinal Tien Hospital and School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan Urology 2013; 81: 1030e1033.

Abstract available at http://jurology.com/ Editorial Comment: It is somewhat remarkable that a class of medical therapy previously thought to be verboten in men with lower urinary tract symptoms, ie antimuscarinics, is now approved in virtually every urological guideline for benign prostatic hyperplasia. It seems reasonable that men with predominantly storage symptoms, ie frequency, urgency, etc, would benefit from antimuscarinic

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therapy either as monotherapy or in combination with another agent approved to treat benign prostatic hyperplasia. However, are there baseline criteria that would a priori predict which men would benefit from antimuscarinic therapy alone? In this Taiwanese study men with predominantly storage symptoms, baseline prostate volume 40 ml or less and peak flow rate 10 ml per second or less seemed to respond better. A number of caveats are noteworthy. What is the definition of a response in this study? The authors use a validated 7-point global response scale ranging from 3 (markedly worse) to +3 (markedly better), in which +1 or greater is considered a response. One could argue that this response is not enough and/or does not correlate with International Prostate Symptom Score (I-PSS). However, should the preferred method of assessing response not be improvement in how a patient feels rather than changes in a metric that seems to be losing steam (I-PSS)? Given that the I-PSS is not widely applicable to both genders, does not adequately assess bother or pain and does not assess incontinence, efforts to develop better metrics should be and are being encouraged. Finally, our group and others have come to the same conclusions. Men with smaller prostates and those with predominantly storage symptoms are ideal candidates for antimuscarinic therapy either as monotherapy or in combination with an alpha-blocker or 5alpha-reductase inhibitor. Steven A. Kaplan, MD

Re: intravesical prostatic protrusion can be a predicting factor for the treatment outcome in patients with lower urinary tract symptoms due to benign prostatic obstruction treated with tamsulosin.

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