COMPLEX DECISION-MAKING NEEDS EVALUATING A MAN WITH BENIGN PROSTATIC DISEASE-

 It was simple in the “good old days”: An elder man protesting of nocturia got his prostate resected. Since then, we have come a long way and are more aware of patient-centered outcomes, validated symptom scores, and objective parameters. The instructions have emerged from benign prostatic hyperplasia (BPH) to male lower urinary tract symptoms (LUTS) due to BPH and not still to the male LUTS due to benign prostatic obstruction (BPO).

The interview with this affair with Alexis E. Te, MD, a known expert in the field, reflects the complicated decision-making now mandatory when a man presents with LUTS.

An older man displaying LUTS may have bigger odds of having BPO, but older age also raises the prevalence of bladder dysfunction, volume-induced nocturia, and metabolic health conditions affecting the urinary system. With new individuals (<40 years), outlet obstruction is fewer likely but “prostatitis” is even less likely—but is most frequently diagnosed. Underactive bladder, pelvic floor dysfunction, and bladder neck obstructions must be at the forefront of the thought process.

In spite of the International Prostate Symptom Score (IPSS) should be a standard, the demand for a physical exam is emphasized in the current guidelines. Added to the prostate, the rectal exam can approach the regional neuro status and pelvic muscle behavior. Prostate-specific antigen screening has become the replacement for exams for some clinicians but is not backed by the guidelines.

Medical therapy has experienced significant advances to examine drugs for outlet obstruction (α-blockers), decreasing the size and preventing detainment (5α-reductase inhibitors), conducting overactive bladder (OAB) symptoms with anticholinergics (with or without concomitant α-blockers). The practice of phosphodiesterase 5 inhibitors has stamping indications for tadalafil (Cialis), but daily dosing is cost-prohibitive if not coated by insurance. The biggest objection is the continued utilize of meds after a procedure for the prostate. Whether that should be considered a therapy failure is an unanswered question. Although the help of anticholinergics for persistent OAB symptoms after therapy can be confirmed, the use of α-blockers is not.

Among the myriad therapy options, the vocabulary of minimally invasive therapy (MIT) is abused to the point that Dr. Te attributes robotic surgery as a “maximally invasive minimally invasive” policy to substitute for open simple prostatectomy. The goal of MIT has always been office-based therapy under local anesthesia, which was realized with microwave and radiofrequency therapy, but the case that they are no longer done is a saga for another day!

Objective conclusions failure and retreatment rate are what began their demise. In the American Urological Association’s 2020 amendment to its Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia guideline,1 the authors wrote, “Guideline 6 is a new instruction recommending that patients be counseled as to the potential risks of treatment failure and demand for additional therapies. First, rates of treatment failure and retreatment are determined by both the period and the completeness of follow-up. Second, the dangers of objective (eg, urinary retention, reduction of flow rate, increasing residual urine, infection) and subjective failure (eg, worsening of IPSS and/or quality of life) development with a longer period of follow-up. Third, retreatment may take the structure of medical therapy, a minimally invasive intervention, or a surgical policy. Fourth, thresholds for and types of retreatment may vary substantially by the provider, patient, division of failure (ie, objective, subjective, or both), and initial treatment modality.”

Retreatment is the latest buzzword and is very controversial, as parameters keep growing. Perhaps the newly formed Society of Benign Prostatic Disease can define this better. Quality of life immediately after medication and catheter duration affects patients a lot extra and is not reflected in 3-, 6-, and 12-month follow-up data.

The other nuance to maneuver around is in patients at higher danger of bleeding, such as those on antiplatelet/anticoagulation drugs.

The bias of the surgeon and their level on the learning curve for the latest analysis is known only to the surgeon. Thus, quoting conclusions of an expert trial as expected outcomes may not be realized by the patient in practice.