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Canadian Urological Association guideline: Male lower urinary tract symptoms/ benign prostatic hyperplasia Flashcards

1
Q

What is the purpose of the updated Canadian Urological Association (CUA) BPH guideline document?

A

The document summarizes state-of-the-art knowledge related to the management of male lower urinary tract symptoms (MLUTS) secondary to benign prostatic hyperplasia (BPH). It updates the 2018 CUA BPH guideline and highlights essential diagnostic and therapeutic information in a Canadian context.

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2
Q

What is the scope of the literature review conducted for the CUA BPH guideline update?

A

The literature review includes information reviewed for the 2010 guideline, an updated MEDLINE search of the English-language literature (using a variety of search terms related to BPH treatment methods), and a review of the most recent American Urological Association (AUA) and European Association of Urology (EAU) guidelines. The management recommendations are based on literature published between 2000 and 2021.

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3
Q

Who are the guidelines directed towards?

A

The guidelines are primarily directed towards the typical male patient over 50 years of age presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO). However, they also apply to non-binary people, transwomen, and any patients who may have anatomical features of a cis-male genitourinary tract, such as a prostate.

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4
Q

How are diagnostic guidelines described in the document?

A

Diagnostic guidelines are described in the following terms: mandatory, recommended, optional, or not recommended. These recommendations were developed based on clinical principle and/or expert opinion.

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5
Q

How are treatment guidelines described in the document?

A

Treatment guidelines are described using the GRADE approach for summarizing the evidence and making recommendations.

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6
Q

What are the mandatory evaluations recommended in the diagnostic guidelines of the 2018 CUA BPH?

A

The mandatory evaluations include:

Patient history
Physical examination, including a digital rectal exam (DRE)
Urinalysis

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7
Q

What is the purpose of the initial evaluation of a man presenting with LUTS according to the CUA BPH guidelines?

A

The purpose of the initial evaluation is to assess symptom severity and bother. It should include a review of relevant prior and current illnesses, prior surgery, and trauma. It is also mandatory to review current medication, including over-the-counter drugs and phyto-therapeutic agents.

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8
Q

Why is a focused physical examination, including a digital rectal exam (DRE), mandatory?

A

A focused physical examination, including a DRE, is mandatory to provide information about the prostate that might influence the management of LUTS.

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9
Q

Why is urinalysis required?

A

Urinalysis is required to rule out diagnoses other than BPH that may cause LUTS and may require additional diagnostic tests.

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10
Q

What is the purpose of using a formal symptom inventory (e.g., International Prostate Symptom Score [IPSS] or AUA Symptom Index [AUA-SI]) in the management of male lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH)?

A

A formal symptom inventory is recommended for an objective assessment of symptoms at initial consultation, for follow-up of symptom evolution for those on watchful waiting, and for evaluation of response to treatment.

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11
Q

In the context of LUTS/BPH, to whom should testing of prostate-specific antigen (PSA) be offered?

A

Testing of PSA should be offered to patients who have at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management, as well as those for whom PSA measurement may change the management of their voiding symptoms.

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12
Q

How can serum PSA be a useful marker in patients without prostate cancer?

A

Among patients without prostate cancer, serum PSA may be a useful surrogate marker of prostate size and may also predict risk of BPH progression.

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13
Q

What are some optional tests that a physician might order when there is diagnostic uncertainty in a case of male lower urinary tract symptoms/benign prostatic hyperplasia?

A

The optional tests could include:

Serum creatinine
Urine cytology
Uroflowmetry
Postvoid residual (PVR)
Voiding diary (recommended frequency volume chart for men with suspected nocturnal polyuria)
Obstructive Sleep Apnea (OSA) screening for men with nocturia over the age of 50 (STOP BANG questionnaire)
Sexual function questionnaire

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14
Q

When is a voiding diary recommended, according to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?

A

A voiding diary (frequency volume chart) is recommended for men with suspected nocturnal polyuria.

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15
Q

For men with nocturia over the age of 50, what kind of screening is recommended by the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?

A

Obstructive Sleep Apnea (OSA) screening is recommended. This is typically performed using the STOP BANG questionnaire.

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16
Q

According to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, what type of questionnaire might be used to evaluate sexual function?

A

A sexual function questionnaire may be used to evaluate sexual function.

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17
Q

What does the acronym “PVR” stand for in the context of urology, and when might it be used according to the Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia?

A

“PVR” stands for Postvoid Residual. It may be used when there is diagnostic uncertainty in a case of male lower urinary tract symptoms/benign prostatic hyperplasia.

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18
Q

What are the diagnostic modalities not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS?

A

The diagnostic modalities that are not recommended in the routine initial evaluation of a typical patient with BPH-associated LUTS include:

Cytology
Cystoscopy
Urodynamics
Radiological evaluation of the upper urinary tract
Prostate ultrasound
Prostate biopsy

These investigations may be required in patients with another indication, such as hematuria, diagnostic uncertainty, DRE abnormalities, poor response to medical therapy, or for surgical planning.

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19
Q

In which situations might the non-recommended diagnostic modalities be required for a patient with BPH-associated LUTS?

A

The non-recommended diagnostic modalities might be required in the following situations:

Presence of hematuria
Diagnostic uncertainty
DRE abnormalities
Poor response to medical therapy
For surgical planning

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20
Q

Figure 1

A

Algorithm of appropriate diagnostic steps in the workup of a typical patient with male lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). PE: physical exam; PSA: prostate-specific antigen; PVR: postvoid residual; U/A: urinalysis.

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21
Q

What are the seven indications for MLUTS/BPH surgery according to the Canadian Urological Association guideline?

A

The indications include:

Recurrent or refractory urinary retention
Recurrent urinary tract infections (UTIs)
Bladder stones
Recurrent hematuria
Renal dysfunction secondary to BPH
Symptom deterioration despite medical therapy
Patient preference.

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22
Q

Is the presence of a bladder diverticulum an absolute indication for MLUTS/BPH surgery?

A

No, the presence of a bladder diverticulum is not an absolute indication for surgery unless associated with recurrent UTI or progressive bladder dysfunction.

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23
Q

Which tests are recommended preoperatively for patients in whom MLUTS/BPH surgery is being considered?

A

Cystoscopy should be performed to evaluate prostate size, as well as presence or absence of significant middle/median lobe and/or bladder calculi. Ultrasound (either by transrectal ultrasound [TRUS] or transabdominal US) is recommended to determine the volume of the prostate and the extent of median lobe presence in order to select appropriate modality of surgical therapy. Information can also be obtained from a recent abdominal computed tomography (CT) or magnetic resonance imaging (MRI).

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24
Q

Why is the determination of prostate size and extent of median lobe important before MLUTS/BPH surgery?

A

The determination of prostate size and extent of median lobe are related to procedure-specific indications. They inform the selection of the appropriate modality of surgical therapy.

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25
What are the purposes of preoperative cystoscopy and ultrasound in the context of MLUTS/BPH surgery?
Cystoscopy is performed to evaluate the prostate size, as well as the presence or absence of significant middle/median lobe and/or bladder calculi. Ultrasound is used to determine the volume of the prostate and the extent of median lobe presence. These assessments guide the selection of the appropriate modality of surgical therapy.
26
What principles should guide therapeutic decision-making for BPH?
The severity of the symptoms, the degree of bother, and patient preference should guide therapeutic decision-making for BPH. Patients should be informed about the risks and benefits of all treatment options if they are bothered enough to consider therapy. A shared decision-making approach should be used to determine the best treatment for the patient.
27
What is the suggested approach for patients with mild BPH symptoms (e.g., IPSS <7)?
Patients with mild symptoms should be counseled about a combination of lifestyle modification and watchful waiting. If these patients have severe bother, they should undergo further assessment.
28
What are the treatment options for patients with moderate (e.g., IPSS 8–18) and severe (e.g., IPSS 19–35) BPH symptoms?
Treatment options include watchful waiting/lifestyle modification, medical therapy, minimally invasive therapy, and surgical therapies.
29
What factors should physicians use to advise patients on their individual risk of symptom progression, acute urinary retention (AUR), or future need for BPH-related surgery?
Physicians should use baseline age, LUTS severity, and prostate volume to advise patients on their individual risk of symptom progression, acute urinary retention, or future need for BPH-related surgery.
30
What lifestyle changes may be suggested for patients with non-bothersome BPH symptoms?
Suggested lifestyle changes include fluid restriction (especially before bedtime), avoidance of caffeinated beverages, alcohol, spicy foods, and certain drugs (diuretics, decongestants, antihistamines, antidepressants), timed or organized voiding (bladder retraining), avoidance or treatment of constipation, weight loss, prevention or treatment of conditions associated with metabolic syndrome, and pelvic floor physical therapy in cases of suspected non-relaxing pelvic floor dysfunction or overactive bladder and/or urinary incontinence.
31
What is the recommended follow-up protocol for patients on watchful waiting for BPH?
Patients on watchful waiting should have periodic physician-monitored visits to monitor for any complications associated with their BPO. Physicians should assess either progression of bother, using a validated questionnaire such as IPSS (subjective), or worsening urinary function, using uroflowmetry or PVR (objective).
32
What should be assessed during follow-up visits for patients started on medical therapy for BPH?
Follow-up visits for patients on medical therapy should assess the efficacy and safety (side effects) of medications. If the patient-directed therapeutic goal is achieved, the patient may be followed by the primary care physician as part of a shared-care approach. The primary care physician should be counseled with clear instructions on follow-up and re-referral as necessary.
33
What is the recommended follow-up protocol for patients who receive prostate surgery for BPH?
Patients who receive prostate surgery for BPH should be reviewed 4–6 weeks after catheter removal to evaluate treatment response, using symptom assessment (e.g., IPSS), and if indicated, uroflowmetry and PVR volume. Side effects and adverse events should also be screened for. The need for and type of further follow-up will be determined by the individual patient’s circumstances and the type of surgical procedure employed.
34
What are some of the alpha-blockers recommended for the treatment of LUTS secondary to BPH?
Alfuzosin, doxazosin, tamsulosin, terazosin, and silodosin are recommended for the treatment of LUTS secondary to BPH.
35
Which alpha-blockers require dose titration and blood pressure monitoring?
Doxazosin and terazosin require dose titration and blood pressure monitoring.
36
What is the impact of alpha-blockers on the natural progression of BPH?
Alpha-blockers do not alter the natural progression of BPH. They have little impact on prostate growth, risk of urinary retention, or the need for BPH-related surgery.
37
What is the most common adverse effect associated with alpha-blockers?
The most common adverse effect associated with alpha-blockers is dizziness, with the highest rates for terazosin and doxazosin.
38
Which alpha-blockers are most often reported with ejaculatory disturbances?
Ejaculatory disturbances are most often reported with tamsulosin and silodosin.
39
What is Floppy iris syndrome and with which alpha-blocker is it most commonly associated
Floppy iris syndrome has been reported in patients on alpha-blockers, particularly tamsulosin. It's not an issue in men with no planned cataract surgery and can be managed by the ophthalmologist.
40
Which factors should influence the choice of alpha-blocker for a patient?
The choice of alpha-blocker should depend on the patient’s comorbidities, side effect profile, and tolerance.
41
According to the Canadian Urological Association guidelines, what is the recommendation for alpha-blockers in the treatment of BPH?
42
What are the proven benefits of 5-ARI therapy for BPH?
5-ARI therapy improves symptoms, shrinks the prostate by 25-30%, and can alter the natural history of BPH by reducing the risk of acute urinary retention (AUR) and the need for surgical intervention.
43
In which patients is the efficacy of 5-ARI treatment noted?
Efficacy of 5-ARI treatment is noted in patients with a prostate volume greater than 30 cc and/or PSA levels greater than 1.5 ng/ml.
44
What are the potential side effects of 5-ARI treatment?
5-ARI treatment is associated with erectile dysfunction, decreased libido, ejaculation disorders, and rarely, gynecomastia and post-finasteride syndrome.
45
What is the recommendation for the use of 5-ARIs (dutasteride and finasteride) in the treatment of LUTS associated with prostatic enlargement?
5-ARIs (dutasteride and finasteride) are recommended as appropriate and effective treatment for patients with LUTS associated with demonstrable prostatic enlargement.
46
What are the prognostic factors suggesting the potential for BPH progression risk?
Serum PSA >1.4 ng/mL, age >50 years, and gland volume >30 cc.
47
How does combination therapy (alpha-blocker and 5-ARI) affect symptom score and peak urinary flow compared to monotherapy options?
Combination therapy significantly improves symptom score and peak urinary flow compared to either of the monotherapy options.
48
What are the potential side effects of combination therapy for BPH?
Combination medical therapy is associated with an increased risk of side effects, particularly ejaculatory disturbances.
49
For which patients is the combination of an alpha-adrenergic receptor blocker and a 5-ARI recommended?
This combination is recommended for patients with symptomatic LUTS associated with prostatic enlargement (>30 cc).
50
When might it be appropriate to consider discontinuing the alpha-blockers in patients successfully managed with combination therapy for BPH?
It may be appropriate to consider discontinuing the alpha-blockers after 6–9 months of combination therapy.
51
What is the recommended course of action if symptoms recur after discontinuing the alpha-blocker in a patient with BPH?
If symptoms recur, the alpha-blocker should be restarted.
52
What are the common storage symptoms associated with Male Lower Urinary Tract Symptoms (MLUTS) in the context of Benign Prostatic Hyperplasia (BPH)?
The common storage symptoms associated with MLUTS in BPH are urgency, frequency, and nocturia.
53
What improvements have antimuscarinics (anticholinergics) and beta-3 agonists shown in male storage LUTS (with and without BPH)?
These medications have shown reductions in frequency, urgency, and urgency incontinence episodes.
54
Name some contemporary antimuscarinics used in treating male storage LUTS.
Contemporary antimuscarinics include tolterodine and fesoterodine.
55
What is the beta-3 agonist used in treating male storage LUTS?
The beta-3 agonist used is mirabegron.
56
What are the potential risks associated with the use of antimuscarinics and beta-3 agonists in treating male storage LUTS?
These medications have shown low rates of urinary retention. However, caution should be exercised in elderly men and those with significant bladder outlet obstruction (BOO) and a Post-Void Residual volume (PVR) of more than 250–300 cc. There is little evidence of safety in men with high PVRs.
57
According to the Canadian Urological Association guidelines, when may antimuscarinics or beta-3 agonists be useful in the context of BPH and what caution is advised?
: Antimuscarinics or beta-3 agonists may be useful in predominantly storage symptoms and BPH. They should be used with caution in those with significant BOO and/or an elevated PVR. This is a conditional recommendation with an evidence level of C.
58
What is the guideline's recommendation for managing mixed LUTS (storage and voiding symptoms)?
The guideline recommends managing mixed LUTS with alpha-blockers in combination with antimuscarinics or beta-3-agonists.
59
Which drug combinations have been studied in clinical trials for the management of mixed LUTS according to the guideline?
The drug combinations studied are tamsulosin 0.4 mg plus solifenacin 5 mg, tamsulosin plus tolterodine ER 4 mg, and tamsulosin 0.4 mg plus mirabegron 50 mg.
60
What are the effects of these combination therapies on storage symptoms and maximum flow rate on uroflowmetry (Qmax)?
Combination therapies provide significant improvement in storage symptoms without clinical or statistical evidence of decreased Qmax or increased risk of retention.
61
Which patients were excluded from the clinical trials studying these combination therapies?
Patients with high PVR >200 ml or a previous history of AUR were excluded.
62
When might an alpha-blocker combined with an antimuscarinic or beta-3 agonist be useful according to the guideline?
The combination may be useful to treat LUTS/BPH in men with both voiding and storage symptoms and failure of alpha-blocker monotherapy.
63
What is the level and type of recommendation for the use of an alpha-blocker combined with an antimuscarinic or beta-3 agonist in treating LUTS/BPH?
It is a conditional recommendation, with an evidence level of B.
64
What role do PDE5Is play in the treatment of male LUTS?
PDE5Is not only improve erectile function, but they are also an effective treatment for male LUTS. They show improvements in IPSS, storage and voiding symptoms, and quality of life.
65
Which PDE5I is approved for MLUTS, and why?
Tadalafil 5 mg daily is approved for MLUTS due to its longer half-life.
66
How does the combination therapy of PDE5Is and alpha-blockers compare to alpha-blockers alone in the treatment of men with voiding symptoms and erectile dysfunction?
Combination therapy with PDE5Is and alpha-blockers is superior to alpha-blockers alone in men with voiding symptoms and erectile dysfunction.
67
Combination therapy with PDE5Is and alpha-blockers is superior to alpha-blockers alone in men with voiding symptoms and erectile dysfunction.
What is the recommendation for using long-acting PDE5Is in men with LUTS/BPH, especially those with both LUTS and erectile dysfunction?
68
What is Nocturnal Polyuria (NP)?
Nocturnal Polyuria (NP) is a condition defined by the International Continence Society (ICS) as an abnormally large volume of urine during sleep. Specifically, 33% of the total daily urine volume occurs at night, while the daily total urine output remains normal.
69
How is Desmopressin related to Nocturnal Polyuria (NP)?
Desmopressin is a synthetic analogue of the antidiuretic hormone, arginine vasopressin (AVP). It reduces total nocturnal voids and increases hours of undisturbed sleep by reducing urine production in men with NP.
70
What is the risk associated with Desmopressin treatment?
While the risk of hyponatremia is low in men with normal baseline serum sodium, sodium levels must be checked at baseline in all men, as well as 4-8 days and 30 days after initiation of treatment in men taking desmopressin melts or men ≥65 years taking 50 μg oral disintegrating tablet.
71
When should Desmopressin be considered as a treatment option?
In men whose predominant symptom is bothersome nocturia and who do not respond to conservative measures or other monotherapies, desmopressin should be considered.
72
What is the Canadian Urological Association's recommendation regarding Desmopressin?
The Canadian Urological Association recommends desmopressin as a therapeutic option in men with LUTS/BPH with nocturia as a result of NP. This is a conditional recommendation, with an evidence level of B.
73
What are some common formulations of phytotherapies used in treating MLUTS/BPH?
The common formulations include Serenoa repens (saw palmetto), Pygeum africanum (African plum bark), and Urtica dioica (stinging nettle).
74
What are the issues associated with phytotherapies for MLUTS/BPH?
Phytotherapies lack consistent formulation, predictable pharmacokinetics, and regulatory oversight
75
How do studies and Cochrane meta-analyses evaluate the effectiveness of phytotherapies for MLUTS/BPH?
Numerous studies and Cochrane meta-analyses report no significant difference between phytotherapies and placebo, as measured by AUA-SI, peak flow rates, prostate volume, residual urine volume, PSA, or quality of life.
76
What are the possible side effects and interactions of phytotherapies for MLUTS/BPH?
There are few side effects associated with phytotherapies, but there are important potential drug interactions.
77
What is the Canadian Urological Association's recommendation regarding the use of phytotherapies for MLUTS/BPH?
The Canadian Urological Association does not recommend phytotherapies as a standard treatment for MLUTS/BPH (strong recommendation, evidence level B).
78
What is the primary standard-reference surgical treatment option for moderate-to-severe Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH) in patients with a prostate volume of 30–80 cc?
Monopolar TURP (M-TURP)
79
What is the current approximate perioperative mortality rate of M-TURP?
Approximately 0.1%
80
List some of the complications associated with M-TURP.
Complications include bleeding (2–9%), capsule perforation with significant extravasation (2%), TUR syndrome (0.8%), urinary retention (4.5–13%), infection (3–4%; sepsis 1.5%), incontinence (<1%), bladder neck contracture (3–5%), retrograde ejaculation (65%), erectile dysfunction (6.5%), and need for surgical retreatment (2%/year).
81
What is Bipolar TURP (B-TURP) and how does it compare to M-TURP?
B-TURP offers a resection alternative to M-TURP in men with moderate-to-severe LUTS secondary to BPH. It has similar efficacy to M-TURP but lower perioperative morbidity. The key difference is the decreased risk of perioperative bleeding and TUR syndrome.
82
What factors should be considered when choosing between M-TURP and B-TURP?
Factors to consider include equipment availability, surgeon experience, and patient preference.
83
What is the recommendation level and evidence level for using M-TURP as a first-line surgical therapy for men with moderate-to-severe LUTS/BPH with a prostate volume of 30–80 cc?
It's a strong recommendation with evidence level A.
84
What is the recommendation level and evidence level for using B-TURP as a first-line surgical therapy for men with moderate-to-severe LUTS/BPH with a prostate volume of 30–80 cc?
It's a strong recommendation with evidence level B.
85
What is Open Simple Prostatectomy (OSP)?
OSP is an effective treatment alternative for men with moderate-to-severe Lower Urinary Tract Symptoms (LUTS) with substantially enlarged prostates (>80 cc) who are significantly bothered by symptoms.
86
What are the other indications for OSP?
Other indications for OSP include plans for concurrent bladder procedure, such as diverticulectomy or cystolithotomy (for very large bladder calculi) and in men who are unable to be placed in dorsal lithotomy position due to severe hip disease.
87
Describe the invasiveness and possible complications of OSP.
OSP is the most invasive surgical method requiring longer hospitalization and catheterization. Complications include transient urinary incontinence (8–10%), bladder neck contracture, and urethral stricture (5–6%).
88
When is OSP recommended as a first-line surgical therapy?
OSP is recommended as a first-line surgical therapy when anatomic endoscopic enucleation of the prostate (AEEP) is unavailable for men with moderate-to-severe LUTS/BPH and enlarged prostate volume >80 cc.
89
What are Laparoscopic Simple Prostatectomy (LSP) and Robot-Assisted Simple Prostatectomy (RASP) typically indicated for?
LSP and RASP are indicated in patients with significantly enlarged prostates (>80–100cc) and bothersome Lower Urinary Tract Symptoms (LUTS). They are also beneficial when performed due to concomitant pathology, such as large bladder stones or bladder diverticulum.
90
What is the evidence for the safety and efficacy of LSP and RASP?
The largest retrospective series includes both techniques and has shown both to be safe and effective. There are no randomized controlled trials comparing LSP and RASP to open simple prostatectomy (OSP) or to any other enucleation procedure.
91
How does Robot-Assisted Simple Prostatectomy (RASP) compare to laser vaporization and enucleation of the prostate in terms of improvement in IPSS, PVR, Qmax, and quality of life?
A systematic review found that RASP showed similar improvements in IPSS (International Prostate Symptom Score), PVR (Post-Void Residual volume), Qmax (maximum flow rate), and quality of life, while having similar complication rates and estimated blood loss (EBL).
92
A systematic review found that RASP showed similar improvements in IPSS (International Prostate Symptom Score), PVR (Post-Void Residual volume), Qmax (maximum flow rate), and quality of life, while having similar complication rates and estimated blood loss (EBL).
In comparison to OSP, the LOS and EBL are significantly lower for RASP.
93
How do catheterization time and length of stay (LOS) with RASP compare to laser enucleation of the prostate?
Catheterization time and LOS are longer with RASP compared to laser enucleation of the prostate.
94
Who would be ideal candidates for Laparoscopic Simple Prostatectomy (LSP) or Robot-Assisted Simple Prostatectomy (RASP)?
LSP or RASP are recommended as alternative surgical therapies for men with moderate-to-severe Lower Urinary Tract Symptoms (LUTS)/Benign Prostatic Hyperplasia (BPH) and enlarged prostate volume >80 cc in centers where there are surgeons with high-level expertise in robotics or laparoscopy.
95
What does AEEP stand for and what principle does it adopt?
AEEP stands for Advanced Energy Endoscopic Prostatectomy. It adopts the principle of open prostatectomy (OP) using different energy sources and instruments.
96
List some energy sources used in AEEP.
The energy sources used in AEEP include the Holmium laser (HoLEP) with or without Moses technology, GreenLight laser (GreenLEP), monopolar enucleation (MonolEP), bipolar enucleation (BipolEP), diode laser (DiLEP), thulium laser (ThuLEP), and thulium fiber laser (ThuFLEP).
97
How does AEEP compare to TURP and OSP in terms of efficacy and safety?
AEEP has been shown to be associated with greater improvements in IPSS, Qmax, and PVR when compared to TURP and OSP. It also results in greater prostate tissue removal, reduced hemoglobin loss, shorter catheterization time, and shorter LOS.
98
AEEP has been shown to be Is AEEP recommended for patients with BPH on anticoagulant (AC) or antiplatelet (AP) therapy?
Yes, recent evidence supports the use of AEEP in patients with BPH on anticoagulant (AC) or antiplatelet (AP) therapy.
99
What is the reoperation rate of AEEP and what is it usually attributed to?
AEEP has a low reoperation rate of 0–3.7%, typically attributed to adenoma regrowth.
100
How many cases are estimated to overcome the learning curve for AEEP?
The procedure requires a steep learning curve, with an estimated 20–50 cases needed to become proficient.
101
In which patients is AEEP recommended as an alternative to TURP or OSP?
AEEP is recommended as an alternative to TURP or OSP in men with moderate-to-severe LUTS and any size prostate >30 cc if performed by an AEEP-trained surgeon.
102
Can AEEP be safely performed in patients on anticoagulant/antiplatelet therapy?
Yes, AEEP can be safely performed in patients on anticoagulant/antiplatelet therapy.
103
What are the comparable outcomes provided by GreenLight-PVP (180W XPS and 120W HPS systems) and TURP in terms of treating benign prostatic hyperplasia?
Both GreenLight-PVP and TURP provide durable improvements in IPSS and Qmax, with similar overall complication rates.
104
What are the advantages of PVP over TURP in the perioperative period?
PVP has better perioperative safety, shorter catheterization time, and shorter hospitalization compared to TURP.
105
How does the five-year mid-term durability of XPS PVP perform in prostates with volumes of an average of 80 grams?
The five-year mid-term durability of XPS PVP reported a 1.1% retreatment rate in prostates with volumes of an average of 80 grams.
106
Is PVP considered safe and effective for elderly men with significant medical comorbidities?
Yes, multiple studies have demonstrated that PVP is safe and effective for elderly men with significant medical comorbidities.
107
In the GOLIATH international trial comparing 180W XPS PVP to TURP for prostate volumes 30–80cc, which treatment showed a statistically significant difference in early adverse events?
The 180W XPS PVP had a statistically significant difference in early adverse events, notably bleeding-related ones, within the first 30 days compared to TURP.
108
According to the Canadian Urological Association guidelines, in which patients is GreenLight PVP therapy recommended as an alternate surgical approach?
GreenLight PVP therapy is suggested as an alternate surgical approach in men on anticoagulation or with high cardiovascular risk.
109
Does the PVP procedure have any size or shape limitations?
There are no size or shape limitations to PVP. Only surgeon expertise and clinical judgment dictate size limitations.
110
In the Canadian setting, how does the cost-effectiveness of PVP compare to TURP?
PVP has been shown to be a cost-effective alternative to TURP in the Canadian setting.
111
What is the recommended therapy for men with a small prostate size (< 30 cc) without a middle lobe suffering from male lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH)?
The recommended therapy is Transurethral Incision of the Prostate (TUIP).
112
How do the symptoms and voiding parameters change after Transurethral Incision of the Prostate (TUIP)?
After TUIP, symptoms and voiding parameters are improved.
113
How does the risk of retrograde ejaculation and TUR syndrome compare between TUIP and TURP?
The risk of retrograde ejaculation (18.2%) and TUR syndrome (0%) is reduced in TUIP compared to TURP.
114
How does the risk of surgical retreatment for LUTS related to BPH compare between TUIP and TURP?
The risk of surgical retreatment for LUTS related to BPH is significantly higher for TUIP (18.4%) than after TURP (7.2%).
115
To whom would you recommend TUIP for the treatment of LUTS?
TUIP is recommended for treating moderate-to-severe LUTS in men with a prostate volume of less than 30 cc, provided there is no middle lobe. Patients should be made aware of the high retreatment rate.
116
Transurethral Microwave Therapy (TUMT) and who is it ideal for?
TUMT is a procedure for treating elderly patients with significant comorbidities or higher anesthesia risks, as it can be performed under local anesthesia. It has short-term success for LUTS improvement but limited long-term durability, with five-year cumulative retreatment rates ranging from 42-59%. It should not be performed on patients with a significant median lobe.
117
What are prostatic stents and what are their limitations?
Prostatic stents can provide short-term relief from Benign Prostatic Obstruction (BPO) in patients temporarily unfit for surgery. However, they are subject to misplacement, migration, poor tolerability, exacerbation of LUTS, and encrustation, limiting their role in moderate-to-severe LUTS treatment.
118
Describe the Prostatic Urethral Lift procedure and its potential outcomes.
The Prostatic Urethral Lift, or UroLift®, provides less effective but adequate and durable improvements in IPSS and QMax compared to TURP while preserving sexual function. Most complications are mild and resolve within four weeks. The surgical retreatment rate is 13.6% over five years. It may be considered for men with LUTS who are interested in preserving ejaculatory function with prostates <80 cc, or those with a small-to-moderate median lobe and bothersome LUTS.
119
What is the Rezum® system and how does it work?
The Rezum® system uses the thermodynamic principle of convective energy transfer to ablate prostatic tissue, leading to significant improvement of IPSS and Qmax at three months, sustained until 12 months, with preservation of erectile and ejaculatory function. Its surgical retreatment rate is 4.4% at five years.
120
Can you describe Aquablation and its efficacy?
Aquablation, which is robotic-guided hydrodissection, ablates prostatic parenchyma while sparing collagenous structures such as blood vessels and the surgical capsule. It has shown comparable improvements in efficacy and safety compared to TURP in men with <80 cc prostates, and preserves erectile and ejaculatory function in nearly 100% and approximately 90% of patients, respectively. Its five-year retreatment rates are low (6% at five years).
121
What is the Temporary Implantable Nitinol Device (iTind) and when is it used?
iTind is a temporary (five days), mechanical, stent-like device designed to remodel the bladder neck and the prostatic urethra through pressure necrosis. It can be offered to men with LUTS interested in preserving ejaculatory function, with prostates 30-80 cc. The retreatment rate is 9% at three years.
122
Explain the procedure of Prostatic Artery Embolization (PAE) and its potential implications.
PAE is a minimally invasive treatment option performed exclusively by interventional radiologists at specialized centers. It results in significant IPSS, Qmax, and PVR improvement compared to baseline at 12 months, but it has inferior outcomes compared to TURP or OSP. PAE may lead to rare ischemic complications like transient ischemic proctitis, bladder ischemia, urethral and ureteral stricture, or seminal vesicles ischemia.
123
What are the complications of Urolift?
Most complications are mild and resolve within four weeks but include dysuria (34%), hematuria (26%), pelvic pain (19%), urge incontinence (7%), and UTI (3%).
124
Figure 2. Male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH) management algorithm. ED: erectile dysfunction; PDE5: phosphodiesterase type 5; PSA: prostate-specific antigen.
125
Figure 3. Treatment algorithm of bothersome lower urinary tract symptoms (LUTS) refractory to conservative/medical treatment or in cases of absolute operation indications.
126
In patients with Acute Urinary Retention (AUR) secondary to BPH, which class of drugs can increase the chances of successful voiding after catheter removal?
Alpha-blockers, specifically tamsulosin, alfuzosin, and silodosin.
127
What is the potential additional benefit of using a 5-Alpha Reductase Inhibitor (5-ARI) in patients with AUR?
It may decrease the risk of future prostate surgery.
128
What is the main approach to treating primary Detrusor Underactivity (DU)?
Facilitate bladder emptying, identify agents that can decrease bladder contractility, or increase urethral resistance.
129
What strategies are available for the management of Detrusor Underactivity (DU)?
Behavioral modification, including scheduled voiding and or double voiding, clean intermittent self-catheterization (CIC), or indwelling catheters.
130
Is Detrusor Underactivity (DU) a contraindication for Transurethral Resection of the Prostate (TURP) or enucleation?
No, the data suggests that DU is not necessarily a contraindication for TURP or enucleation.
131
What steps are necessary to assess BPH-related bleeding?
A complete assessment, including history and physical examination, urinalysis (routine microscopy, culture and sensitivity, cytology), upper tract radiological assessment, and cystoscopy.
132
What drug has been reported to reduce the risk of recurrent BPH-related hematuria?
Finasteride, a type of 5-ARI.
133
In BPH patients with elevated serum PSA and negative prostate biopsy, what is a potential benefit of 5-ARI therapy?
It may reduce the risk of prostate cancer detection.
134
What is the potential risk associated with 5-ARI use?
A possible low absolute increased risk (0.5–0.7%) in incidence of high-grade (Gleason 8–10) cancer.
135
In patients on 5-ARI therapy for BPH, what should be done if there is a rising PSA 6–12 months after PSA nadir is reached?
They should be assessed for the possibility of high-grade prostate cancer.
136
What is the common age-related disorder afflicting men, as mentioned in the guideline document?

09. HPB (870) (8 decks)

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