Prognosis Flashcards
Olmsted country
prevalence of moderate to severe LUTS in over 50
30%
46% in over 70
26% in 40-49
Olmsted country author year number of men age groups assessment follow up period
Jacobsen 1999 2115 white men randomly selected no previous drug therapy 40-79 3 contacts in 42 months, IPSS and flow rate 25% had trus for prostate size
increase in LUTS symptoms in Olmsted
0.18 AUA SI points per year on average
rate of increase higher in men in 70s vs 40s
incidence of AUR over 4 years in Olmsted county
2.7% cumulative incidence over 4 years
57 men out of 2115
AUR risk 40-49 3/1000
9/1000 in 70-79 if IPSS less than 7
34/1000 if IPSS >7
risk AUR 1% for men in 50s, 9% in over 70
3% had TURP, although 9.5% in men 70-79
risk factors for progression - 7
PSA over 1.4 4x volume over 30 4x Age 70-79 8x qmax <12 4x AUA SS >8 3x PVR more than 50mls 3x
PLESS study author year drugs follow up period
McConnell 1998, NEJM proscar long term efficacy and safety study finasteride vs placebo 4 years
PLESS finasteride effect prostate size symptom score flow risk of surgery retention
Proscar long term efficacy and safety study
3040 men with mod severe luts, qmax less than 15, PSA less than 10
designed to enrol men with large prostate so mean volume 54 mls
18% reduction volume, volume increased 14% in placebo
symptoms score down 1.6
flow improved 2 ml/sec
reduction retention and surgery 55% from 10 to 5%
AUR risk reduced 7 to 3%
PLESS risk factor for retention
PSA
prostate volume
8 x if PSA more than 1.4
3 x if volume more than 40cc
PLESS side effect finasteride
decreased libido impotence reduced volume ejaculate breast enlargement rash
prostate volume change in PLESS
decreased 18% in FIN group
increased 14% in placebo group
alpha blocker MA
IPSS score improvement
qmax improvement
side effect profile
Djavan MA Eur Urol 1999 IPSS improvement 30-40% flow rate improvement 16-25% alfuzosin and tamsulosin better SE profile tamsulosin lower effect on BP
ALFAUR study
RR of twoc
RR of need surgery 6 months
2005
McNeil
RRR 27% at 72 hours of alfuzosin for retention
29% decreased need surgery at 6 months when continued treatment
MTOPS author year men arms follow up
medical therapy of prostatic symptoms mcConnell 2003 NEJM 2047 men FIN, DOX 4.5 years follow up
MTOPS selection criteria mean PSA median prostate volume age IPSS markers of progression 6
volume 31 cc PSA median 1.6 PSA 10 or less age 50 or more IPSS 8-30 limited at 30 markers of progression AUR failed twoc IPSS >4 creatinine >133 recurrent UTI incontinence
AUR rate in MTOPS
placebo 0.6% AUR rate
FIN or FIN+DOX reduce risk surgery and retention
DOX alone did not reduce risk AUR
symptom score improvement MTOPS
FIN and DOX diverge difference at year 4
IPSS improvement DOX 6 points, FIN 4 points, FIN and DOX 7 points, placebo 5 points
QMax improvement MTOPS
DOX 4 ml/sec
FIN 2ml/sec
FIN and DOX 5 ml.sec
evidence for psa reduction
from MTOPS
FIN reduced PSA by 50%
MTOPS reduction progression
reduction in retention with DOX
39%
35%
versus FIN alone 34% 68% versus COMBO 66% 81%
CombAT author year patients arms follow up
Roehrborn 2007 4844 patients DUT and TAM four years
CombAT median prostate volume age IPSS PSA selection primary end points
median prostate volume 49cc so bigger than MTOPS PSA 1.5 to 10 age 50 or more IPSS 12 or more time to surgery or AUR
CombAT results
DUT vs TAM time line to drop in IPSS
combo better than both for symptoms
combo better than TAM alone for reduction surgery and retention
TAM rapid reduction in IPSS from baseline by 5 in 3 months
DUT took 15 months to reach same drop
DUT and TAM same rapid reduction by 4 months but better than TAM alone by 9 months which was sustained over 2 years
reduction in AUR and BPH surgery with DUT or DUT and TAM vs TAM alone
but no difference in reduction retention and surgery in combo vs dut alone
RRR 65% at year 4
ARR 11.9% vs 4.2% diversing from TAM alone by 8 month
haematuria and FIN paper
Kearney J Urol 2002
Finasteride for haematuria
75% had no further haematuria at 3 years
what change in IPSS related to subjective worsening of LUTS
4 points
aur risk in olmsted country in 50s and 70s
1% in 50s vs 9% in over 70
olmsted county median peak flow
21 in 40-49
14 in 70-79
national prostatectomy audit year no of men how many having elective operation great improvement how many worse death rate
1992 5337 men 1/3 having elective operations 64% better 4% worse death rate 0.2%
UPSTREAM author year type primary outcome secondary outcome no men
Drake 2020 non inferiority RCT 18 months change in IPSS surgery as secondary outcome 860 men randomised to RC and UDS UDS arm showed non inferiority of mean IPSS
abrams paper expected improvement luts in boo vs no boo
90% vs 60% after turp if BOO vs no BOO
reynard paper 1998 ICS BPH study
> 1200 men
ipss, uroflow and PFS
Qmax of 10mls/sec had PPV of 70% for BOO based on PFS done, sensitivity 47%
15 mls/sec specificity 38% and PPV 67%, sensitivity 82%
Thus 53% of BOO had flow rate of over 10ml/sec
18% of patients with BOO had flow rate of over 15ml/sec
reynard paper 1998 ICS BPH study
> 1200 men
ipss, uroflow and PFS
Qmax of 10mls/sec had PPV of 70% for BOO based on PFS done, sensitivity 47%
15 mls/sec specificity 38% and PPV 67%, sensitivity 82%
Thus 53% of BOO had flow rate of over 10ml/sec
18% of patients with BOO had flow rate of over 15ml/sec
risk factors AUR
volume more than 30 PSA more than 1.4 IPSS more than 7 Qmax less than 12 age more than 70 vs 40-49 PVR
