Hiperprasia Benigna d Ela Prostata

8/9/2019 Hiperprasia Benigna d Ela Prostata

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1.

Clinical manifestations and diagnostic evaluation of benign prostatic

hyperplasia

Authors

Glenn R Cunningham, MD

Dov Kadmon, MD

ection !ditor

Michael " #$%eary, MD, M"&

Deputy !ditor

%ee "ar', MD

Disclosures( Glenn R Cunningham, MD )othing to disclose. Dov Kadmon, MD)othing to disclose. Michael " #$%eary, MD, M"& )othing to disclose. %ee

"ar', MD !mployee of *p+oDate, nc. !mployment -pouse( )ovartis. !/uity#0nershiptoc' #ptions -pouse( )ovartis. Contributor disclosures are

revie0ed for con2icts of interest by the editorial group. 3hen found, these

are addressed by vetting through a multi4level revie0 process, and throughre/uirements for references to be provided to support the content.

Appropriately referenced content is re/uired of all authors and mustconform to *p+oDate standards of evidence. Con2ict of interest policy

All topics are updated as ne0 evidence becomes available and our peerrevie0 process is complete.

%iterature revie0 current through( ep 5617. 8 +his topic last updated( Mar

19, 561:.

)+R#D*C+#) ;


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is poor. +his discrepancy probably results from changes in bladder function1 that occur 0ith aging and from enlargement of the transitional Bone of

the prostate that is not al0ays evident on rectal eamination.

"atients 0ith


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prior to 15 is attributed to 0idespread introduction of "A determinationsand prostate screening in the *nited tates, and part of the fall since then

may be related to individuals being diagnosed at an earlier stage in theprevious years. Although the #lmsted County study 0as a population4based

prospective study, most of the men 0ere 0hite. t is unclear 0hether the

results translate to other racial and ethnic groups.

J+he Massachusetts Male Aging tudy evaluated men 76 to H6 years of agein communities surrounding cant changes in discharges for primary


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1,1H. erum "A is a stronger predictor of prostate gro0th than age orbaseline prostate volume 19, and therefore "A should be a good predictor

of ris' for acute urinary retention. -ee ?Acute urinary retention?.

A population4based study follo0ed 199 men =6 to H= years of age andfound that prostate volume 0as associated 0ith age and prior prostatevolume over a period of 7.5 years 1. +his allo0ed prediction of $normal$

prostate volume using age and prostate volume history. +he authors suggest

that it may be possible to use a model to identify men 0ho should betreated and those 0ho can be follo0ed 0ithout treatment.

"rostate cancer ;


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optional evaluations, and they diFer some0hat from those of the A*A57,5=.

&istory ; +he history may provide important diagnostic information. n

addition to /uestioning the man about obstructive urinary symptoms, it isimportant to as' about the follo0ing(

J&istory of type 5 diabetes, 0hich can cause nocturia and is a ris' factor for


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is administered by an intervie0er to visually impaired and illiterate men:5. &o0ever, it correlates poorly 0ith prostate siBe and pea' urinary 2o0

rates ::4:=.

+he nternational "rostate ymptom core -" uses the same /uestionsand scale as the A*A symptom score and adds a disease4speci>c /uality oflife /uestion( ?f you 0ere to spend the rest of your life 0ith your urinary

condition the 0ay it is no0, ho0 0ould you feel about thatO? :=.

t also has been sho0n that a voiding diary that includes nocturia, diuria and

void volume may provide more meaningful information of prostate volume

and maimum urinary 2o0 rates than A*A symptom score :.

"hysical eamination ; A digital rectal eamination should be done to

assess prostate siBe -normal prostate siBe bet0een H to 1 grams, 0ith anaverage of 11 grams :H and consistency and to detect nodules,

induration, and asymmetry, all of 0hich raise suspicion for malignancy. -ee

?Clinical presentation and diagnosis of prostate cancer?. Rectal sphinctertone should be determined, and a neurological eamination performed.

R!C#MM!)D!D +!+ ; +he American *rologic Association -A*Arecommends an urinalysis and a serum "A for the routine management of

patients 0ith %*+ 5:. 3e also obtain a serum creatinine for assessingrenal function and evaluate for possible urinary obstruction.

*rinalysis ; *rinalysis should be obtained to detect the presence of urinary

infection or bloodI the latter could indicate bladder cancer or calculi. t isunclear 0hether benign hematuria is more common in patients 0ith


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underlying renal or prerenal diseaseI it also increases the ris' forcomplications and mortality after prostatic surgery. *ltrasonography of the

bladder, ureters and 'idneys is indicated if the serum creatinineconcentration is high. -ee $*ltrasonography and plain abdominal 4rays$

belo0.

erum prostate speci>c antigen ; "rostate cancer can cause obstructive

symptoms, although the presence of symptoms is not predictive of prostate

cancer :5. Measurements of serum "A may be used as a screening testfor prostate cancer in these men 0ith c antigen?(

J+he speci>city of the serum "A assay is lo0er in men 0ith obstructive

symptoms than in asymptomatic men 75. n men 0ith prostateenlargement, the serum "A value and prostate volume have a log4linear

relationship 7:,77, but there are con2icting data on its utility for predictingdevelopment of %*+ 7=,7. #lder men tend to have a steeper rate of

increase in prostate volume 0ith increasing serum "A concentrations. @ree

"A appears to have a higher correlation 0ith prostate volume than total"A 7H.

J&igh values occur in men 0ith prostatic diseases other than cancer,

including


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bladder scan can help to insure that the void volume is P 1=6 m% 79.Among men 0ith ed =1. +his test is usually reserved

for men 0ith urinary symptoms and maimal 2o0 rates above 1= m%sec

and those in 0hom the clinical manifestations are atypical and there is

reason to suspect some problem other than or in addition to


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*rethrocystoscopy ; *rethrocystoscopy is not recommended for routineevaluation. t can be useful in detecting calculi, urethral stricture, and

bladder cancer. ome urologists routinely perform urethrocystoscopy toassist in planning for surgical therapy of men 0ith


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)@#RMA+#) @#R "A+!)+ ; *p+oDate oFers t0o types of patienteducation materials, +he


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unusual patients and for those being considered for invasive treatments.-ee $#ptional tests$ above.

5.

Epidemiology and pathogenesis of benign prostatic hyperplasiaAuthorsGlenn R Cunningham, MDDov Kadmon, MDSection EditorMichael P O'Leary, MD, MPHDeputy EditorLee Park, MD

Disclosures:Glenn R Cunningham, MD Nothing to dicloe! Dov Kadmon, MD Nothing to dicloe! Michael !"#eary, MD, M$ Nothing to dicloe! #ee ar%, MD "m#loyee o$ %#&oDate, nc! "m#loyment ()#oue*+Novarti! "uity O-nerhi#.)tock O#tion ()#oue*+ Novarti!

Contri/utor dicloure are revie-ed $or con$lict o$ interet /y the editorial grou#! 0hen $ound, thee areaddreed /y vetting through a multi1level revie- #roce, and through reuirement $or re$erence to /e#rovided to u##ort the content! 2##ro#riately re$erenced content i reuired o$ all author and mut con$orm to%#&oDate tandard o$ evidence!

Conflict of interest policy

2ll to#ic are u#dated a ne- evidence /ecome availa/le and our#eer revie- #roceicom#lete!#iterature revie& current through' )e# 3456! 7 (his topic last updated' )e# 54, 3458!

)*(R!D+C()!*9 :enign #rotatic hy#er#laia (:PH* i a common #ro/lem among older

men, and i re#oni/le $or conidera/le dia/ility; ho-ever, it i an in$reuent caue o$ death!2ccording to the 0orld Health Organi4 -ere 4!? to5!?.544,444 @5A; death $rom :PH i rare in the %nited )tate

@3A! 2 cohort tudy o$ 6,B4> men -ho under-ent tranurethral reection o$ the #rotate /et-een

5=B and 5=>6 at the Kaier Permanente Medical Center in Oakland revealed no ece

mortality -hen com#ared -ith mortality o$ age1matched men -ho did not undergo the urgery

@8A!

&he large num/er o$ men -ith the ym#tom o$ thi diorder, the eay acce to diagnotic

tet, and the availa/ility o$ drug thera#y make it a##ro#riate $or the #rimary care #rovider to

#artici#ate in the management o$ men -ith thi diorder! &o do o reuire an a##reciation $or

-hat i kno-n regarding the e#idemiology and etiology o$ :PH, -hich -ill /e revie-ed here!&he diagnoi and management o$ thi diorder are dicued ele-here! ()ee EClinical

mani$etation and diagnotic evaluation o$ /enign #rotatic hy#er#laiaEand EMedical

treatment o$ /enign #rotatic hy#er#laiaEandE&ranurethral #rocedure $or treating /enign

#rotatic hy#er#laiaE!*

E)DEM)!#!G9 &he #rotate on average -eigh 34 gram in normal 351 to 841year1old

men, and the -eight change little therea$ter unle the man develo# :PH @6A! Ho-ever,

/ecaue o$ the #revalence o$ thi diorder, the mean #rotate -eight at auto#y increae a$ter

age ?4 year ($igure 5*!

revalence9 &he #revalence o$ hitologically diagnoed #rotatic hy#er#laia increae $rom

> #ercent in men aged 85 to 64, to 64 to ?4 #ercent in men aged ?5 to 4, to over >4 #ercent inmen older than age >4 ($igure 3*! &he :altimore Longitudinal )tudy o$ 2ging com#ared the age1
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#eci$ic #revalence o$ #athologically de$ined :PH at auto#y -ith the clinical #revalence /aed

u#on hitory and the reult o$ digital rectal eamination @?A! &here -a good agreement

/et-een the clinical #revalence and auto#y incidence in men o$ all age!

2 maFor di$$iculty in com#aring the #revalence o$ clinical :PH among di$$erent grou# ha /een

the lack o$ a common de$inition! &he Olmted County tudy $ound the #revalence o$ moderateor evere lo-er urinary tract ym#tom (L%&)* $or men in the $i$th, ith, eventh, and eighth

decade o$ li$e to /e 3, 88, 65, and 6 #ercent, re#ectively @ A! n a community1/aed grou# o$

?43 men aged ?? to B6 year -ithout #rotate cancer, the #revalence o$ :PH -a 5= #ercent

uing the criteria o$ a #rotate volume a/ove 84 mL and a high nternational Protate )ym#tom

)core (P))* @BA! Ho-ever, the #revalence -a only 6 #ercent i$ the criteria -ere a #rotate

volume a/ove 84 mL, a high core, a maimal urinary $lo- rate /elo- 54 mL.ec, and a #ot1

void reidual urine volume greater than ?4 mL!

Ris% factors9 Race ha ome in$luence on the rik $or :PH evere enough to reuire urgery!

0hile the age1adFuted relative rik (RR* o$ :PH neceitating urgery i imilar in /lack and

-hite men, /lack men le than ? year old may need treatment more o$ten than -hite men@>A! n a tudy o$ 86,36 men, com#ared -ith -hite, 2ian had a lo-er rik $or nocturia (RR

4!B, =? C 4!?14!=*, #hyician diagnoed :PH (RR 4!B, C 4!314!?*, and tranurethral #rotate

urgery (RR 4!3, C 4!514!*, -hile rik $or /lack and -hite -ere imilar @=A! n the 2merican

Male Health Pro$eional )tudy, men o$ 2ian ancetry -ere le likely (relative rik 4!6, =? C

4!314!>* to undergo urgery $or :PH a com#ared -ith -hite men @54A! :lack men had imilar

rik to -hite men in thi tudy! n a community am#le o$ 36>4 men in the %nited )tate,

moderate to evere L%&) -ere more common in /lack than in -hite (65 veru 86 #ercent*

@55A, and /lack had greater total and tranitional = a#anee men

ranging in age $rom 64 to B= year+ the a#anee men had ome-hat higher ym#tom core

than 2merican men @5?A! Ho-ever, the 2merican men had an a##roimately

mL.decade increae in #rotate i


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ym#tomatic :PH in the Protate Cancer Prevention &rial @3BA! &here a##ear to /e a -eak

invere relationhi# /et-een auto#y $inding o$ :PH and cirrhoi! Men -ith advanced

cirrhoi have lo-er urinary ym#tom core, maller #rotate volume and higher ratio o$

erum etradiol to erum tetoterone @3>A!

Mot men -ith cirrhoi have chronic alcoholim! 2lcohol conum#tion, #articularly conum#tiono$ eceive amount o$ alcohol (three or more drink #er day*, -hich can reduce androgen

level, may reduce the rik o$ :PH @3=A!

2ging men and -omen have imilar urinary ym#tom core even though they di$$er greatly in

/ladder outlet o/truction @84A! &here i no relationhi# /et-een vaectomy and :PH! n a

longitudinal, #o#ulation1/aed tudy, #rotatiti -a aociated -ith an increaed rik o$

u/euent #rotatim, enlarged #rotate, or :PH @85A! 2n o/ervational tudy $ound an invere

aociation /et-een ue o$ nonteroidal antiin$lammatory drug (N)2D* and rik o$ :PH @83A;

thi may /e related to actual im#rovement in :PH -hen men take N)2D @88A!

"rectile dy$unction i common in men -ith L%&) @86A! 2 tudy o$ ?44 urology o$$ice in

Germany evaluated 54,444 conecutive #atient -ith L%&) and $ound that 3 #ercent o$#atient had ym#tom o$ erectile dy$unction @8?A!

$)S(!#!G9 :PH develo# #rimarily in the #eriurethral or tranitional 3 urgical #ecimen @8>A! &he invetigator $ound a

high correlation /et-een in$lammation, nternational Protate )ym#tom )core (P))*, and#rotate volume! )imilarly, an analyi $rom the #lace/o arm o$ the Protate Cancer Prevention

&rial $ound that lo-1olu/le tumor necroi $actor rece#tor and elevated interleukin

concentration -ere aociated -ith increaed :PH rik @8=A!

A($!GE*ES)S9 Older age and the #reence o$ $unctioning Leydig cell o$ the tete are

eential $or the develo#ment o$ :PH! &hu, :PH i very rare in men -ith hy#ogonadim -ith

onet /e$ore age 64 year -ho are not treated -ith androgen! )tudie have eamined the

molecular and cellular change aociated -ith :PH @64A! t i likely that multi#le $actor are

caually related to the develo#ment o$ :PH @65A!

&he #athogenei o$ :PH remain incom#letely undertood! Po#ulation1/aed o/ervationaltudie, dieae regitrie, in vitro tudie o$ human tiue, and clinical trial continue to

contri/ute to our undertanding o$ the #athogenei o$ thi common diorder!

Androgen9 &he neceity $or androgen, in #articular dihydrotetoterone, during #rotate

develo#ment i /et illutrated /y o/ervation in men -ith congenital de$iciency o$ ?1al#ha1

reductae activity (ty#e 3*, the en


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n general, the concentration o$ dihydrotetoterone in #rotatic tiue are not higher in men

-ith :PH than in thoe -ithout :PH! &hu, ece intra#rotatic converion o$ tetoterone to

dihydrotetoterone i not re#oni/le $or the develo#ment o$ :PH @6?A! &here are, ho-ever,

change in androgen rece#tor in the #rotate! &hee rece#tor are #rimarily located in

e#ithelial cell in normal #rotatic tiue, a com#ared -ith a more heterogeneou ditri/ution

(e#ithelial and tromal cell* in hy#er#latic #rotatic tiue @6A! 2 egment o$ DN2 $or the 2Rencode $or a varia/le num/er o$ glutamine re#eat! Reult o$ one tudy ugget that rik o$

urgery $or :PH i increaed -ith decreaed C2G re#eat @6BA; ho-ever, analyi o$ 65 :PH

cae and ?3B control $rom the Protate Cancer Prevention &rial $ailed to $ind an aociation

/et-een C2G re#eat length and :PH rik @6>A! One tudy re#orted an increae in coactivator

and another noted a decreae in core#reor o$ the androgen rece#tor in :PH tiue @6=,?4A!

)erum tetoterone or dihydrotetoterone concentration do not a##ear to /e higher in men in

-hom the #rotate ultimately /ecome hy#er#latic than in men in -hom it doe not! &he

Phyician' Health )tudy $ound imilar erum tetoterone concentration at the initial

eamination in 834 men -ho had :PH treated urgically u# to nine year later and 834 men

-ho did not develo# #rotatic dieae @?5A! 2 neted cae1control tudy o$ teroidconcentration and rik o$ :PH $ound that the lo-et uartile o$ tetoterone, etradiol, and

tetoterone+5B/eta1diol1glucoronide ratio -ere aociated -ith the highet rik o$ :PH @3BA!

n ummary, the availa/le evidence indicate that tetoterone and dihydrotetoterone are

neceary /ut not u$$icient to caue :PH!

Estrogen9 &he mot com#elling evidence $or a role o$ etrogen in the #athogenei o$ :PH i

that induction o$ the diorder in dog i #otentiated /y the addition o$ etrogen @68,66A! &hi

relationhi# ha /een #artially e#lained /y etrogen induction o$ androgen rece#tor! n

addition, the $inding o$ an increae in the ratio o$ etrogen to androgen in the erum in older

men ugget a role $or etrogen in the maintenance, /ut not necearily the cauation, o$ :PH!&he age1related increae in the erum etrogen.androgen ratio i aociated -ith an increae in

the etrogen.androgen ratio in #rotatic tiue, e#ecially in the troma @?3A! &he #rotate alo

contain the en


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Protatic tromal cell contain etrogen rece#tor, and the concentration are lo-er in

hy#er#latic than in normal #rotatic tiue @?>A! &he concentration o$ #rogeterone

rece#tor in the t-o ty#e o$ tiue are imilar!

&reatment o$ men -ith :PH -ith atametane, an aromatae inhi/itor, reduced erum

etrogen concentration /ut did not relieve ym#tom, increae the urine $lo- rate, orreduce #rotatic i


16/43

are conitent -ith a lo-er a#o#totic rate in :PH @B5,B3A! &hee o/ervation alo attet to the

di$$iculty in cauing regreion o$ eta/lihed :PH in the a/ence o$ increaing cell death!

Iurthermore, androgen de#rivation doe not alter :cl13 e#reion, -hich ha /een $ound to /e

increaed in hy#er#latic tiue @B8A!

)ncreased stem cells9 &he i4A! 2nalye o$ microarray revealed 33B gene

that -ere di$$erentially e#reed /et-een the t-o grou#! &hi included gro-th $actor gene,

cell cycle gene, a#o#toi gene, in$lammation gene and androgen1regulated gene!

)*-!RMA()!* -!R A()E*(S9 %#&oDate o$$er t-o ty#e o$ #atient education material,

&he :aic and :eyond the :aic! &he :aic #atient education #iece are -ritten in #lain

language, at the ?thto thgrade reading level, and they an-er the $our or $ive key uetion a

#atient might have a/out a given condition! &hee article are /et $or #atient -ho -ant a

general overvie- and -ho #re$er hort, eay1to1read material! :eyond the :aic #atient

education #iece are longer, more o#hiticated, and more detailed! &hee article are -rittenat the 54thto 53thgrade reading level and are /et $or #atient -ho -ant in1de#th in$ormation

and are com$orta/le -ith ome medical Fargon!

Here are the #atient education article that are relevant to thi to#ic! 0e encourage you to #rint

or e1mail thee to#ic to your #atient! (ou can alo locate #atient education article on a

variety o$ u/Fect /y earching on #atient in$o and the key-ord(* o$ interet!*

:aic to#ic (eeEPatient in$ormation+ :enign #rotatic hy#er#laia (enlarged #rotate*

(&he :aic*E*

:eyond the :aic to#ic (ee EPatient in$ormation+ :enign #rotatic hy#er#laia (:PH*(:eyond the :aic*E*
http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/71,72http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/71,72http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/73http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/73http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/51,74http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/75http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/75http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/76http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/76http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/77http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/77http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/78http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/78http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/75http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/79http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/79http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/80http://www.uptodate.com/contents/benign-prostatic-hyperplasia-enlarged-prostate-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-enlarged-prostate-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-enlarged-prostate-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/71,72http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/73http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/51,74http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/75http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/76http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/77http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/78http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/75http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/79http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia/abstract/80http://www.uptodate.com/contents/benign-prostatic-hyperplasia-enlarged-prostate-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-enlarged-prostate-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-basics?source=see_linkhttp://www.uptodate.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-basics?source=see_link


17/43

S+MMAR

&he #revalence o$ hitologically diagnoed #rotatic hy#er#laia increae $rom >

#ercent in men aged 85 to 64, to 64 to ?4 #ercent in men aged ?5 to 4, to over >4

#ercent in men older than age >4! ()ee 'Prevalence'a/ove!*

:lack men are more likely than -hite men to have larger #rotate volume and more

moderate to evere L%&)! 2ian men are le likely than -hite and /lack men to have

:PH! ncreaed rik o$ :PH -a aociated -ith higher $ree P)2 level, heart dieae,

ue o$ /eta1/locker, and lack o$ #hyical eercie! ()ee 'Rik $actor'a/ove!*

:PH develo# #rimarily in the #eriurethral or tranitional


18/43

:.

Medical treatment of benign prostatic hyperplasiaAuthorsGlenn R Cunningham, MDDov Kadmon, MDSection EditorMichael P O'Leary, MD, MPH

Deputy EditorLee Park, MD

Disclosures:Glenn R Cunningham, MD Nothing to dicloe! Dov Kadmon, MD Nothing to dicloe! Michael !"#eary, MD, M$ Nothing to dicloe! #ee ar%, MD "m#loyee o$ %#&oDate, nc! "m#loyment ()#oue*+Novarti! "uity O-nerhi#.)tock O#tion ()#oue*+ Novarti!



2ll to#ic are u#dated a ne- evidence /ecome availa/le and our#eer revie- #roceicom#lete!#iterature revie& current through' )e# 3456! 7 (his topic last updated' ul 5B, 3456!

)*(R!D+C()!*9 :enign #rotatic hy#er#laia (:PH* /ecome increaingly common a men

age ($igure 5*! :PH can lead to urinary ym#tom that may /ene$it $rom medical or urgical

treatment! Ho-ever, many men -ith :PH are aym#tomatic or have only mild ym#tom and

may not reuire thera#y!

&he medical thera#y o$ :PH -ill /e revie-ed here! )urgical and other invaive thera#ie, the

clinical mani$etation, natural hitory, diagnoi o$ :PH, and the e#idemiology and

#athogenei o$ :PH are all dicued e#arately! ()ee E&ranurethral #rocedure $or treating/enign #rotatic hy#er#laiaEandEClinical mani$etation and diagnotic evaluation o$ /enign

#rotatic hy#er#laiaEandE"#idemiology and #athogenei o$ /enign #rotatic hy#er#laiaE !*

Lo-er urinary tract ym#tom (L%&)* in men o$ uncertain etiology, or $rom etiologie other than

:PH, alo are dicued e#arately! ()eeELo-er urinary tract ym#tom in menE!*

DE-)*)()!*S9 2 num/er o$ di$$erent term and a//reviation are ued -hen dicuing

ym#tomatic :PH! &hee include+

Lo-er urinary tract ym#tom (L%&)*

:enign #rotatic enlargement (:P"*

:enign #rotatic o/truction (:PO*

:ladder outlet o/truction (:OO*
http://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/home/conflict-interest-policyhttp://www.uptodate.com/home/editorial-policyhttp://www.uptodate.com/home/editorial-policyhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F55614&topicKey=PC%2F6891&rank=1~150&source=see_link&search=hiperplasi+prostaticahttp://www.uptodate.com/contents/image?imageKey=ENDO%2F55614&topicKey=PC%2F6891&rank=1~150&source=see_link&search=hiperplasi+prostaticahttp://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/lower-urinary-tract-symptoms-in-men?source=see_linkhttp://www.uptodate.com/contents/lower-urinary-tract-symptoms-in-men?source=see_linkhttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/contents/medical-treatment-of-benign-prostatic-hyperplasia/contributorshttp://www.uptodate.com/home/conflict-interest-policyhttp://www.uptodate.com/home/editorial-policyhttp://www.uptodate.com/contents/image?imageKey=ENDO%2F55614&topicKey=PC%2F6891&rank=1~150&source=see_link&search=hiperplasi+prostaticahttp://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/clinical-manifestations-and-diagnostic-evaluation-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-benign-prostatic-hyperplasia?source=see_linkhttp://www.uptodate.com/contents/lower-urinary-tract-symptoms-in-men?source=see_link


19/43

:P" i the #hyical enlargement o$ the #rotate that occur a the reult o$ the hitologic

change o$ :PH! :PO i :OO in the etting o$ :P"!

:P" and :OO econdary to :PH are $reuently diagnoed clinically on the /ai o$ L%&)! 0e

-ill ue the a//reviation :PH.L%&) $or L%&) #reumed to /e econdary to :PH, ometime

called ym#tomatic :PH!)*D)CA()!*S -!R ($ERA9 &he common ym#tom o$ :PH are increaed $reuency o$

urination, nocturia, heitancy, urgency, and -eak urinary tream! &hee ym#tom ty#ically

a##ear lo-ly and #rogre gradually over a #eriod o$ year! ()eeEClinical mani$etation and

diagnotic evaluation o$ /enign #rotatic hy#er#laiaE, ection on 'Natural hitory'!*

n general, thee ym#tom only reuire thera#y i$ they have a igni$icant im#act on a #atient'

uality o$ li$e @5A! "ven -ithout thera#y, many men -ill e#erience ta/ili #ercent im#roved @ 8A! &hu, the deciion to

treat :PH.L%&) involve /alancing the everity o$ the #atient' ym#tom -ith #otential ide

e$$ect o$ thera#y!

:PH may alo reuire thera#y i$ :OO i creating a rik $or u##er tract inFury uch a

hydrone#hroi or renal inu$$iciency, or lo-er tract inFury uch a urinary retention, recurrent

in$ection, or /ladder decom#enation (eg, lo- #reure detruor contraction; #ot1void

reidual o$ 3? #ercent o$ total /ladder volume* @6A! n general, #atient -ho develo# thee

ym#tom -ill reuire invaive thera#y @3A! ()eeE&ranurethral #rocedure $or treating /enign

#rotatic hy#er#laiaE!*

&he deciion to treat i uually /aed on the everity o$ ym#tom and the #atient' tolerance

$or thee ym#tom! %e o$ the 2%2 ym#tom core (alo kno-n a the nternational Protate

)ym#tom )core @P))A* (ta/le 5* #ermit uantitation o$ ym#tom everity and monitoring o$ym#tom #rogreion over time! 2dditionally, the P)) add a uetion a/out E/otherE to the

2%2 core! &hee uetionnaire are eay and uick to com#lete; ho-ever, not all clinician

ue them to ae ym#tom!

%rine $lo- rate during voiding can alo /e eaily meaured! &hi i a noninvaive tet that i

readily availa/le to urologit, /ut uually i not availa/le to #rimary care clinician! &hu,

medical treatment uually i initiated on the /ai o$ ym#tom in the #rimary care etting!

0hen ym#tom occur in the etting o$ autonomic or evere #eri#heral neuro#athy or $ollo-ing

invaive treatment o$ the urethra or #rotate, #atient hould /e re$erred $or urologic evaluation

rather than tarted on treatment /y a #rimary care clinician!

AGE*(S9 &he /ladder outlet o/truction o$ :PH ha t-o com#onent+

2 dynamic (#hyiologic, reveri/le* com#onent related to the tenion o$ #rotatic mooth

mucle in the #rotate, #rotate ca#ule, and /ladder neck

2 $ied (tructural* com#onent related to the /ulk o$ the enlarged #rotate im#inging u#on

the urethra

&-o clae o$ drug, al#ha1adrenergic antagonit and ?1al#ha1reductae inhi/itor, act u#on

the dynamic and $ied com#onent o$ /ladder outlet o/truction, re#ectively!

2l#ha1adrenergic antagonit a##ear to /e more e$$ective than ?1al#ha1reductae inhi/itor $or

hort1term and long1term treatment o$ :PH.L%&) @?A! Ho-ever, only ?1al#ha1reductaeinhi/itor have demontrated the #otential $or long1term reduction in #rotate volume and need
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20/43


21/43

men, the ym#tom core (ta/le 5* decreaed 84 to 64 #ercent, and urinary $lo- rate

increaed 5 to 3? #ercent!

&he elective al#ha15D antagonit, na$to#idil, may alo /e e$$ective although long term

randomi


22/43

Mechanism9 &hee drug act /y reducing the i


23/43

reult a$ter 6>1month $ollo-1u# in men -ith :PH randomly aigned to dutateride, com#ared

to #lace/o @68A!

&he "nlarged Protate nternational Com#arator )tudy ("PC)*, an indutry1#onored trial,

com#ared treatment -ith $inaterideordutateride$or 53 month @66A! &he #rimary outcome

re#orted, reduction in #rotate volume, -a not igni$icantly di$$erent $or the t-o drug, althoughthi outcome may not have clinical igni$icance! &he drug -ere alo not igni$icantly di$$erent in

the econdary end#oint o$ urinary $lo- rate and urinary ym#tom core, and advere e$$ect

-ere imilar!

&he ?1al#ha1reductae inhi/itor are more e$$ective in men -ith larger #rotate, and their

e$$ect on acute urinary retention and reduction in need $or urgery reuire chronic treatment $or

more than a year!

Dosing9 %nlike -ith al#ha antagonit, doing -ith ?1al#ha1reductae inhi/itor do not reuire

titration!Iinateridecan /e initiated and maintained at ? mg once daily!

)imilarly, dutateridecan /e initiated and maintained at 4!? mg once daily!

Side effects9 &he maFor ide e$$ect o$ thee drug are decreaed li/ido and eFaculatory or

erectile dy$unction! &hee occurred in 6 to #ercent o$ men in a randomi #ercent $or any eual advere event* @6?A, and thi may /e more

re$lective o$ clinical #ractice! Ho-ever, in a long1term trial o$ $inateride veru #lace/o in 8464

men -ith :PH, advere eual e$$ect -ere increaed only during the $irt year o$ thera#y @6A!

)erum #rotate1#eci$ic antigen (P)2* concentration decreae /y a/out ?4 #ercent @88A, a

change that mut /e ke#t in mind in inter#reting the reult o$ erum P)2 meaurement in men

treated -ith thi drug @6BA! Iinding $rom the Protate Cancer Prevention &rial ugget that P)2

value /e corrected /y a $actor o$ 3 $or the $irt 36 month o$$inaterideue, and /y a $actor o$3!? $or longer term ue @6>A! ()eeEMeaurement o$ #rotate #eci$ic antigenE, ection on

':enign #rotatic hy#er#laia'!*

Iinateridedoe not caue lo o$ /one @6=A, #erha# /ecaue erum etradiol concentration

do not change! 2 cae1control tudy $ound no #oitive aociation /et-een ue o$ $inateride

and hi# $racture, and actually $ound ome evidence o$ lo-er rik o$ $racture -ith $inateride ue

@?4A!

n randomi


24/43

One tudy that eamined thi iue involved o/ervational $ollo-1u# o$ a randomiA!

Short.term efficacy9 n the eteran 2$$air Coo#erative )tudy, 533= men -ith :PH (mean

#eak urinary $lo- rate o$ 54!? mL.ec* -ere randomly aigned to

#lace/o, $inateride(? mg.day*, tera


25/43

Com/ination thera#y reduced the rik o$ clinical #rogreion /y #ercent, igni$icantly

greater than -ith either drug alone!

)ym#tom core im#roved -ith all thera#ie, /ut to a greater degree -ith com/ined

thera#y!

Com/ination thera#y or $inateridealone (/ut not doa!6 $or com/ination thera#y, 58!B $or doa


26/43

Antimuscarinics 9 )ome men -ith :PH.L%&) may alo have $reuency, urgency, and

incontinence related to an overactive /ladder! :ladder contraction are timulated /y

acetylcholine e$$ect on mucarinic rece#tor in mooth mucle o$ the /ladder! 2 randomi randomi


27/43

M!D)-)CA()!* !- ($ERA9 Patient -ho e#erience ide e$$ect -ith either al#ha1

adrenergic antagonit or ?1al#ha1reductae inhi/itor can reaona/ly /e -itched to the other

agent! Patient -ho have o/tructive ym#tom on an al#ha1adrenergic antagonit may /e

candidate $or antimucarinic treatment i$ they have lo- #ot1void reidual volume, and

#atient -ho do not tolerate any o$ thee thera#ie can /e o/erved o$$ thera#y or can /e

re$erred $or invaive thera#y!

Patient -ho are on com/ination thera#y and do not e#erience an adeuate re#one over 53

to 36 month may -ih to conider invaive thera#ie a -ell! Patient -ith #rogreion o$

dieae on thera#y -ill generally reuire invaive thera#y! ()ee E&ranurethral #rocedure $or

treating /enign #rotatic hy#er#laiaE!*

!($ER S(RA(EG)ES9 Patient -ith :PH.L%&) hould avoid medication that can

eacer/ate ym#tom or induce urinary retention! &hee include anticholinergic medication

uch a edating antihitamine and adrenergic agent uch a decongetant!

:ehavioral modi$ication may /e hel#$ul! &hee include avoiding $luid #rior to /edtime or /e$ore

going out, reducing conum#tion o$ mild diuretic uch a ca$$eine and alcohol, and dou/levoiding to em#ty the /ladder more com#letely!

2 randomi


28/43

:enign #rotatic hy#er#laia (:PH* /ecome increaingly common a men age! :PH

can lead to urinary ym#tom that may /ene$it $rom medical or urgical treatment!

Ho-ever, many men -ith :PH are aym#tomatic or have only mild ym#tom and may not

reuire thera#y! 2dditionally, many men -ith ym#tom -ill im#rove or ta/ili


29/43

7

(ransurethral procedures for treating benign prostatic hyperplasiaAuthorsGlenn R Cunningham, MDDov Kadmon, MDSection EditorMichael P O'Leary, MD, MPHDeputy EditorKathryn 2 Collin, MD, PhD, I2C)

Disclosures:Glenn R Cunningham, MD Nothing to dicloe! Dov Kadmon, MD Nothing to dicloe! Michael !"#eary, MD, M$ Nothing to dicloe! Kathryn A Collins, MD, hD, -ACS"m#loyee o$ %#&oDate, nc!



2ll to#ic are u#dated a ne- evidence /ecome availa/le and our#eer revie- #roceicom#lete!#iterature revie& current through' )e# 3456! 7 (his topic last updated' )e# 5>, 3456!

)*(R!D+C()!*9 :enign #rotatic hy#er#laia (:PH* /ecome increaingly common a menage! Men -ith clinically igni$icant lo-er urinary tract ym#tom (L%&)* uggetive o$ :PH -ho

do not $ind adeuate relie$ -ith medical treatment may /ene$it $rom tranurethral reection or

a/lation to enlarge the urethral channel to reduce the amount o$ #rotate tiue around the

urethra! Mot #rocedure are #er$ormed via the urethra (ie, tranurethral* uing a cytoco#e!

&ranurethral reection o$ the #rotate (&%RP* ha /een the main $orm o$ treatment $or many

year in men -ith :PH, and remain the tandard againt -hich other treatment hould /e

com#ared! Mot men -ho undergo &%RP e#erience a marked decreae in urinary ym#tom

core, and a u/tantial increae in maimal urinary $lo- rate! Ho-ever, the com#lication

and cot aociated -ith &%RP have encouraged develo#ment o$ everal alternative method

to remove or detroy #rotatic tiue uing a variety o$ energy ource!

&ranurethral #rocedure $or reection or a/lation o$ #rotate tiue, and other thera#ie $or the

treatment o$ :PH -ill /e revie-ed here! &he clinical mani$etation and management o$ :PH

are revie-ed ele-here! ()ee EClinical mani$etation and diagnotic evaluation o$ /enign

#rotatic hy#er#laiaEandEMedical treatment o$ /enign #rotatic hy#er#laiaE!*

)*D)CA()!*S -!R (REA(ME*(9 :enign #rotate enlargement i the #hyical enlargement

o$ the #rotate gland that i due to hitologic change kno-n a /enign #rotatic hy#er#laia

(:PH*! ()ee E"#idemiology and #athogenei o$ /enign #rotatic hy#er#laiaE !*

:ladder outlet o/truction due to :PH i $reuently diagnoed clinically on the /ai o$ lo-er

urinary tract ym#tom -hich can #reent acutely, or, more o$ten, chronically! 2 deciion to treat

:PH i uually /aed u#on the everity o$ ym#tom determined /y either the 2merican

%rological 2ociation )ym#tom nde (2%21)* (ta/le 5*, or the nternational Protate
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)ym#tom )core (UP)) * @5A, -hich are very imilar! n general, ym#tom only reuire thera#y

i$ they have a igni$icant im#act on a #atient' uality o$ li$e! 0hether to #roceed to urgical

intervention i generally /aed u#on the adeuacy o$ medical thera#y, the develo#ment o$

com#lication, and #atient #re$erence, rather than any #eci$ic urological #arameter! &he

medical treatment o$ /enign #rotatic hy#ertro#hy i dicued e#arately! ()ee EMedical

treatment o$ /enign #rotatic hy#er#laiaE!*

General indication $or urgical intervention include+

)urgery o$$er the mot e$$ective reolution o$ /ladder outlet o/truction ym#tom o$ the

lo-er urinary tract uggetive o$ :PH, and can /e o$$ered to #atient -ith moderate1to1

evere chronic ym#tom -ho are /othered /y their ym#tom! ()ee'Chronic lo-er

urinary tract ym#tom'/elo-!*

)urgery i generally recommended $or #atient -ith ym#tom o$ acute urinary retention

that i re$ractory to medical thera#y! ()ee '2cute urinary retention'/elo-!*

)urgery i alo the treatment o$ choice $or #atient -ho have renal inu$$iciency

econdary to :PH, -hether due to acute urinary retention or lo-er urinary tract ym#tom,or i$ there i clear evidence o$ /ladder outlet o/truction on urodynamic evaluation!

Patient -ith a median lo/e con$iguration are unlikely to re#ond to medical thera#y and

hould alo #re$erentially /e treated urgically! 2 median lo/e con$iguration re#reent a

lo/e o$ hy#er#latic tiue that #rotrude into the lumen o$ the /ladder #roducing a

mechanical o/truction to urine $lo- /y occluding the /ladder neck like a valve each time

the /ladder contract during voiding! Ior #atient -ho $ail medical thera#y, -e ugget

#rotate imaging, either uing tranrectal ultraound or /y direct viuali


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reection o$ the #rotate (/i#olar &%RP*! ()ee E2cute urinary retentionE, ection on 'nitial

management'and E2cute urinary retentionE, ection on ')urgical thera#y'!*

Many men -ho are a/le to void ucce$ully a$ter removal o$ the catheter eventually have

recurrent urinary retention! 2 an eam#le, in one tudy o$ 33> men, ? #ercent had a

recurrence -ithin a -eek a$ter the initial e#iode and > #ercent -ithin a year @A! Iactor#redictive o$ recurrence included a retained volume ?44 mL and a maimum $lo- rate o$

J? mL.min a$ter the e#iode o$ retention! 2nother im#ortant trati$ication o$ the rik $or recurrent

acute urinary retention i -hether or not the e#iode -a #ontaneou or #reci#itated /y ome

other event (eg, unrelated urgery, o#ioid, cold medication* @BA!

&he rik o$ develo#ing acute urinary retention in men -ith :PH de#end u#on the #o#ulation

tudied! n one re#ort o$ more than 8444 men -ith :PH -ho -ere randomiA! n thi tudy, the /aeline erum P)2 concentration and #rotate volume -ere the

/et #redictor o$ the develo#ment o$ acute urinary retention! ()ee EMedical treatment o$ /enign#rotatic hy#er#laiaE!*

REARA()!*9 Prior to urgical treatment o$ /enign #rotatic hy#er#laia (:PH*, -e o/tain

a erum #rotate #eci$ic antigen (P)2*, $ree and total, and although not mandatory, -e #re$er

to o/tain a tranrectal #rotate ultraound to ae the i


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had igni$icantly higher rate o$ /ladder clot (58 veru 6!B #ercent*, tran$uion (5!= veru

5!4 #ercent*, late hematuria (5?!4 veru >!6 #ercent*, and throm/oem/olic event (3!6 veru

4!B #ercent*, and a igni$icantly longer duration o$ ho#itali


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techniue uch a electrocautery (diathermy*, laer, radio$reuency device, and micro-ave

device!

&ranurethral reection techniue include+

&ranurethral reection o$ the #rotate (&%RP* (ee 'Mono#olar &%RP'/elo-

and':i#olar &%RP'/elo-*

&ranurethral laer enucleation (ee'HoL"P and &huL"P'/elo-*

&ranurethral a/lation techniue include+

Plama va#ori due to the emergence o$ alternative techniue

@35A! 2t our intitution, /i#olar &%RP and #lama va#ori


34/43

lasma vapori4ation 56button6 procedure79 Plama va#ori


35/43

$o#E and (hu#E9 &he -avelength o$ light emanating $rom the Holmium+ttrium1

2luminium1Garnet (2G* (3564 nm -avelength* laer @6816A and &hulium+2G (3456 nm

-avelength* @65,6B16=A laer i near the #eak o$ -ater a/or#tion (3544 nm*, -hich

neceitate direct contact o$ the laer $or tiue a/lation! 2 modi$ication o$ the tandard

Holmium and &hulium 2G laer create a #ulating tream o$ /u//le $rom the ti#, eentially

turning the device into a laer kni$e, -hich allo- reection o$ tiue (ie, HoL"P+ holmium laerenucleation o$ the #rotate; &huL"P+ thulium laer enucleation o$ the #rotate* @ 64,66A! &he

#rocedure i #er$ormed imilar to /i#olar &%RP uing the laer ti# intead o$ a /i#olar cautery

loo#! Like &%RP, tiue can /e #reerved $or hitologic eamination! Ho-ever, -ith HoL"P and

&huL"P, the i


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rostatic urethral lift9 2 novel #rocedure, the #rotatic urethral li$t (eg, %roli$t, Neotract, nc!

Pleaanton, C2*, a##ear to /e -ell tolerated and i e$$ective $or treating :PH @?B,?>A! &he

device i introduced into the urethra and ued to com#re the #rotate tiue, there/y

increaing the urethral lumen and reducing o/truction to urine $lo-! )u/euently, one or more

im#lant(* are delivered into the #rotatic urethra to maintain urethral #atency! &hi techniue

may /e an o#tion $or men -ho are #oor candidate $or more invaive #rocedure! 2lthoughhort1term reult (out to 53 month* demontrating a$ety and e$$icacy are availa/le @?B,?=,4A,

longer $ollo-1u# -ill /e needed to determine the dura/ility o$ the device!

n a multicenter tudy, 34 men -ho -ere at leat ?4 year old -ith 2merican %rological

2ociation )ym#tom nde (2%2)* 58, a maimum $lo- rate S53 mL #er econd, and

#rotate 84 to >4 cc -ere randomi year @ 6A+

&he #rimary outcome o$ treatment $ailure (death, re#eated or intracta/le urinary retention,

reidual urinary volume over 8?4 mL, the develo#ment o$ /ladder calculu, ne- and#eritent incontinence, a high 2%2 ym#tom core, or a dou/ling o$ the erum creatinine

concentration* occurred le $reuently in the &%RP grou# com#ared -ith -atch$ul -aiting

(> veru 5B #ercent*! Ho-ever, only 36 #ercent o$ men -ho -ere -atched reuired

urgery during the $ollo-1u# #eriod, although /y the end o$ $ive year o$ $ollo-1u#, 8

#ercent had undergone urgery @?A!

&%RP reulted in a greater decreae in reidual urine volume (4 mL veru 65 mL

decreae -ith -atch$ul -aiting* and greater increae in maimal urinary $lo- rate ( veru

4!6 mL.ec*!

&he ym#tom core decreaed $rom 56! to 6!= in the urgery grou# and $rom 56! to =!5

in the -atch$ul1-aiting grou#! &he reult in the -atch$ul -aiting grou# ugget that mengradually ada#t to the ym#tom!
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2 ytematic revie- com#ared mono#olar and /i#olar (&%RP* $or clinical e$$ectivene and

advere event @8A! 2 total o$ 36 trial -ere included in the revie-! No igni$icant di$$erence

-ere $ound in term o$ nternational Protate )ym#tom )core (P))* or health1related uality o$

li$e (HRYL* core; ho-ever, it hould /e noted that mot o$ the included trial had hort1term

$ollo-1u# S5 year! Com#ared -ith mono#olar &%RP, /i#olar &%RP ha a igni$icantly lo-er rik

$or advere event including tranurethral reection yndrome (rik ratio @RRA 4!53, =? C4!4?14!85*, clot retention (RR 4!6>, =? C 4!8414!BB*, and /lood tran$uion (RR 4!?8, =? C

4!8?14!>3*!

(+R versus non.(+R techni8ues9 &here are a limited num/er o$ high1uality trial

com#aring &%RP -ith non1&%RP #rocedure, or other minimally invaive #rocedure @1>A!

Non1&%RP #rocedure that remove a u$$icient uantity o$ #rotate tiue, uch a laer

enucleation (HoL"P, &huL"P*, #lama va#ori


38/43

tay and horter length o$ catheteri40, 5340 laer*, urologic ym#tom

im#rovement $ollo-ing &%RP and PP -ere imilar in i trial, /etter $or &%RP in t-o

trial, and /etter $or PP in one trial @3=A! nteretingly, o#erating time -a horter in the

&%RP grou# /y nearly 34 minute! Later trial uing higher #o-er laer (5340 K&P @B8A,

5>4 0 Greenlight @B6A* $ound imilar urine ym#tom core, uro$lo-metry #arameter, andcom#lication rate com#ared -ith &%RP; ho-ever, length o$ catheteri


39/43

(+R versus prostatectomy9 O#en #rotatectomy account $or le than $ive #ercent o$

o#eration $or :PH in the %nited )tate @35,>5A, /ut it i #er$ormed more o$ten in other countrie

@>3,>8A! 2 la#aroco#ic.ro/otic techniue ha alo /een decri/ed! Given the emerging

technologie decri/ed a/ove (/i#olar &%RP, PP, HoL"P, &huL"P*, it i likely that the ue o$

o#en #rotatectomy -ill continue to diminih -ith time! 2t #reent, it i uually generally only

o$$ered to men -ho are good urgical candidate and in -hom the #rotate i etimated to-eigh more than ?4 gram @>6A!

Protatectomy can /e #er$ormed through the /ladder, ie, tranveically a a u#ra#u/ic

techniue, or directly through the ca#ule o$ the #rotate a a retro#u/ic techniue! 2 tudy

com#aring la#aroco#ic #rotatectomy -ith hitorical control -ho received o#en #rotatectomy

concluded that the #rocedure have imilar e$$icacy and that the la#aroco#ic #rocedure

reuired longer o#erating room time, /ut led to a horter ho#ital tay and le /lood lo @>?A!

n ome tudie, o#en #rotatectomy had lo-er com#lication and mortality rate than &%RP

@>A, /ut the di$$erence #ro/a/ly relate to #atient election $or the #rocedure @>BA!

n a #ro#ective tudy o$ =43 men in Germany -ho under-ent o#en #rotatectomy (mean#rotate i3A! Mean #eak urine

$lo- increaed $rom 54!6 to 38!5 mL.ec, and #otvoid reidual decreaed $rom 56?!5 to 5B!?

mL

C$!)CE !- R!CED+RE9 &he choice o$ #rocedure $or the treatment o$ :PH i /aed u#on

#atient value, medical rik, and the im#act o$ #otential com#lication @>>1=4A! Ior mot men

-ho reuire an invaive #rocedure to treat :PH, -e ugget tranurethral reection o$ the

#rotate (/i#olar &%RP*, -hich i e$$ective at reducing ym#tom and avoid the need $or

re#eat treatment! 2t our intitution, /i#olar &%RP (along -ith #lama va#ori


40/43

#rocedure -ith lo-er urinary and eual ide e$$ect than &%RP! &he im#rovement in

urodynamic and ym#tom core #arameter are generally in$erior to &%RP or va#ori


41/43

2leeding9 2n increaed rik o$ /leeding -ith &%RP, relative to other tranurethral #rocedure,

ha /een $ound in mot @55,58,56,B,=,B?,>4A, /ut not all tudie @54,=A! &he rik o$ /leeding i

increaed in #atient -ho reuire antithrom/otic thera#y, -hich i needed in a/out 84 #ercent o$

#atient undergoing &%RP! ()ee '2ntithrom/otic thera#y'a/ove!*

n the eteran 2dminitration tudy, hemorrhage reuiring tran$uion occurred in 5 #ercent o$#atient undergoing &%RP @6A! n metaanalye, tran$uion -a reuired in 8 to B #ercent o$

&%RP #atient and 4 to 5 #ercent o$ #atient undergoing non1&%RP reection or a/lation

#rocedure @B,=A! 2 ytematic revie- that identi$ied 54 trial com#aring tranurethral inciion

o$ the #rotate (&%P* -ith &%RP $ound a igni$icantly lo-er rik $or /lood tran$uion com#ared

-ith &%RP (relative rik @RRA 4!4, =? C 4!4814!5* @?4A! Clot retention -a lo-er $or

#hotoelective va#ori? #atient, the rik $or &%R yndrome

-a igni$icantly reduced $or #atient undergoing micro-ave thermothera#y com#ared -ith

&%RP (relative rik 4!58, =? C 4!4314!>5* @>4A!

Se3ual dysfunction9 &he overall incidence o$ eual dy$unction (erectile dy$unction,

retrograde eFaculation* $ollo-ing urgical #rocedure to treat :PH varie @ =>1544A! 2lthough ne-

onet erectile dy$unction i uncommon (J54 #ercent*, retrograde eFaculation i common at

a/out ? #ercent!

n the 2 tudy decri/ed a/ove, eual $unction -a imilar a$ter &%RP or -atch$ul -aiting

@?A! Ho-ever, in a econd tudy in -hich men -ith :PH -ere randomly aigned to &%RP,

laer thera#y, or -atch$ul -aiting, reduced eFaculation -a common in the urgery and laer

grou# @545A! On the other hand, erectile $unction and #ain on eFaculation -ere /oth im#roved in

the urgery grou# com#ared -ith the other t-o grou#! )imilarly, a #ro#ective tudy $ound

-orening eFaculatory $unction a$ter &%RP, /ut trend to-ard im#roved erectile $unction and

#ain on eFaculation @543A!

No di$$erence in ne- onet eual dy$unction -ere een in a trial that com#ared mono#olar

&%RP -ith /i#olar &%RP @544A! Micro-ave thermothera#y had a igni$icantly decreaed rik $orretrograde eFaculation com#ared -ith &%RP (relative rik, 4!8=, =? C 4!3514!B?* in a

ytematic revie- @>4A! n a trial com#aring radio$reuency a/lation -ith &%RP in 535 men -ith

:PH, #atient treated -ith radio$reuency a/lation had $e-er advere event, including

retrograde eFaculation (4 veru 65 #ercent*, and erectile dy$unction (8 veru 35 #ercent* @BBA!

+rethral stricture9 2ny intrumentation o$ the urethra carrie the rik o$ trauma -hich heal

-ith car $ormation reulting in urethral tricture @548A! ()eeE&reatment o$ urethral tricture

dieae in menE!*

n the eteran 2dminitration tudy dicued a/ove @6A, late #oto#erative com#lication

included contracture o$ the /ladder neck reuiring urgery (6 #ercent*, urethral tricture

reuiring dilation (6 #ercent*, and o/truction reuiring a econd &%RP (8 #ercent*!
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ntents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/98-100http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/65http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/101http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/102http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/100http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/80http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/77http://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/103http://www.uptodate.com/contents/treatment-of-urethral-stricture-disease-in-men?source=see_linkhttp://www.uptodate.com/contents/treatment-of-urethral-stricture-disease-in-men?source=see_linkhttp://www.uptodate.com/contents/transurethral-procedures-for-treating-benign-prostatic-hyperplasia/abstract/4


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n ytematic revie-, urethral tricture occurred in 3 to 6 #ercent o$ #atient undergoing

#lama va#ori #ercent o$ &%RP #atient

@B,BB,>4A! n a metaanalyi o$ 34 randomi


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a/lation and inciion #rocedure, and retreatment i common! Data on long1term

outcome are limited $or mot #rocedure! ()ee'Outcome com#arion'a/ove!*

Ior men -ho reuire an invaive #rocedure and are in good health, -e ugget

tranurethral reection o$ the #rotate (&%RP* (Grade 12*! 0e ue /i#olar tranurethral

reection o$ the #rotate (/i#olar &%RP*, or /i#olar #lama va#ori

Hiperprasia Benigna d Ela Prostata

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