Current clinical management strategies for benign prostatic hyperplasia

摘要

This article summarizes the major new findings on clinical management for benign prostatic hyperplasia (BPH) that were presented at the annual meeting of the American Urological Association (AUA) in May 2008. The management of symptomatic BPH has been changed significantly over the last decade in response to the availability of new treatment options. Prior to the 1980s, open prostatectomy was the only widely accepted intervention for BPH. Since then, the advent of new medical therapies for BPH and the introduction of a range of minimally invasive therapies have provided for men with lower urinary tract symptoms (LUTS) secondary to BPH.1 In this year's AUA meeting, several new findings were reported in the filed of BPH which involved epidemiology, clinical progression, drug therapy and new technologies in surgical therapy of BPH. Clinical progression BPH has been demonstrated to be a slowly progressive disease.2,3 The most common clinical event of BPH progression is the severity of symptoms, and the final stage of disease progression is receiving surgery. In the clinical practice of BPH, it is very important to understand risk factors earlier in the prediction of disease progression both for urologists and patients. Generally, patient age, prostate volume and serum prostate specific antigen (PSA) value have been recognized to be the most common risk factors in association with BPH progression.1,2 Urologists from Netherlands reported the results of a community-based BPH epidemiological research, the Krimpen study.4 Through a questionnaire and urological examinations, 1688 men were involved in this study and received 4354 person years follow up. The Krimpen study showed that the patient age, functional bladder capacity, prostate volume, the history of cardiac diseases, and education level may have accounted for the BPH progression. According to this research finding, we should refer to more risk factors when making a decision on the treatment choice for the patients with LUTS/BPH. Medical therapy Drug therapies recommended for BPH in recently published guidelines include α-adrenergic blockers, 5α-reductase inhibitors, aromatase inhibitors, and numerous plant extracts.5,6 Both α-adrenergic blockers and 5α-reductase inhibitors are widely prescribed for the treatment of BPH because the safety and efficacy of drugs in these classes have been critically examined. A potential role of medical therapy is to prevent the development of BPH or its progression. For the patients at high risk for developing urinary retention or/and receiving surgery, the combination therapy of α-blocker with 5α- reductase inhibitor has significantly delayed the clinical progression of BPH.2 Urologists from America, Canada and Italy reported the results of a new combination therapy CombAT study. The CombAT study is an ongoing four-year, international, randomised, double-blind clinical research. The purpose of this study was to investigate the efficacy and safety of dutasteride (5α-reductase inhibitor) and tamsulosin (α-blocker) combination therapy as well as the comparison study of this combination therapy with each monotherapy. The data of initial two years of CombAT showed that dutasteride and tamsulosin combination therapy provided significant improvement on international prostate symptom score (IPSS) and BPH Impact Index (BII) as compared with each monotherapy at 24-month. According to the results of CombAT, it is clear that the long term combination therapy would be more valuable than monotherapy for the BPH patients. Surgical therapy Although the number of patients receiving BPH surgery has been greatly reduced with the advent of effective drug therapy, surgical therapy is still believed to be the final stage of the disease progression. For decades, transurethral resection of the prostate (TURP) has been considered the "gold standard" surgical intervention for patients with LUTS/BPH.1 On the other hand, the relatively high incidence of complications tradi