Management Approaches

The overall aim of therapy is to improve both symptoms and quality of life. Both the EAU and AUA guidelines9'29 list a number of recommended treatments for LUTS associated with BPH. Those listed by the EAU are outlined in Table 4; watchful waiting (i.e., no intervention) is advised if patients have minimal symptoms, 5a-reductase inhibitors or aj-adrenoceptor antagonists are recommended in patients with moderate-to-severe LUTS, with combination therapy being an option for those with large prostate volumes, at risk of developing complications or progressing, and surgery is advised for those who do not improve after medical therapy, do not want medication, or have complications such as acute urinary retention (AUR), bladder stones, recurrent infections, or recurrent hematuria refractory to medication. The type of surgery undertaken is usually based on prostate size, surgeon's judgment, and the presence of comorbidities.

The most recent addition to these guidelines has been the inclusion of combination therapy with a 5a-reductase inhibitor (finasteride) and an aradrenoceptor antagonist (doxazosin). This recommendation was based on findings from a recent large-scale trial known as MTOPS, which had a mean follow-up of 4-5 years and included a total of 3047 BPH patients. The study showed that combination of finasteride and doxazosin reduced the risk of symptomatic progression by 67% compared with 39% (doxazosin) and 34% (finasteride); the risk of AUR was reduced by 79% compared with 31% (doxazosin) and 67% (finasteride) and the risk of BPH-related surgery was reduced by 67%.51

Table 4 Treatment recommendations for LUTS associated with BPH

Treatment

EAU 2004 recommendation

Watchful waiting Medical therapy a1-Blocker Alfuzosin Doxazosin Tamsulosin Terazosin SARI

Dutasteride Finasteride Combination therapy a1-Blocker plus SARI Plant extracts

Minimally invasive therapies High-energy TUMT TUNAa

Prostatic stents4 Surgical therapies TUIP TURP

Open prostatectomy Transurethral holmium laser enucleation Transurethral laser vaporizationa Interstitial laser coagulation" Transurethral laser coagulationa Emerging therapies Ethanol injections High-intensity focused ultrasound Water-induced thermotherapy PlasmaKinetic tissue management

Recommended

Recommended Recommended Recommended Recommended

Recommended Recommended

Recommended Not recommended

Recommended Recommended Recommended

Recommended Recommended Recommended Recommended Recommended Recommended Recommended

5ARI, 5a-reductase inhibitors; TUIP, transurethral incision of the prostate; TUMT, transurethral TUNA, transurethral resection of the prostate; TURP, transurethral incision of the prostate. Reproduced with kind permission from Madersbacher, S.; Alivizatos, G.; Nordling, J.; Sanz, Rosette, J. J. M. C. H. Eur. Urol. 2004, 46, 547-554. a Not as first-line treatment.

bOnly to high-risk patients as an alternative to permanent catheterization.

microwave thermotherapy; C. R.; Emberton, M.; de la

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