Management of LUTS due to BPHMade possible under an Made possible under an educational grant from:educational grant from:Case 4Learning objectivesDiscussion of this case will assist urologists to:Advise patients on the choice of -blockers, 5- reductase inhibitors, and phytotherapyDefine the role of noninvasive techniques (especially TUNA)Case PresentationAlbert Scoffield, 64 y.o. engineerHypercholesterolemiaSmokesNo major illnesses or operationsMarried, sexually activeHistoryIncreasing LUTS for 10 yearsRecent increase in irritative symptomsAUA symptom score 18, bothersome score 5ExaminationGeneral examination - normalProstate - 75 gm, smooth, rubbery gland. No nodulesInvestigationsInvestigationResultSerum PSA2.8 ng/mLUrinalysisNormalSerum creatinine85 mol/L UroflowmetryAverage maximum flow on 3 readings = 5.2 mL/secPVRLess than 20 mLDiscussion Point # 1The patient wants relief of his symptoms. Which therapeutic agent or class of agent would you suggest?Medical Management of LUTS due to BPHPhytotherapySaw palmetto, numerous herbal extractsSaw palmetto, numerous herbal extractsLittle long-term efficacy dataLittle long-term efficacy dataMetaMeta-analysis suggests saw palmetto better than -analysis suggests saw palmetto better than placebo, as effective asplacebo, as effective as finasteride finasteride(Wilt T. JAMA 1998;280:1604)(Wilt T. JAMA 1998;280:1604)Medical Management of LUTS due to BPH5- reductase inhibitor (finasteride)long-term complications of BPH, may long-term complications of BPH, may need for need for surgery surgery More effective with larger prostates ( 30 to 40 More effective with larger prostates ( 30 to 40 gm)gm)May May prostate volume 20% to 30% prostate volume 20% to 30%ErectileErectile dysfunction in 5% dysfunction in 5%(McConnell J. N(McConnell J. N Engl Engl J J Med Med 1998;338:557) 1998;338:557)Medical Management of LUTS due to BPHAlpha-blockersMore effective in More effective in inging symptoms and symptoms and ing uroflowing uroflow thanthan finasteride finasterideRapid responseRapid responseCan cause abnormal ejaculation (up to 5%)Can cause abnormal ejaculation (up to 5%)TamsulosinTamsulosin gives fewer cardiovascular side gives fewer cardiovascular side effects thaneffects than terazosin terazosin or or doxazosin doxazosin( (GoldenbergGoldenberg S. Can J S. Can J Urol Urol 1998;5:551) 1998;5:551)Discussion Point # 2The patient is worried about sexual side effects, has heard about thermotherapy, and requests your advice. What would you say?Transurethral Needle Ablation of the Prostate (TUNA)Produces temperature of 100 CDestroys nerves (permanent -blockade), dessicates/shrinks tissueDone under topical anesthesiaAs effective as TURP in ing symptoms, not as good at ing flow rateLess expensive than TURP, fewer complicationsLong-term data not availableDiscussion Point # 3The patient decides on a TURP, but requests laser. What are the arguments for and against laser TURP?Laser TURPHolmium laser produces very localized temperature of 2000 CLess bleeding than conventional TURPShorter in-hospital staySome centres use local anesthesiaUsually shorter catheterization period, may not be necessaryDiscussion Point # 4The next day, this well-informed but unfortunate patient has a large MI, complicated by ongoing atrial fibrillation, requiring warfarin therapy, and ongoing angina requiring multiple medications. In hospital, he develops urinary retention and fails two trials of voiding. What now?A Complicated Case of BPHIndwelling catheter used for six months, but risk of infection, bleeding, discomfort, are concernsCIC considered, but risk of bleeding because of warfarinLaser surgery could be done under local anesthesia, but pain could provoke anginaProstatic stent probably the best option