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LUTS assessment and management

LUTS assessment and management. Ahmed Ibrahim May 2019 Urology Department Peterborough City Hospital. The Burden. Pathophysiology. Men with moderate-to-severe LUTS may have an increased risk of major adverse cardiac events.

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LUTS assessment and management

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  1. LUTS assessment and management Ahmed Ibrahim May 2019 Urology Department Peterborough City Hospital

  2. The Burden

  3. Pathophysiology

  4. Men with moderate-to-severe LUTS may have an increased risk of major adverse cardiac events • Gacci, M., et al. Male Lower Urinary Tract Symptoms and Cardiovascular Events: A Systematic .Review and Meta-analysis. EurUrol, 2016. 70: 788.

  5. Complications

  6. DDX

  7. Evaluation A- History : • 1- Identify potential causes and relevant comorbidities, including medical and neurological diseases,currentmedication, lifestyle habits. • 2- Address the patient’s concerns : • Prostate cancer ? • Progression ? • AUR ? • Therapeutic options ? • 3- Self-completed validated symptom questionnaire : IPSS , FVC , IIEF.

  8. International Prostate Symptom Score (IPSS) questionnaire • This questionnaire contains seven symptom questions and one quality of life (QoL) question. “mildly symptomatic” (1-7 points) “moderately symptomatic” (8-19 points) “severely symptomatic” (20-35 points). • Limitations • The IPSS is not suitable to assess incontinence and post-micturition symptoms. • The IPSS questionnaire does not differentiate bother caused by each separate symptom.

  9. B- Physical Examination • Suprapubic area. • External genitalia: Urethral discharge, meatal stenosis, phimosis • DRE • lower limbs • Neurological examination C- Urine analysis

  10. OPTIONAL • PSA • U & Es • Flow rate and PVR • Upper tract imaging • Cystoscopy • UDS

  11. PSA With a specificity of 70%, and sensitivity of 70%, approximate age-specific criteria for detecting men with prostate glands exceeding 40 mL are PSA > 1.6 ng/mL, > 2.0 ng/mL, and > 2.3 ng/mL, for men with BPH in their 50s, 60s, and 70s, respectively • Roehrborn, C.G., et al. Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. Urology, 1999. 53: 581.

  12. Flow rate

  13. PVR • Monitoring of changes in PVR over time may allow for identification of patients at risk of AUR.

  14. U & Es

  15. Imaging • Upper tract (Hydronephrosis) • PVR • Prostate size and shape

  16. Cystoscopy

  17. UDS

  18. Progression 🚩 • The risk factors for progression • prostate size of greater than 30g . • PSA of greater than 1.4. • Either an IPSS of more than 12 or a Qmax of less than 10mls/sec. • Clinical progression of BPH • (IPSS) increase ≥4 points. • acute urinary retention (AUR). • urinary incontinence. • renal insufficiency • recurrent UTIs

  19. Non-invasive tests in diagnosing bladder outlet obstruction • Detrusor/bladder wall thickness • Bladder weight • IPP : Intra Prostatic Protrusion • Doppler US • prostate volume/height • near-infrared spectroscopy • penile cuff test

  20. EAU

  21. Treatment • WW / Behavioral and dietary modifications • Medical therapy • Phytotherapy • Minimally invasive surgery • Surgery

  22. WW • Education • Reassurance • Life style / Diet • Medication review • Periodic monitoring

  23. Medical therapy • α1-Adrenoceptor antagonists (α1-blockers) • 5α-reductase inhibitors • Muscarinic receptor antagonists / B3 agonists • Phosphodiesterase 5 inhibitors • Desmopressin / Diuretics • Combination thearpy

  24. α1-blockers

  25. 5α-reductase inhibitors

  26. Anti Muscarinic / B3 Agonists • The short-term data suggest that combination of antimuscarinic and α-blocker therapy is safe with minimal risk of retentioni n carefully selected men. • It would seem advisable to avoid treating men with a substantial residual urine (200 mL or more in most studies)

  27. PDE5Is • ED and BPH share common risk factors • Suggested pathogenetic factors include impaired NO and cGMP signaling, autonomic adrenergic overactivity and prostate / pelvic ischemia from atherosclerosis. 

  28. Surgical treatment of LUTS • The incorporation of medical management and new technologies has changed which treatment options are selected for the treatment of LUTS and BPH.

  29. postoperative complications and patients discharged with a catheter were more common in 2008 than 1988

  30. Minimally Invasive Therapy • 1- Transurethral microwave thermotherapy (TUMT): intraurethralcatheter with a cooling system . prostatic heating and coagulative necrosis. • 2- High intensity focused ultrasound (HIFU)transrectal probe is used. GA or heavy intravenous sedation is required. • 3-Transurethral radiofrequency needle ablation (TUNA) transurethral needle delivery system • 4- Water-induced thermotherapy(WIT) : is another thermal-based therapy for BPO that aims to produce heat-induced coagulative necrosis using heated water . 45-minute OP procedure with topical lidocaine jelly .

  31. 5- Prostatic stents • Permanent stents are biocompatible, allowing for epithelialisation. Temporary stents do not epithelialiseand may be either biostable or biodegradable • are associated with significant complications such as migration , encrustation, infection and chronic pain.

  32. The TIND is a nickel-titanium alloy, or nitinol, device which is placed transurethrally into the prostatic urethra to exert outward pressure on the obstructive prostatic lobes for 5 days prior to removal.

  33. PAE • Complications: • Irritative symptoms. • Hematuria • Postembolization syndrome 36% • Major complications < 1% : Bladder Ischemia , Persistent Perineal pain.

  34. Intra-prostatic injections • Various substances have been injected directly into the prostate in order to improve LUTS, these include Botulinum toxin-A (BoNT-A), NX-1207 and PRX302. • The primary mechanism of action of BoNT-A is through the inhibition of neurotransmitter release from cholinergic neurons. BoNT-A also appears to act by modulating the neurotransmissions of sympathetic, parasympathetic and sensory nerve terminals in the prostate, leading to a reduction in growth and apoptosis of the prostate. • A recent meta-analysis showed no differences in efficacy compared with placebo and concluded that there is no evidence of clinical benefits in medical practice.

  35. Urolift (prostatic urethral lift) • PUL involves the transurethral placement of small permanent intraprostaticimplants ,Under LA , day-case setting. • Advantages: ability to treat LUTS due to BPH whilst preserving both erectile and ejaculatory functions. • At 3 years, the mean total IPSS was significantly improved by 41.1%, quality of life (QoL) by 48.8%, and Qmax by 53.1%. • 10.7% patients originally randomized to PUL required surgical reintervention for treatment failure within the first 3 years. • Not inferior to TURP and HOLEP in improving IPSS, QoL or Qmax. Superior to TURP in regards to Complications. • A limitation of UroLiftprocedure is that it had been recommended for the treatment of obstructing lateral prostate lobes, but not for obstructing prostatic median lobe.

  36. convective water vapor energy (WAVE) • The Rezum system utilizes (WAVE) to ablate prostatic tissue • Office or hospital setting using oral pain medication . Applicable to all prostate zones including the median lobe and prostate volumes greater than 30 cm3. • The procedure lasts up to 20 minutes . • It is consists of a portable generator and a single-use disposable delivery device which is introduced into the body through the urethra and is guided to the prostate using a telescopic lens. • RF energy is produced by the generator and this heats up water outside of the body to generate vapour or steam. The steam is then delivered to the prostate. • WAVE was shown to provide rapid and durable improvements in LUTS whilst preserving erectile and ejaculatory function.

  37. Aquablation • Aquablation is a water ablation therapy combining image guidance and robotics for the removal of prostatic tissue . • high-velocity saline stream selectively ablate prostatic glandular tissue while sparing collagenous structures such as blood vessels and capsule. • The extent and depth of ablation was predetermined by endoscopic and TRUS guidance. • All aquablation treatments were performed under general / Spinal anaesthesia. • Mean procedural time was 48 min with an aquablation treatment time of 8 min. • The ablated tissue is aspirated through ports in the handpiece and can be used for histology. Haemostasis can be achieved by cautery or by inflating a Foley balloon catheter inside the prostatic cavity. Catheter time 2-4 days.

  38. TUIP • TUIP shows similar efficacy and safety to TURP for treating moderateto-severe LUTS secondary to BPO in men with prostates < 30 mL. without large median lobe. • No case of TUR-syndrome has been recorded, the risk of bleeding requiring transfusion is negligible and retrograde ejaculation rate is significantly lower after TUIP, but the re-operation rate is higher compared to TURP.

  39. TURP • TURP is the current standard surgical procedure for men with prostate sizes of 30-80 mL and bothersome moderate-to-severe LUTS secondary of BPO. • 20 contemporary RCTs with a maximum follow-up of five years, TURP resulted in a substantial mean Qmax improvement (+162%), a significant reduction in IPSS (-70%), QoL score (-69%), and PVR (-77%) • Failures were associated with DUA rather than re-development of BPO • Peri-operative mortality 0.1% , TUR syndrome 1.1% and morbidity 11.1%. bleeding requiring transfusion 2%. • In a large-scale study of 20,671 men, the overall re-TURPwas 2.9%, 5.8% and 7.4% at one, five, and eight years follow-up, respectively. • Re-operation was more common after TUIP (18.4%) than after TURP (7.2%)

  40. M-TURP / B-TURP • RCTs with mid- to long-term follow-up (up to 60 months) show no differences in efficacy parameters. • Early pooled results concluded that no differences exist in short-term urethral stricture/BNC rates, but B-TURP is preferable due to a more favourableperi-operative safety profile (elimination of TUR-syndrome; lower clot retention/blood transfusion rates; shorter irrigation, catheterisation, and possibly hospitalization times)

  41. Bipolar transurethral vaporisation of the prostate (B-TUVP) • minimal direct tissue contact (hovering technique). • Early pooled results concluded that no significant differences exist in short-term efficacy (IPSS,QoL score, Qmax and PVR) between plasmakinetic B-TUVP and TURP • B-TUVP has a lower short-term major morbidity compared to TURP

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