Evidence-based guidelines for the treatment of lower urinary tract symptoms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary from AURO.it.

BACKGROUND: The first Italian national guidelines were developed by the Italian Association of Urologists and published in 2007. Since then, a number of new drugs or classes of drugs have emerged for the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH), new data have emerged on medical therapy (monotherapies and combination therapies), new surgical techniques have come into practice, and our understanding of disease pathogenesis has increased. Consequently, a new update of the guidelines has become necessary. METHODS: A structured literature review was conducted to identify relevant papers published between 1 August 2006 and 12 December 2010. Publications before or after this timeframe were considered only if they were recognised as important milestones in the field or if the literature search did not identify publications within this timeframe. The quality of evidence and strength of recommendations were determined according to the Grading of Recommendations Assessment, Development and Evaluation framework. MAIN FINDINGS: Decisions on therapeutic intervention should be based on the impact of symptoms on quality of life (QoL) rather than the severity of symptoms (International Prostate Symptom Score (IPSS) score). A threshold for intervention was therefore based on the IPSS Q8, with intervention recommended for patients with a score of at least 4. Several differences in clinical recommendations have emerged. For example, combination therapy with a 5α-reductase inhibitor plus α blocker is now the recommended option for the treatment of patients at risk of BPH progression. Other differences include the warning of potential worsening of cognitive disturbances with use of anticholinergics in older patients, the distinction between Serenoa repens preparations (according to the method of extraction), and the clearly defined threshold of prostate size for performing open surgery (>80 g). While the recommendations included in these guidelines are evidence based, clinical decisions should also be informed by patients' clinical and physical circumstances, as well as patients' preferences and actions. CONCLUSIONS: These guidelines are intended to assist physicians and patients in the decision-making process regarding the management of LUTS/BPH, and support the process of continuous improvement of the quality of care and services to patients.

Penile enlargement.

PURPOSE OF REVIEW: As male genital corrective surgery is becoming increasingly requested by patients, the need to reach a general consensus on indications and techniques is now imperative. This review of published data provides an overview concerning patient selection modalities, benefits/risks and expected outcomes of surgery. Finally, the article focuses on ethical issues caused by the growing aesthetic nature of this surgery. RECENT FINDINGS: Interest has been sparked by animal studies, the description of innovative techniques for lengthening and girth enhancement techniques, reconstructive phalloplasty and penile implant surgery. Data suggest that better objective surgical outcomes are possible, though in many cases long-term data and patient-rated satisfaction details are lacking. Most importantly, studies show the importance of having a multidisciplinary team in charge of patient selection. SUMMARY: Although more long-term data are required before a general consensus can be reached, recent findings point to the absolute need for a thorough psychological assessment of men requesting penile enhancement surgery. Urologists should work in very close collaboration with psychologists or psychosexologists both during the preoperative phase (to verify eligibility for surgery) and afterwards (to provide counselling).

Evidence-based guidelines for the management of lower urinary tract symptoms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary.

BACKGROUND AND SCOPE: Despite the high prevalence and huge socio-economic impact of benign prostatic hyperplasia (BPH) in Italy, no national guidelines have been produced so far. This is a summary of the first Italian guidelines on the diagnosis and treatment of lower urinary tract symptoms (LUTS) related to uncomplicated BPH, prepared by a multidisciplinary panel under the auspices of the Italian Association of Urologists and introduced in Italy in 2003. An update compiled by the authors is also included. METHODS: Relevant papers published from 1998 to 2003 (updated to 2006) were identified through a structured literature review and the quality of evidence presented therein was graded according to the Centre for the Evaluation of Effectiveness in Health Administration (CeVEAS) system. Recommendations were based on evidence from the literature, but also on feedback from practitioners and specialists. MAIN FINDINGS/RECOMMENDATIONS: Given the prevalence of BPH, all men aged > or = 50 years of age should be asked about LUTS and informed about disease characteristics and therapeutic options, while sexual function should always be assessed in patients with severe and long-standing LUTS. Initial assessment should include medical history (including drug and co-morbidity history), digital rectal examination, urinalysis, International Prostate Symptom Score-Quality of Life (IPSS-QoL) and a voiding diary, while prostate-specific antigen (PSA) and measurement of prostate volume by suprapubic ultrasonography are indicated in fully informed patients with a life expectancy of > or = 10 years in whom BPH progression could influence treatment choices. QoL considerations should dictate whether to start active treatment. When QoL is not affected by LUTS, watchful waiting is indicated if symptoms are mild, acceptable if they are moderate. When QoL is affected, medical therapy with alpha1-blockers or 5alpha-reductase inhibitors (the latter indicated in patients with increased prostate volume) is appropriate. Combined therapy with alpha1-blockers + 5alpha-reductase inhibitors should only be considered in patients at high risk for progression (prostate volume > 40 mL or PSA > 4 ng/mL), since the incremental cost of combination therapy vs. monotherapy with alpha1-blockers or finasteride is prohibitive. Selection of the type of surgery should be based on the surgeon's experience, the presence of co-morbid conditions and the size of the prostate. Open prostatectomy and transurethral resection of the prostate (TURP) are recommended in patients with acute or chronic retention of urine, and acceptable in obstructed patients with moderate/severe symptoms and worsened QoL. Transurethral incision of the prostate (TUIP) is acceptable when prostate volume is < or = 30 mL. Holmium laser enucleation of the prostate (HoLEP) may be proposed to motivated patients where expert surgeons are available. Transurethral microwave thermotherapy (TUMT) or transurethral needle ablation (TUNA) may be proposed to motivated patients who prefer to avoid surgery and/or do not respond to medical treatment. The possible effects of medical or surgical treatments on sexual function should always be discussed. CONCLUSIONS: These guidelines are intended to provide a framework for health professionals involved in BPH management in order to facilitate decision-making in all areas and at all levels of healthcare.

Cancer detection with TRUS-guided 10-core biopsy of the prostate. an institutional assessment at the first, repeated and surgical specimen biopsy.

OBJECTIVES: We retrospectively investigated the results of the 10-core scheme that our institute has adopted for three years. The aim of this study is to evaluate the cancer detection rate in different sets of biopsies (first, second, third and surgical specimen biopsy). MATERIAL AND METHODS: Patients with clinical suspicion of prostate cancer based on abnormal digital rectal examination, increase of PSA or hypoechoic lesion at transrectal ultrasound were subjected to a 10-core biopsy. Ten biopsies were taken following the traditional sextant technique and 4 more biopsies were obtained from the lateral peripheral zone. In addition, a group of 19 specimens of retropubic radical prostatectomy were biopsied immediately following surgery. RESULTS: Of 664 patients 247 (37.2%) were positive for prostate cancer at first biopsy. Eighty-one out of 664 patients were subjected to a second biopsy for persistent elevation or increasing of PSA, or in case of tumor associated histological findings such as high PIN and ASAP. The cancer detection rate in this group was 19.8% (16/81). Of the remaining 65 patients who were negative at second biopsy, 12 received a third biopsy for persistent clinical suspect of cancer, and 2 were positive (16.7%). In 19 surgical specimens, 14 biopsies were confirmed positive and 5 were negative (73.7%). CONCLUSIONS: The extended biopsy such as the 10-core scheme showed to be a reliable protocol, taking an adequate cancer detection rate either at first or repeated biopsy with no increase in morbidity.