[Perceptions of benign prostatic hyperplasia according to the perspective of patients and general practitioners - the Trophée study]. / Perceptions de l'hypertrophie bénigne de la prostate par le patient et le médecin généraliste - étude Trophée.

OBJECTIVE: To compare the perception of benign prostatic hypertrophy (BPH) between patients and general practitioners (GPs) in terms of severity and evolution of symptoms and medication adherence. METHODOLOGY: A cross-sectional observational study was performed in France in a sample of GPs who included patients for whom a BPH treatment was prescribed. Data were collected on patient and GP characteristics, diagnosis, BPH management, severity and evolution of symptoms and medication adherence. RESULTS: One thousand and ninety-eight patients were recruited by 247 GPs. In 87.4% of cases, diagnosis was performed by GPs. Among them, 82.7% of patients were treated by monotherapy. The choice of a treatment was mainly based on treatment efficacy and the patient's opinion was taken into account by 5% of GPs. The patient's evaluation of symptoms severity was consistent with the GP's in 53.9% of cases. A worsening of symptoms was reported significantly more frequently by patients (18.5%) than by GPs (8.8%). Among 94 patients who reported poor adherence, GPs estimated that the level of medication adherence was good for 72 of these (77%). CONCLUSION: There was discordance between the evaluation made by GPs and by patients on the perception of BPH symptoms and medication adherence. The patient's opinion was rarely taken into account in the therapeutic decision, reflecting a lack of shared medical decision-making, which would be helpful for the physician in order to optimize BPH management.

Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management.

Benign prostatic hyperplasia (BPH) is a complex disease that is progressive in many men. BPH is commonly associated with bothersome lower urinary tract symptoms; progressive disease can also result in complications such as acute urinary retention (AUR) and BPH-related surgery. It is therefore important to identify men at increased risk of BPH progression to optimise therapy. Several factors are associated with progression, including age and prostate volume (PV). Serum prostate-specific antigen level is closely correlated with PV, making it useful for determining the risk of BPH progression. Medical therapy is the most frequently used treatment for BPH. 5-alpha-reductase inhibitors impact the underlying disease and decrease PV; this results in improved symptoms, urinary flow and quality of life, and a reduced risk of AUR and BPH-related surgery. Alpha-blockers achieve rapid symptom relief but do not reduce the overall risk of AUR or BPH-related surgery, presumably because they have no effect on PV. Combination therapy provides greater and more durable benefits than either monotherapy and is a recommended option in treatment guidelines. The Combination of Avodart and Tamsulosin (CombAT) study is currently evaluating the combination of dutasteride with tamsulosin over 4 years in a population of men at increased risk of BPH progression. A preplanned 2-year analysis has shown sustained symptom improvement with combination therapy, significantly greater than with either monotherapy. CombAT is also the first study to show benefit in improving BPH symptoms for combination therapy over the alpha-blocker, tamsulosin, from 9 months of treatment.

[How to operate kidney puncture in percutaneous nephrolithotomy?]. / Comment ponctionner un rein pour réaliser une néphrolithotomie percutanée?

Obtaining a precise percutaneous calyceal puncture gave way to the development of percutaneous nephrolithotomy, one of the first micro-invasive techniques described in urology. Both radiologist and urologist can perform puncture, sometimes in a collaborative effort. However, being followed by a true surgical procedure, it should be done in the O.R; perfect knowledge of the procedure is mandatory for every urologist. Standard guidance uses a fluoroscopic C-arm device, only able to guide the needle precisely towards the apex of the chosen calyx. Moving the C-arm with cephalad tilting will provide 3-D imaging. Ultrasound guidance is an alternative, but might be difficult with non dilated upper tract. CT guidance and retrograde puncture are rarely used. The access is to be adapted according to the patient (adult or child), type of stone (single or multiple access), or kidney position (eutopic or ectopic). Direct ad stable puncture entering the apex of the chosen calyx is a pre-requisite for easy and efficient subsequent nephrolithotomy.

[Early prostate cancer 2005. New 2005 data]. / Nouveaux résultats du programme early prostate cancer 2005.

The Early Prostate Cancer (EPC) Program consists of three randomised, double blind, placebo-controlled trials that assess bicalutamide either as adjuvant to treatment of curative intent or alone (radical prostatectomy, radiotherapy or watchful waiting) in patients with non-metastatic prostate cancer. In total, 8113 men have been enrolled in a 1/1 ratio to receive bicalutamide 150 mg/day orally or a matching placebo. We present the results at a median follow-up. No significant results are yet observed on overall survival in the localised, low-risk disease groups. For patients with locally advanced disease, adjuvant hormonal therapy significantly improves objective progression-free survival over placebo. Moreover, adjuvant bicalutamide offers a significant benefit in terms of overall survival in radiotherapy treated patients for locally advanced prostate cancer.

[Management of patients with benign prostatic hyperplasia by urologists: the DUO study]. / Prise en charge, par les urologues, des patients présentant une hypertrophie bénigne de prostate: l'etude DUO.

UNLABELLED: The DUO study intended to define the factors determining diagnostic and treatment strategies for benign prostatic hyperplasia (BPH) management. METHODS: This longitudinal, observational study was conducted in France (June 2004 to March 2005), with a representative sample of private and hospital urologists. RESULTS: 1027 BPH patients were included by 202 urologists and 856 were followed-up 6 months later. Mean I-PSS was 14.9 (+/- 6.7) at inclusion and 10.5 (+/- 6.7) at the follow up visit. At inclusion, pharmacologic treatment was prescribed to 84% of the patients, surgery to 13% and no treatment to 3%. Factors in favour of surgery (versus drugs) were BPH severity (OR = 2.5 if IPSS = 20), patients' choice (OR = 2.5), quality of life improvement (OR = 2.2), post-void residual (OR = 2.1) and dribbling (OR = 1.6). Patients' age and prostatic volume have no impact on this choice. Factors in favour of a combination of an alpha-blocker plus an 5alpha-reductase inhibitor (versus an alpha-blocker) were prostate volume (OR = 7.8), patient's age (OR-3.0 if age = 74) and post-void residual (OR = 2.3) and those in favour of a 5alpha reductase inhibitor (versus an alpha-blocker) were prostate volume (OR = 7.6), PSA results (OR = 5.8), patients' age (OR = 5.4 if > 74 years, OR = 2.1 if > 68 years). CONCLUSION: Medical or surgical treatment of BPH results in IPSS improvement at 6 months. Patients' age and prostatic volume favour 5alpha-reductase inhibitor initiation and have no impact on surgical treatment decision. Surgery is performed in severe BPH or when patients expecting a quality of life improvement do that choice.

[Is volume of surgical activity relevant for surgeon's evaluation?]. / Les volumes opératoires sont-ils des critêres pertinents pour l'evaluation des chirurgiens?

"Often done, better done" is a popular saying that may lead health authorities to use the volume of surgical activity to assess surgical quality, including eventually this criteria in their certification manual. Very few data indeed support this idea in Urology. On the other hand, well-conducted studies clearly show that high volume activity does not always avoid surgical complications. Moreover, fair statistics should be applied to urologists, with proper calculation of confidence intervals, before scrutinizing reasons why they may appear "to differ" from the assigned goal or their colleagues' average. This, for major urologic operations, can only be done after a prolonged observation period, sometimes reaching over a decade.

[The UrEpik study: a descriptive epidemiological approach to lower urinary tract symptoms, sexual disorders and urinary continence in four countries]. / L'étude urEpik: une approche d'épidémiologie descriptive des troubles mictionnels, sexuels et de la continence à travers quatre pays.

UrEpik is a cross-sectional, epidemiological study undertaken in four cities (Auxerre, Birmingham, Nijmegen and Seoul) to determine the prevalence of lower urinary tract symptoms, urinary incontinence and erectile dysfunction in men aged from 40 to 80 years and their female partners, if applicable. Numerous evaluation questionnaires were collected by post, telephone or direct contact from 4876 men and 3657 women. The prevalence of lower urinary tract disorders was significantly different from one country to another, but increased constantly with age in particular in men with an I-PSS between 8 and 19 for whom it increased by approximately 10% per decade. Incontinence in men seems to be an important problem both in terms of discomfort score and wearing of protection and it increases with age. Analysis of erectile dysfunction (ED) gave different results depending on the method of investigation used. The SFI (sexual functional index) showed a positive correlation between ED and age, which was not found by direct questioning. The psychological impact of ED varied according to culture and age of the subject.

[The PCPT study: the viewpoint of an urologist involved]. / L'etude PCPT: regards d'un urologue intéressé.

The PCPT study investigating the possibility of decreasing the incidence of prostate cancer by daily administration of 5 mg of finasteride for 7 years appears to be a major clinical study in the management of this disease. Recently published in the New England Journal of Medicine, it makes difficult reading. The current article aims to demonstrate the main methodological characteristics of this study, to describe the most significant results and to discuss its clinical applications in daily urological practice.

The management of localized prostate cancer.

At this point in time, the only possibility of curing prostate cancer is through the early detection and treatment of localized disease. The large number of treatment options available for localized prostate cancer, including radical prostatectomy, radiotherapy (either external beam or interstitial), hormone therapy and watchful waiting, can be confusing for the patient. These treatments are associated with different adverse effects, further complicating the treatment decision. As there will inevitably be a trade-off between expected cure and acceptable adverse effects, it is important to discuss all options with the patient. The doctor and patient must together decide the appropriate treatment for him and his tumor.

The value of patient-doctor dialog in the treatment of early prostate cancer.

A lack of information about the characteristics of prostate cancer, the treatment options available, and the negative effects associated with each treatment option leaves many newly diagnosed patients feeling anxious, depressed and confused, and can ultimately lead to feelings of distrust towards the treating physician. Improving patient-doctor dialog increases the chances of successfully achieving the patient's goals in managing their disease. Factors considered important for improving patient-doctor dialog include an individualized approach to care, providing the patient with complete, comprehensive and unbiased information on treatment options, and allowing the patient sufficient time to come to a treatment decision.

[Prevalence of lower urinary tract disorders and incontinence in Auxerre. French segment of the UrEpik study]. / Prévalence des troubles du bas appareil urinaire et de l'incontinence chez les adultes auxerrois. Volet français de l'étude UrEpik.

OBJECTIVES: To estimate the prevalence of low urinary tract symptoms (LUTS) and urinary incontinence among men and women aged 40 to 79 years. METHODS: A postal survey was carried out in a community-dwelling random sample, in Auxerre, France. LUTS were assessed using the International Prostate Symptom Score (IPSS). Urinary incontinence (UI) was assessed using a score based upon four questions. RESULTS: 1216 men and 591 women participated in the survey. 19.2% of men and 13.7% of women reported moderate to severe LUTS (IPSS > 7). 73% of men and 29% of women suffered from UI. Among men and women reporting severe symptoms of UI (0.4 and 5.4% respectively), one third had been prescribed medications for urinary disorders within the previous six months. CONCLUSION: This survey confirms the high prevalence of LUTS and urinary incontinence among a community-dwelling sample of men and women, and highlights the need for management of these disorders.

[Prevalence of nocturia among people in Auxerre: the French part of the UrEpik study]. / Prévalence de la nycturie chez les adultes auxerrois: volet français de l'étude UrEpik.

OBJECTIVES: To estimate the prevalence of nocturia among men and women aged 40 to 79 years old. MATERIAL AND METHODS: A postal survey was carried out in a community-dwelling random sample in Auxerre, France. Nocturia was assessed using the item 7 of the International Prostate Symptom Score (IPSS). RESULTS: 1216 men and 591 women participated in the survey. Average nocturnal urinary frequency was 0.98 and 0.95 among men and women, respectively. Between the age ranges 40-49 years and 70-79 years, the frequency increased from 0.70 to 1.61 among men, and from 0.72 to 1.31 among women. In the age range 70-79 years, 48.1% of men and 31% of women awakened from sleep to urinate at least twice per night. CONCLUSION: Patients and primary care physicians should be more informed about screening and management options, and impact of nocturia on quality of life and related morbidity.

[Efficiency and tolerance of terazosine in ambulatory patients with benign prostatic hypertrophy: comparative randomized and double-blind trial versus alfuzosin. The MG Terazosine Group]. / Efficacité et tolérance de la térazosine chez des patients ambulatoires présentant une hypertrophie bénigne de la prostate: essai comparatif contre alfuzosine, randomisé, en double-aveugle. Le Groupe MG Térazosine.

OBJECTIVE: To compare, in general practice, the efficacy and safety of terazosin (5 mg per day in single dose) versus alfuzosin (7.5 mg per day in 3 doses) in patients with symptomatic benign prostatic hyperplasia (BPH) treated for 16 weeks. MATERIAL AND METHODS: Thirteen investigators included patients over the age of 50 years presenting with BPH with an International Prostate Symptom Score (IPSS) greater than 12 and a post-voiding residual volume less than 300 ml. After a one-week observation period, these patients were randomized to receive either terazosin or alfuzosin for 16 weeks (112 days) under double-blind conditions. The primary endpoint was the percentage reduction of the IPSS score at 3 weeks and 16 weeks; the secondary endpoint was the IPSS quality of life score. Safety was evaluated by recording adverse events and monitoring blood pressure. RESULTS: Seventy four patients were included: 39 in the terazosin group, 35 in the alfuzosin group. The 2 groups were not significantly different before treatment. Improvement of the IPSS score was similar in the 2 treatment groups (p = 0.97 at 3 weeks, and p = 0.29 at 16 weeks), as was the improvement of the quality of life score (p = 0.47 at 3 weeks and p = 0.71 at 16 weeks). Treatment was considered to be "effective or very effective" in 31 patients (86%) in the terazosin group, and in 28 patients (82%) in the alfuzosin group. The IPSS score was greater than or equal to 12 before treatment for all patients included in the study. Twenty-five patients had a score < 12 at 3 weeks versus 56 at 16 weeks (p = 0.0001). Seven patients had a quality of life score less than 2 before treatment, versus 38 at 3 weeks, and 56 at 16 weeks (p = 0.0001). No significant difference was observed between the 2 groups in terms of the number of adverse events reported, or the course of blood pressure and prostate specific antigen. No patient dropped out of the study because of treatment-related adverse events. Two deaths were observed in the terazosin group (2 patients aged 86 and 93 years), but any relation to treatment was excluded. CONCLUSION: During this study, terazosin appeared to be as effective and as well tolerated as alfuzosin.

[Morbidity of endoscopic prostatic resection: 3-month prospective study. Practical Urology Club]. / Morbidité de la résection endoscopique de la prostate: étude prospective à 3 mois. Club d'Urologie Pratique.

OBJECTIVES: To quantify the complications of TUR of prostate occurring during the first three post-operative months. PATIENTS AND METHODS: Multicentric cooperative study where skilled urologists, aged between 45 and 55 years old, with various practice settings, compile complications in their consecutive patients undergoing TURP between March and June 1996. 410 patients have been assessed by 17 urologists. RESULTS: Rate of intraoperative complications is low with 10 patients being transfused and 3 TUR syndromes being observed. Two deaths occurred in patients aged 84 and 92 years-old at post-op day 27 and 30 respectively. Twenty four percent of patients experienced at least one complication during the observation period, the most frequent of which was asymptomatic bacteriuria in 8.5%. Urethral--mainly meatal--stenosis was the main cause for the readmission/reintervention rate (6.5%). CONCLUSION: Early morbidity/mortality of TURP for BPH albeit real, occurs in a small percentage of patients, with a general mild intensity. Alongside with excellent objective and subjective outcome, these rates allow TUR of prostate to remain the gold-standard treatment for BPH.

Androgen deprivation for prostatic carcinoma: a rationale for choosing components.

Ever since prostatic carcinoma was discovered to be dependent on the hormone androgen for its proliferation, androgen deprivation has been the treatment of choice for advanced cases of prostate cancer. Originally, treatment was limited to surgical castration or estrogen therapy. However, the introduction of luteinizing hormone-releasing hormone analogues, antiandrogens, and newer treatment modalities, such as combined androgen blockade, has made choosing a treatment strategy more complex. Assuming that each modality is equally effective, emphasis should be placed on increasing patient tolerance and compliance by the use of long-acting, nontoxic treatments with simple dosing regimens and minimal side effects. This review focuses on the factors influencing the final choice of treatment strategy.

Adjuvant treatment for failure of local radical therapy.

Adjuvant treatment is suitable where localised tumour recurrence justifies further treatment following failed radical prostatectomy. External beam radiotherapy is effective and may be enhanced by concomitant androgen deprivation therapy. Early adjuvant androgen deprivation therapy compared with 'deferred' therapy may drastically reduce morbidity and possibly increase survival in prostate cancer. A large clinical study is underway.

Estrogen reduction by aromatase inhibition for benign prostatic hyperplasia: results of a double-blind, placebo-controlled, randomized clinical trial using two doses of the aromatase-inhibitor atamestane. Atamestane Study Group.

BACKGROUND: The concept of estrogen withdrawal by an aromatase inhibitor in the treatment of benign prostatic hyperplasia (BPH) was assessed in a prospective, randomized, double-blind, placebo-controlled multicenter trial. METHODS: Two hundred and ninety-two patients with clinical symptoms of BPH were randomly allocated to one of the following treatments for 48 weeks: placebo or the selective aromatase inhibitor, atamestane, at a daily dose of 100 mg or 300 mg. Both doses of atamestane significantly reduced serum concentrations of estradiol and estrone, and produced a slight, dose-dependent, counter-regulatory increase in peripheral androgen concentration. RESULTS: Clinical symptoms improved during treatment in all three groups. Even after 48 weeks, the effect of active treatment did not exceed the effect seen with placebo. Overall tolerance of 100 mg atamestane was excellent, but 300 mg showed a slightly increased incidence of side effects compared with placebo. CONCLUSIONS: The conclusion from this study is that the reduction in estrogen concentration using the selective aromatase inhibitor atamestane has no effect on clinically established BPH.