Updated BPH guidelines focus on patients, not procedures
New recommendations reflect evolving therapies, shared decision-making and changing evidence in BPH management.
New guidelines on benign prostatic hyperplasia (BPH) were published in May and introduced during the afternoon Plenary on Saturday. There are no dramatic changes, but earlier guidelines have been updated to reflect new technologies and new approaches.
“Lower urinary tract symptoms are very common, often attributable to BPH,” said panel moderator Jaspreet S. Sandhu, MD, attending urologist at the Memorial Sloan Kettering Cancer Center in New York City. “Seventy percent of men over the age of 60 have some element of BPH, and treatments, particularly procedural, are evolving quickly and expanding actively.”
Newer, less invasive approaches are gaining attention, especially those with the potential to spare ejaculation. More importantly, the guidelines are patient-focused rather than procedure-focused,
“This is a patient-centered guideline with shared decision making from the center,” Dr. Sandhu said. “That’s what we focused on as opposed to a procedure-based guideline.”
The initial evaluation and approach to treating BPH remain the same, he continued. Every patient should be counseled as an individual. Urologists should discuss options for intervention, beginning with behavioral and lifestyle modifications.
The new guidelines rely on two distinct grades of evidence. One is the expert opinion of the panel, a consensus based on literature reviews back to 2009 for medical approaches and 2014 for surgical intervention.
The other is a clinical principle, which is an existing, agreed-upon statement that may or may not have clinical evidence. There is little evidence that the use of 5-alpha reductase inhibitors (5ARI) is helpful in managing BPH, for example, but the class is widely used to slow or prevent progression. Trials have shown that the class is not associated with increased mortality.
Lifestyle modification and weight loss are typically the first and least aggressive approaches for many patients. Alpha blockers and 5ARIs are the usual first-line medications. New evidence supports the use of daily low-dose tadalafil with alpha blockers to help preserve ejaculatory function. Earlier guidelines had advised against the combination due to a lack of evidence.
Daily low-dose tadalafil plus finasteride is another new medical approach.
Transurethral resection of the prostate is still the leading surgical intervention. There are two approaches: the familiar monopolar or a newer bipolar. Both are effective, and the choice depends largely on the surgeon’s experience. Other acceptable procedures are transurethral incision of the prostate and transurethral vaporization of the prostate.
Two more familiar procedures, transurethral microwave therapy and transurethral needle ablation, are now considered legacy technologies and no longer recommended.
Prostate artery embolism (PAE), a technique from interventional radiology, is an acceptable approach but is not recommended. There is evidence of at least a short-term benefit for PAE versus observation in select patients, but insufficient evidence to recommend it.
