a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Benign Prostatic Hyperplasia and Lower Urinary TractSymptoms: Research Priorities Cosimo De Nunzio Sascha Ahyai , Riccardo Autorino Alexander Bachmann Waldemar Bialek Alberto Briganti , Oliver Reich Roman Sosnowski Nikesh Thiruchelvam Giacomo Novara for the European Association of Urology Young Academic Urologists BPH Group a Department of Urology, Sant’Andrea Hospital, University ‘‘La Sapienza,’’ Rome, Italy; b Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; c Urology Clinic, Second University of Naples, Naples, Italy; d Universita¨tsspital Basel, Urologische Klinik, Basel, Switzerland;e Department of Urology, University Hospital of Lublin, Lublin, Poland; f Department of Urology, Vita-Salute University San Raffaele, Milan, Italy;g Department of Urology, Munich-Harlaching Hospital, Munich, Germany; h Department of Urology, M. Sklodowska-Curie Memorial Cancer Center, Warsaw,Poland; i Department of Urology - Addenbrookes Hospital, Cambridge, UK; j Department of Oncological and Surgical Sciences, Urology Clinic, University of Lower urinary tract symptoms (LUTS) and benign prostatic safety issues and expert opinion, with a low level of evidence hyperplasia (BPH) are highly prevalent in men beyond their fourth decade . Previously, LUTS were thought to Despite recent advances in the field, some issues related to depend on BPH and bladder outlet obstruction (BOO) in men; this condition are still under investigation. A number of however, a simple cause-and-effect relationship cannot be issues remain poorly understood in the field of BPH. The established . In fact, benign prostatic enlargement (BPE) pathophysiology of BPH remains a conundrum. Prostate with LUTS remains a very common diagnosis in our daily disorders occur as a result of aging, and the metabolic practice. Epidemiologic studies suggest that age, genetic changes associated with aging seem to be important. Despite factors, and sexual hormones play major roles as risk factors the current knowledge of risks factors, we do not know why for BPH; the only known associations for BPH progression are the prostate grows in one man and does not in others and age and prostate volume More recently, metabolic why symptoms develop in some and not in others syndrome, detrusor overactivity, prostatic inflammation, Aging is associated with an imbalance of sexual hormones, cell-signaling disorders, and neurologic, cardiac, and renal although the exact role in BPH initiation, development, dysfunctions have been hypothesized to contribute to the and progression remains obscure . Androgens have a development of LUTS . Hence the very common urologic permissive role in BPH, but there is no clear cause-and-effect diagnosis of men with BPE and LUTS is likely to be multifactorial and complex. Clinically, this is demonstrated Nocturia still needs to be clarified. Storage symptoms are by the fact that most patients with BPE suffer from LUTS, but known to be most bothersome, and nighttime increased only some patients presenting with LUTS have clinically urinary frequency bothers not only patients but also their partners. Research on nocturia treatment confirms that no Revision of the terminology of LUTS became necessary to therapy is truly effective, and surgery is not better than reflect our understanding and to improve patient manage- drugs in reducing the number of voids per night ment. But validated instruments aimed at qualifying urinary The importance of urodynamics in the assessment of symptoms have not been implemented as widely as patients with BPH is still under debate. For many years, expected. Most recommendations for the use of diagnostic clinical experience and dogma directed the management of tests evaluating patients with LUTS continue to be based on BPH and BOO, but only in the last decade did clinical * Corresponding author. Department of Urology, Sant’Andrea Hospital, University ‘‘La Sapienza,’’ Rome, Italy. Tel. +39 0633777716.
E-mail address: (C. De Nunzio).
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
E U R O P E A N U R O L O G Y 6 0 ( 2 0 1 1 ) 1 2 0 5 – 1 2 0 6 research show that BOO is not necessarily a progressive urologists with the purpose of boosting the research activity condition and the outcome of BPH surgery may be in some critical areas of urology and improving academic independent of the degree of BOO. The question is not collaboration among different centers in Europe. Specifically, whether we need to do urodynamic evaluation in patients we were given the task of investigation in the field of BPH and with BPH but is the value of the information we obtain from LUTS. We will start by looking at the feasibility of developing pressure-flow studies Despite appropriate investigation a BOO/BPH nomogram and improving diagnostic tools, and surgical management, we continue to have patients who characterizing BPH management in Europe, and determining may remain symptomatic after prostatic surgery the relationship between bladder stones and BPH. We hope Urodynamic study is a powerful way to investigate our energies will be enough to address some of the issues bladder behavior in the storage phase and in the diagnosis noted here. We find the task simultaneously daunting and of obstruction, but the clinical value of bladder sensation and detrusor dysfunction remains poorly understood One ofthe assumptions in this area is that symptoms in patients Conflicts of interest: The authors have nothing to disclose.
with BPE are due to BOO, and treatment consists of reducingoutlet resistance to a minimum. However, the lowest class inthe Schaefer nomogram is not composed of normal individuals but rather of patients who underwent trans-urethral resection of the prostate, suggesting this is a natural [1] Briganti A, Capitanio U, Suardi N, et al. Benign prostatic hyperplasia and its aetiologies. Eur Urol Suppl 2009;8:865–71.
nonobstructed condition . Finally, after 100 yr of BPH [2] Alcaraz A, Hammerer P, Tubaro A, et al. Is there evidence of a surgery, we do not know how much tissue we should remove.
relationship between benign prostatic hyperplasia and prostate Adenomectomy removes the adenoma entirely, whereas cancer? Findings of a literature review. Eur Urol 2009;55:864–75.
transurethral surgery leaves a variable degree of luminal [3] Maserejian NN, Giovannucci EL, McKinlay JB. Dietary macronutri- patency with no clear association with symptomatic control.
ents, cholesterol, and sodium and lower urinary tract symptoms in Surgery is a difficult area of clinical research, and surgeons sometimes avoid challenging successful proce- [4] Abrams P, Griffiths D, Hofner K, et al. The urodynamics of LUTS. In: dures and concepts of management with an evidence-based Chatelain C, Denis L, Foo KT, et al. editors. Benign prostatic hyper- view. Despite the fact that peer-reviewed literature plasia. Plymouth, UK: Health Publications; 2001. p. 227–81.
flourishes, with hundreds of new papers published every [5] Cabelin MA, Te AE, Kaplan SA. Benign prostatic hyperplasia: chal- lenge in the new millennium. Curr Opin Urol 2000;10:301–6.
>300 papers were indexed in PubMed in 2010 [6] Cornu J-N, Cussenot O, Haab F, Lukacs B. A widespread population dealing with these topics alone), several issues in the field of study of actual medical management of lower urinary tract symp- toms related to benign prostatic hyperplasia across Europe and beyond official clinical guidelines. Eur Urol 2010;58:450–6.
 The role of androgens and estrogens in LUTS due to BPH [7] Helfand BT, Evans RM, McVary KT. A comparison of the frequencies of medical therapies for overactive bladder in men and women: analysis  The prognostic value of BOO for BPH progression of more than 7.2 million aging patients. Eur Urol 2010;57:586–91.
 The prognostic value of detrusor underactivity and [8] Porst H, McVary KT, Montorsi F, et al. Effects of once-daily tadalafil overactivity in the outcome of BPH treatment on erectile function in men with erectile dysfunction and signs  The relationship between prostate debulking and out- and symptoms of benign prostatic hyperplasia. Eur Urol 2009; [9] Mamoulakis C, Ubbink DT, de la Rosette JJMCH. Bipolar versus monopolar transurethral resection of the prostate: a systematic Some of the relevant questions in medicine remain review and meta-analysis of randomized controlled trials. Eur Urol unanswered because, in the absence of an economic interest, there is not enough drive to design, initiate, and [10] Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional complete the research needed to address the different outcomes and complications following transurethral procedures issues. The European Association of Urology has recently for lower urinary tract symptoms resulting from benign prostatic supported the development of groups of young academic enlargement. Eur Urol 2010;58:384–97.


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