Management of Benign Prostatic Hypertrophy
http://www.100md.com
《新英格兰医药杂志》
This book — whose authors include 10 Chicago urologists, 12 other U.S. urologists, and an eminent urologist from Ireland — reviews the anatomy, pathophysiology, and causes of benign prostatic hypertrophy, or hyperplasia (BPH), and discusses the assessment and treatment of the condition. However, an opportunity is missed in this book. One author states that "one of the most basic, yet most important, difficulties in the evaluation and management of men with BPH concerns definitions. In a strict sense, BPH is a histologic diagnosis." Both the International Consultations of the World Health Organization and the International Continence Society have recommended that the term BPH be used for histologic diagnosis, the term benign prostatic enlargement when the gland is anatomically enlarged, and the term benign prostatic obstruction when the gland produces an obstruction that is characterized by a low maximal flow rate and high voiding pressure. These distinctions are important because the loose use of the term BPH means that the characteristics of the disorder in any given patient cannot be deduced. Precise definition is needed — for example, in describing a patient with troublesome lower urinary tract symptoms without evidence of benign prostatic enlargement or obstruction. In such a case, as is pointed out in the chapter on definitions, "urinary symptoms . . . may result from a variety of other causes."
The book acknowledges the benign nature of lower urinary tract symptoms in most patients, but there is an important section on the relatively rare cases of renal impairment secondary to benign prostatic obstruction. Basic clinical assessment is covered briefly in the section on alpha-adrenergic–blocking agents, although the book stresses the usefulness of the frequency–volume chart. The section on the role of urodynamics describes the tests well and, in a well-reasoned manner, outlines the areas of dispute concerning their place in routine assessment. The sections on drug therapy cover alpha-adrenergic agonists and 5-alpha-reductase inhibitors but only briefly mention combination therapy with an agent from each group.
The authors state that although it is difficult to compare various alpha-adrenergic blockers, the use of such agents can now be regarded as first-line management in primary care. The historical aspects of the 5-alpha-reductase inhibitors and the rationale behind the drugs' use are interesting. However, there is no clear statement regarding the respective roles of alpha-adrenergic blockers and 5-alpha-reductase inhibitors in treating patients with lower urinary tract symptoms, and there is little discussion of the choice between these two classes of drugs for the prevention of episodes of urinary retention and operations for prostatic obstruction. It would be helpful to see data regarding which criteria are appropriate for treatment in order to prevent a complication. However, it is not clear from many published papers whether the episodes of urinary retention that were discussed required catheterization and subsequent transurethral resection of the prostate.
In keeping with the wide range of procedures that are available in the United States, chapters in the book deal with the various types of minimally invasive, and generally less effective, treatments of prostatic obstruction, including transurethral needle ablation, transurethral microwave thermotherapy, interstitial laser coagulation, high-intensity focused ultrasonography, water-induced thermotherapy, and ethanol injections. It is interesting that the book cites few data to support the use of such procedures in patients with prostatic obstruction that leads to acute retention — the acid test for any treatment. Only transurethral resection, transurethral incision, and open enucleation of the prostate clearly pass this test, although holmium-laser enucleation probably also qualifies but is not discussed. It would be useful to see a management algorithm that ranked these therapies into some sort of hierarchy of effectiveness. One suspects that fashion, remuneration, and the individual views of patients and urologists determine choice.
In summary, the book provides a lot of useful information that will guide the clinicians who care for patients with lower urinary tract symptoms. The literature on the multifarious forms of treatment for prostatic obstruction is reviewed well. The editors appear not to have encouraged categorical recommendations, an attitude that will be welcomed by many but regretted by some.
Paul Abrams, M.D.
Bristol Urological Institute
Bristol BS10 5NB, United Kingdom((Current Clinical Urology)
The book acknowledges the benign nature of lower urinary tract symptoms in most patients, but there is an important section on the relatively rare cases of renal impairment secondary to benign prostatic obstruction. Basic clinical assessment is covered briefly in the section on alpha-adrenergic–blocking agents, although the book stresses the usefulness of the frequency–volume chart. The section on the role of urodynamics describes the tests well and, in a well-reasoned manner, outlines the areas of dispute concerning their place in routine assessment. The sections on drug therapy cover alpha-adrenergic agonists and 5-alpha-reductase inhibitors but only briefly mention combination therapy with an agent from each group.
The authors state that although it is difficult to compare various alpha-adrenergic blockers, the use of such agents can now be regarded as first-line management in primary care. The historical aspects of the 5-alpha-reductase inhibitors and the rationale behind the drugs' use are interesting. However, there is no clear statement regarding the respective roles of alpha-adrenergic blockers and 5-alpha-reductase inhibitors in treating patients with lower urinary tract symptoms, and there is little discussion of the choice between these two classes of drugs for the prevention of episodes of urinary retention and operations for prostatic obstruction. It would be helpful to see data regarding which criteria are appropriate for treatment in order to prevent a complication. However, it is not clear from many published papers whether the episodes of urinary retention that were discussed required catheterization and subsequent transurethral resection of the prostate.
In keeping with the wide range of procedures that are available in the United States, chapters in the book deal with the various types of minimally invasive, and generally less effective, treatments of prostatic obstruction, including transurethral needle ablation, transurethral microwave thermotherapy, interstitial laser coagulation, high-intensity focused ultrasonography, water-induced thermotherapy, and ethanol injections. It is interesting that the book cites few data to support the use of such procedures in patients with prostatic obstruction that leads to acute retention — the acid test for any treatment. Only transurethral resection, transurethral incision, and open enucleation of the prostate clearly pass this test, although holmium-laser enucleation probably also qualifies but is not discussed. It would be useful to see a management algorithm that ranked these therapies into some sort of hierarchy of effectiveness. One suspects that fashion, remuneration, and the individual views of patients and urologists determine choice.
In summary, the book provides a lot of useful information that will guide the clinicians who care for patients with lower urinary tract symptoms. The literature on the multifarious forms of treatment for prostatic obstruction is reviewed well. The editors appear not to have encouraged categorical recommendations, an attitude that will be welcomed by many but regretted by some.
Paul Abrams, M.D.
Bristol Urological Institute
Bristol BS10 5NB, United Kingdom((Current Clinical Urology)