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Purpose of Review: While BPH, and the complications that follow, represents the largest cause of urologic suffering both in the USA and globally, the underlying causes remain unknown. As the age of the population grows and providers dwindle, better understanding, treatments and prevention of this disease process are critical. Multiple lines of research have suggested a genetic or genomic component, and we have summarized the recent findings and avenues for future exploration. Recent Findings: Micro-RNAs are a relatively newly found class of genetic modulators that are intimately integrated with cellular function, and a number of specific imbalances or defects in these controlling molecules are associated with BPH. Similarly, single nucleotide polymorphisms and genome-wide arrays have allowed identification of cellular pathways that also appear linked with development of histologic BPH in ageing men. Alterations of these systems, including both hormonal and nonhormonal defects such as failure of senescence, appear to be linked with this hyperplasia. Summary: The wide suffering caused by this unplanned growth of the prostate demands better understanding of its causes. We summarize current findings and open avenues of genetic and genomic research: imbalances in specific miRNAs and other imbalanced gene/protein expression pathways, specifically including TGF-β, multiple CYP- genes, and the microenvironments of the ER and AR receptors. Failures of senescence may be involved. The overarching causes are currently indistinguishable from the downstream effects, and much work remains. [ABSTRACT FROM AUTHOR]

Purpose of Review: BPH is prevalent in men above the age of 50. The standard surgical treatment (TURP) has good clinical outcomes among the different treatment options, but it is associated with functional side effects as the urinary incontinence and erectile dysfunction. This has led to many innovations in the minimal invasive therapies of the prostate aiming to get equivalent outcomes to the TURP but with less side effects. Recent Findings: Prostate artery embolization is one of these therapies which has recently granted acceptance by the NICE as one of the treatment options for BPH. Recent publications have shown the effectiveness of this technique in improving the lower urinary tract symptoms with minimal side effects. Summary: Owing to the ischemic changes that happens to the prostate following the procedure, patients may experience post embolization syndrome which in few cases may cause high grade morbidities. In this article, the PAE procedure effectiveness and the possible side effects will be reviewed. [ABSTRACT FROM AUTHOR]

Purpose of review: In the last decades, new promising technologies for the treatment of BPH-related lower urinary tract symptoms (LUTS) have been widely experienced in clinical practice, with the aim of offering fewer complications but similar functional outcomes compared with the gold standard transurethral resection of the prostate (TURP). Among these so-called minimally invasive approaches, transurethral implantation of first- and second-generation temporary implantable nitinol device (TIND and iTIND, respectively) (Medi-Tate; Medi-Tate Ltd., Or Akiva, Israel) has been included by the European Association of Urology (EAU) Guidelines as one of the available alternative treatments to TURP. In the present paper, we conducted a systematic review of the current literature on TIND and iTIND implantation focusing on functional outcomes. Medline, Embase, and Cochrane databases were queried for relevant Literature in May 2021. Recent findings: Data regarding the use of temporary implantable nitinol device for BPH are still very limited, with only seven studies currently available in Literature. All the studies report that both TIND and iTIND procedures are safe, effective, and well tolerated. Moreover, such treatments seem to not affect patient's sexual and ejaculatory functions. Summary: Current clinical evidence suggests that temporary implantation of first- and second-generation temporary implantable nitinol devices are valid options for the minimally invasive surgical treatment of BPH-related LUTS. Further studies are required in order to confirm the functional results, especially over a long-term follow up. [ABSTRACT FROM AUTHOR]

Purpose of Review: The purpose of this review is to summarize the literature on safety and efficacy of minimally invasive thulium laser procedures for benign prostatic hypertrophy (BPH). Recent Findings: Recent studies have confirmed long-term safety and efficacy of thulium laser prostatectomy. There has been recent literature published from around the world confirming safety and efficacy in treatment of large prostates, obese patients, and in patients taking oral anticoagulation. Newer thulium laser systems use a wavelength of 1.9μm instead of 2 μm. Thus far, no clinical differences have been seen in outcomes of thulium laser procedures done with this wavelength. Summary: The high-power thulium laser was first introduced in 2005 for treatment of BPH [1]. Thulium vapoenucleation (ThuVEP), thulium laser resection of the prostate-tangerine technique (TmLRP), thulium laser enucleation (ThuLEP), and thulium vaporization (ThuVP) are techniques for thulium laser prostatectomy that have been described. Studies using the 70W to 200W thulium laser systems demonstrated good efficacy of these procedures with low morbidity and few complications in prostates of small to medium sizes [2]. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP, and holmium laser enucleation of prostate (HoLEP) [1]. In general, thulium laser prostatectomy appears to have longer operative times, shorter catheterization times, shorter hospital stay, and lower transfusion rates compared to standard and bipolar TURP. Outcomes of HoLEP and thulium enucleation techniques appear to be similar. Overall, thulium laser prostatectomy appears to be very safe and effective with low morbidity [3]. [ABSTRACT FROM AUTHOR]

The epidemiology of benign prostatic hyperplasia (BPH) and male lower urinary tract symptoms (LUTS) has evolved considerably during the past several years. The term LUTS describes a distinct phenotype and allows for a broad epidemiologic description of urinary symptoms at a population level. Although it is becoming the preferred term for studying urinary symptoms in populations, LUTS remains interconnected with BPH in the literature. The incidence and prevalence of BPH and LUTS are increasing rapidly as the US population ages. BPH and LUTS are associated with serious medical morbidities, an increased risk of falls, depression, diminished health-related quality of life, and billions of dollars in annual health care costs. Although age and genetics play important roles in the etiology of BPH and LUTS, recent insights at the population level have revealed that modifiable risk factors are likely key components as well. Serum dihydrotestosterone, obesity, elevated fasting glucose, diabetes, fat and red meat intake, and inflammation increase the risk; vegetables, regular alcohol consumption, exercise, and NSAIDs decrease the risk.

Purpose of Review: This review discusses the role of aquablation therapy for the treatment of benign prostatic hyperplasia in those with prostate volumes between 80 and 150 mL (WATER II trial). Recent Findings: Aquablation therapy reduced International Prostate Symptoms Scores, improved urinary flow rate, and preserved ejaculatory function in the majority of sexually active patients. Other advantages include faster operative times and a shorter learning curve. Adverse events were low and predominantly centered around bleeding risk. Summary: Aquablation therapy is effective and safe in the surgical management of large prostates thereby offering alternatives to surgeons and patients alike. [ABSTRACT FROM AUTHOR]

Purpose of Review: Benign prostatic hyperplasia (BPH) is a common age-related benign proliferation of the epithelial and stromal components of the prostate. Symptomatic BPH is associated with the progressive development of lower urinary tract symptoms (LUTS), which left untreated can deteriorate over time and lead to acute urinary retention, urinary incontinence, recurrent urinary tract infections, and/or obstructive uropathy. Recent Findings: Surgical or medical treatment that correct bladder outlet obstruction from BPH in patients generally resolves voiding symptoms and reduces the urine levels of neurotrophins. Histological analysis of the prostate biopsies obtained from BPH patients enrolled in large clinical studies supported the role of prostatic inflammation in BPH/LUTS. However, the invasive nature of biopsy motivates the research in alternative biofluids for the discovery of biomarkers to influence the clinical management of BPH. We recently reported that urinary levels of chemokines are associated with the evidence of prostatic inflammation and measures of obesity in BPH patients. Summary: Detection of inflammatory mediators in urine of BPH patients has the potential to displace biopsy for discriminating BPH-related pathologies, identify risk of progressive disease, and personalize the management of BPH-related LUTS. [ABSTRACT FROM AUTHOR]

Purpose of Review: Benign prostatic hyperplasia (BPH) is a common condition that affects a majority of the aging male population. The majority of aging male population was afflicted with lower urinary tract symptoms (LUTS). Over the past several years, there has been an armamentarium of advances in the treatment of this condition to improve a patient's quality of life (QoL). A new treatment that shows promising results is the i-TIND system, an implantable device.Recent Findings: We present the most current literature on this therapy. There are ongoing trials evaluating the use of the newer second-generation i-Tind, although there are currently no functional differences from the first-generation device. The pilot study of the first-generation device was shown to improve both IPSS score and Qmax over the course of 12 months with a trend to benefit in the 24 to 36-month period. The i-Tind represents another attempt to introduce an office-based procedure for the treatment of BPH. The preliminary results seem to indicate that this device shows efficacy in improving urinary symptoms.Summary: There is promising evidence for the use of i-Tind as an office-based treatment for BPH. An important consideration, however, will center on patient selection. There will be a cohort of men who elect to undergo this minimally invasive procedure over the gold standard TURP. However, this will not be a viable treatment option for men with particularly large prostate volumes. [ABSTRACT FROM AUTHOR]

Purpose of Review: Benign prostatic enlargement and obstruction may result in lower urinary tract symptom (LUTS) and have a negative impact on a patient's quality of life. The purpose of this review is to analyze different management options, specifically evaluating the cost-effectiveness of medical versus surgical therapy for BPH.Recent Findings: We performed a detailed review comparing various studies regarding the cost-effectiveness of different management options that were conducted in the last 5 years. When comparing monotherapy with combination therapy in medical treatments, the latter was found to be more cost-effective. Branded combined medical therapies were found to be much more expensive than generic medical therapies but demonstrated the same therapeutic outcome. When looking at operative options, specifically among the transurethral surgeries, there are more invasive options, including mono/bipolar transurethral resection of prostate (TURP) and laser vaporization and there are less invasive modalities (MIST) such as Urolift, Rezūm, transurethral microwave thermotherapy (TUMT), and transurethral needle ablation (TUNA). The findings demonstrated the cost of the more invasive options depended on whether the procedure was conducted as an inpatient or outpatient, with inpatient surgeries being the more expensive. In this context, GreenLight PVP, being performed as an outpatient procedure, was less expensive than TURP. Both of them provided the best relief in BPH symptoms but were found to have a higher incidence of side effects. Accordingly, it has been estimated the cost of MIST to be not only cheaper (except Urolift) than invasive transurethral options, but noted to have fewer side effects, especially in terms of ejaculatory dysfunction.Summary: Although combination generic medical therapy has been shown to be the least costly option, when invasive surgical management, such as TURP or GreenLight PVP as the most expensive, cost by itself is not the only metric to assess a BPH therapy. The more valuable criterion, such as cost-effectiveness, must be examined. In this light, MIST and especially Rezūm do appear to have a cost-effectiveness advantage over the other procedures due to its lower price and fewer side effects, while providing similar clinical efficacy. [ABSTRACT FROM AUTHOR]

Purpose of Review: To review recent data on the prevalence and treatment of the symptom of urgency in men with benign prostatic enlargement (BPE).Recent Findings: In recent years, researchers have moved to separate out individual lower urinary tract symptoms (LUTS) to see the individual impact. A recent registry trial put the prevalence of urgency at 38% in men with BPE. Other studies have reported urgency present in 64% of men with LUTS. While urgency is not as frequent a complaint in BPE as nocturia and frequency, it does have an impact on health-related quality of life. It is not increased in men with diabetes or the metabolic syndrome. Contributing factors may include prostate inflammation and decreased bladder blood flow from outlet obstruction. While some response is seen with treatment with alpha-blockers, more recently, anticholinergic and beta 3 medications are being used for refractory urgency in men with BPE.Summary: Urinary urgency is commonly reported in men with benign prostatic enlargement and is just beginning to be better evaluated with screening tools commonly used in overactive bladder patients. Specific medical therapy for urgency is helping to improve the response rate above traditional BPE therapy. [ABSTRACT FROM AUTHOR]

The Rezūm System™ is based on phase-change convective heat transfer with water vapor (steam) to ablate tissue. This is distinctly different than conductive heat transfer used by earlier devices such as radiofrequency or microwave systems. A summary of the early work is presented as well as a discussion of the important principles that make phase-change convective heating particularly useful in the prostate. Preliminary work suggests clinical promise for treating men with BPH and has led to a large scale trial to assess safety and efficacy of the procedure. [ABSTRACT FROM AUTHOR]

It is well known that age is the major risk factor for benign prostatic hyperplasia (BPH). A histologic diagnosis of BPH will develop in approximately half of men over 40. Of these men, approximately 50 % will develop notable lower urinary tract symptoms (LUTS), which increase in prevalence between age 40 and 80 []. The degree of prostatic enlargement, which impacts the severity of symptoms experienced, is highly variable. The presence of lower urinary tract symptoms is often indicative of bladder outlet obstruction (BOO) secondary to BPH, especially in the elderly. The treatment of BPH, which includes medical, minimally invasive, and surgical therapies, aims to improve subjective symptoms and quality of life. This review focuses on novel therapies for BOO secondary to BPH in the elderly. [ABSTRACT FROM AUTHOR]

Although alpha-blockers, 5-alpha-reductase inhibitors and prostatectomy are clearly efficacious treatment options for men with LUTS/BPH, these therapies are less than perfect. This has led to the investigation of new treatment options for men with LUTS/BPH. Three of these new treatment options include anticholinergics, phosphodiesterase-5-inhibitors (PDE5I), and botulinum toxin A (BoNT-A). Of these, anticholinergics and PDE5I have demonstrated a clear efficacy in appropriately selected patients. On the other hand, despite initial promising data , recent studies have not supported a clear efficacy with intraprostatic BoNT-A. The literature on anticholinergics, PDE5I, and BoNT-A is reviewed. Areas for future research within the field are then presented along with guidelines for prescribing these therapies. [ABSTRACT FROM AUTHOR]

Lower urinary tract symptoms (LUTS) in men are a prevalent condition with complex and multifactorial etiology. Different types of symptoms overlap among them and treatment has evolved to a more holistic and individualized approach. Advances in the understanding of LUTS pathophysiology has led to the development of new drugs and compounds to treat male LUTS. Recently, new drugs, such as phosphodiesterase type 5 inhibitors and beta3 adrenergic agonists, have been approved for the treatment of LUTS and have just made it to clinical practice. New agents for intraprostatic injection, for instance PRX302 and NX-1207, are currently under evaluation in clinical trials with promising results. Rho-kinase inhibitors, transient receptor potential channel blockers and activators of soluble guanylyl cyclase are examples of compounds targeting different pathways involved in the pathophysiology of male LUTS, which have been tested in experimental studies. New advances in pharmacotherapy may also allow combination of drugs to achieve synergistic effect. [ABSTRACT FROM AUTHOR]

Acute urinary retention (AUR) is a common urological emergency usually associated with bladder outlet obstruction due to benign prostatic hyperplasia (BPH). BPH becomes increasingly prevalent in an aging population with 80 to 90 % of men in their eighth decade of life having histological evidence of BPH in post-mortem studies. A review of the literature to date has been performed to make recommendations on the best management of AUR associated with BPH. Urethral or suprapubic catheterisation followed by medical therapy with an alpha-blocker prior to a trial of voiding is currently the mainstay of treatment in men presenting with a first episode of painful retention secondary to BPH. A selective alpha 1 blocker should be started as soon as possible after catheterisation with a trial of voiding attempted after a minimum of 48 hours treatment. At presentation with AUR consideration should be given to starting a 5-alpha reductase inhibitor, in men with a prostate >40 g or PSA >1.4 ug/l to reduce the risk of disease progression. In patients unlikely to pass a trial of voiding such as those with a high retention volume (approximately >1000 ml) consideration should be given to urgent surgery. Definitive surgical treatment involves bladder outlet surgery, if necessary, in the form of a prostatectomy, with the gold standard currently being a transurethral resection of the prostate (TURP) and should best be attempted as soon as possible out with the emergency setting and preferably without a catheter. [ABSTRACT FROM AUTHOR]

Benign prostate hyperplasia (BPH) occurs in up to 50 % of men by age 50, and the incidence increases with age. The rate of erectile dysfunction (ED) in patients with BPH ranges from 30 to 70 %, but can be as high as 90.5 % in males aged over 50 years. BPH/lower urinary tract symptoms (LUTS) and sexual dysfunction (SD) can have a substantial negative impact on a man's quality of life (QoL). Symptom severity and impact on QoL in each condition increase when LUTS and ED coexist. Age and erection change in patients with LUTS could also correlate with ejaculation dysfunction. However, urologists and primary care physicians appear to under-recognize SD in men with BPH/LUTS. We review the mechanisms of action, association, and effect of treatment between BPH and ED. [ABSTRACT FROM AUTHOR]

Bladder calculi in elderly are thought to be commonly associated with presence of bladder outlet obstruction. However there is a role of systemic factors in pathogenesis of calculi. It is clear that enlarged prostate may be an innocent bystander in many elderly patients having bladder calculi. There are varieties of options available for management of both these conditions. The present review is focused on understanding of pathogenesis of bladder calculi in elderly male. It also provides an overview of various treatment modalities described in literature for management of this condition. Approach in each case should be individualized based on the patient's clinical criteria and his choice, availability of various endourological gadgets, surgical expertise and experience. [ABSTRACT FROM AUTHOR]

Over the past decade there are a number of encouraging reports of clinical success of intraprostatic injection of botulinum toxin A (BoNT/A) as a method of management of lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). The rational is a unique dual mechanism of action on the smooth muscle and glandular components of the prostate. BoNT is able to block the presynaptic release of acetylcholine from the parasympathetic efferent nerve. The efficacy may also result from an inhibitory on the ganglionic and post-ganglionic fibers of autonomic nervous system inducing diffuse atrophy and apoptosis of prostate glands. The injection of BoNT/A into the prostate is a minimally invasive outpatient alternative treatment of BPH/LUTS. To date, several studies have demonstrated the efficacy of intraprostatic injection of BoNT/A against symptomatic BPH and this article discusses the efficacy and safety of BoNT therapy for treatment of BPH /LUTS. [ABSTRACT FROM AUTHOR]

Epidemiologic data in adult men exhibit a strong relationship between erectile dysfunction (ED) and lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), indicating that men affected by ED should also be investigated for LUTS/BPH and those presenting with storage or voiding LUTS should be investigated for co-morbid ED. Common pathophysiolgical mechanisms underlying both LUTS/BPH and ED, including alteration of NO/cGMP or RhoA/Rho-kinase signaling and/or vascular or neurogenic dysfunction, are potential targets for proposed phosphodiesterase type 5 inhibitors (PDE5-Is). Several randomized controlled trials and only a few reviews including all commercially available PDE5-Is demonstrated the safety and efficacy of these drugs in the improvement of erectile function and urinary symptoms, in patients affected either by ED, LUTS, or both conditions. [ABSTRACT FROM AUTHOR]

As men age, the incidence of benign prostatic hyperplasia and bothersome lower urinary tract symptoms increases. Until recently, treatment modalities focused on prostatic-directed management, but there has been a shift in focus as emerging research has implicated the bladder as a significant player in the development of lower urinary tract symptoms secondary to benign prostatic hyperplasia. Although initially avoided in this population, recent studies have demonstrated the safety and efficacy of antimuscarinics. Epidemiologic studies illustrating the link between erectile dysfunction and lower urinary tract symptoms then led to the investigation of phosphodiesterase-5 inhibitors for symptom management. Novel agents, including β adrenoreceptor agonists, are now being introduced in trials. These agents may offer the efficacy of an anticholinergic without the associated side effects. As future research develops, we are sure to see the introduction of a host of novel agents in the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia. [ABSTRACT FROM AUTHOR]

The two-micron (thulium) laser is the newest laser technique for treatment of bladder outlet obstruction resulting from benign prostatic hyperplasia (BPH). It takes less operative time than standard techniques, provides clear vision and lower blood loss as well as shorter catheterization times and hospitalization times. It has been identified to be a safe and efficient method for BPH treatment regardless of the prostate size. [ABSTRACT FROM AUTHOR]