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Background: It is unclear how cumulative multivariable effects of clinically relevant covariates impact response to pharmacological treatments for lower urinary tract symptoms (LUTS)/benign prostatic enlargement (BPE)., Objective: To develop models to predict treatment response in terms of International Prostate Symptom Score (IPSS) and the risk of acute urinary retention (AUR) or BPE-related surgery, based on large data sets and using as predictors baseline characteristics that commonly define the risk of disease progression., Design, Setting, and Participants: A total of 9167 patients with LUTS/BPE at risk of progression in three placebo-controlled dutasteride trials and one comparing dutasteride, tamsulosin, and dutasteride + tamsulosin combination therapy (CT) were included in the analysis to predict response to placebo up to 24 mo and active treatment up to 48 mo., Outcome Measurements and Statistical Analysis: Predictors included age, IPSS, total prostate volume (PV), maximum urinary flow rate (Q max ), prostate-specific antigen, postvoid residual urine (PVR), α-blocker usage within 12 mo, and randomised treatment. A generalised least-squares model was developed for longitudinal IPSS and a Cox proportional-hazards model for time to first AUR/surgery., Results and Limitations: The vast majority of patients benefit from dutasteride or CT when compared with tamsulosin alone. The predicted IPSS improvement with dutasteride or CT increased with greater PV and severity of symptoms at baseline. The tamsulosin effect was lower with greater baseline PV and tended to decrease over time. Predicted AUR/surgery risk was greater with tamsulosin versus CT or dutasteride; this risk increased with larger PV, higher PVR, and lower Q max (all at baseline). An educational interactive web-based tool facilitates visualisation of the results (www.bphtool.com). Limitations include: the placebo and active-treatment predictions are from different studies, the lack of similar studies for external validation, and the focus on a population at risk of progression from the 4-yr CombAT study., Conclusions: Predictive modelling based on large data sets and visualisation of the risk for individual profiles can improve our understanding of how risk factors for disease progression interact and affect response to different treatments, reinforcing the importance of an individualised approach for LUTS/BPE management., Patient Summary: We used data from previous studies to develop statistical models for predicting how men with lower urinary tract symptoms or benign prostate enlargement and at risk of disease complications respond to certain treatments according to their individual characteristics., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners in patient decisions about appropriate health care. Appropriate methodologies and rigorous strategies are required to achieve high-quality CPGs. However, several challenges may occur during the development of guidelines. This article highlights current hot topics related to the development of guidelines for the management of non-neurogenic male lower urinary tract symptoms (LUTS) including benign prostatic obstruction (BPO). Challenges include: (1) periodic updating of guidelines because of the rapid and continuous accumulation of new evidence and a range of emerging treatment options; (2) the requirements for inclusion of new interventions in guidelines; (3) inclusion of the values and preferences of patients with LUTS who have different needs and characteristics; and (4) a need to improve guideline implementation and adherence. Actions to overcome these challenges are also discussed. PATIENT SUMMARY: Guidelines are considered to improve the quality of clinical decisions by helping doctors and contributing to the consistency of care. The development and successful translation into clinical practice of guidelines on male lower urinary tract symptoms require management of several issues, including the identification and incorporation of patients' values and preferences., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Safety and efficacy of tamsulosin and tadalafil for men with benign prostatic enlargement (BPE) and/or erectile dysfunction (ED) are defined. However, there are only a few pilot studies on combination therapy with these drugs for men with lower urinary tract symptom (LUTS)/BPE and ED. Moreover, preliminary reports are limited to 12 wk, without any information about subsequent therapies., Objective: To evaluate the impact of discontinuation of tamsulosin versus tadalafil 12 wk after combination therapy., Design, Setting, and Participants: Fifty consecutive patients with moderate-to-severe LUTS (International Prostate Symptom Score [IPSS] > 7) and mild-to-severe ED (International Index of Erectile Function-5 [IIEF-5] < 22) were treated with combination therapy (tamsulosin 0.4mg/d plus tadalafil 5mg/d) for 12 wk. After 12 wk, 25 patients discontinued tamsulosin (Group TAD), while 25 patients discontinued tadalafil (Group TAM)., Outcome Measurements and Statistical Analysis: Efficacy variables were IPSS (total, voiding, storage) and IIEF-5. Paired samples t test and analysis of variance were used., Results and Limitations: Groups TAD and TAM presented similar features (age, BMI, metabolic profile) including symptoms scores at baseline. Similar and significant improvements in IPSS (total, voiding, and storage) and IIEF-5 were recorded in both groups after 12 wk of combination therapy (all p< 0.001). Total IPSS was similar between the two groups at the end of the trial. However, we found between-group significant differences from baseline to 24 wk and from 12 to 24 wk in storage-IPSS (Group TAD: -3.32 vs Group TAM: -1.24, p= 0.002; Group TAD: +0.24 vs Group TAM: +1.20, p= 0.040, respectively) and in IIEF-5 (Group TAD: +4.64 vs Group TAM: +0.16, p< 0.001; Group TAD: -1.64 vs Group TAM: -4.40, p= 0.003). No significant treatment-related adverse event was recorded in both groups., Conclusions: After 12 wk of combination therapy, monotherapy with tadalafil for further 12 wk allows to preserve the improvement of storage IPSS and IIEF-5, in addition to total IPSS., Patient Summary: In this report we evaluated the discontinuation of tamsulosin or tadalafil after 12 wk of combination therapy. We found that tadalafil monotherapy, for a further 12 wk, aids in retaining the improvement of storage symptoms and erectile function., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Determining whether members follow guidelines, including guidelines prepared to help direct practice management during the coronavirus disease 2019 (COVID-19) pandemic, is an important goal for medical associations., Objective: To determine whether practice of urologists is in line with guidelines for the management of common urological conditions during the COVID-19 pandemic produced by leading (inter)national urological associations., Design, Setting, and Participants: Self-selected urologists completed a voluntary survey available online from March 27 to April 11, 2020 and distributed globally by the Société Internationale d'Urologie., Outcome Measurements and Statistical Analysis: Responses to two survey questions on the (1) management of 14 common urological procedures and (2) priority scoring of 10 common urological procedures were evaluated by practice setting and geographical region using chi-square and one-way analysis of variance analyses, respectively., Results and Limitations: There were 2494 respondents from 76 countries. Oncological conditions were prioritised over benign conditions, and benign conditions were deferred when feasible and safe. Oncological conditions with the greatest malignant potential were prioritised over less aggressive cancers. Respondents from Europe were least likely to postpone and most likely to prioritise conditions identified by guidelines as being of the highest priority. Respondents' priority scoring of urological procedures closely matched the priorities assigned by guidelines. The main limitation of this study is that respondents were self-selected, and access to the survey was limited by language and technology barriers., Conclusions: Prioritisation and management of urological procedures during the COVID-19 pandemic are in line with current guidelines. The greatest agreement was reported in Europe. Observed differences may be related to limited resources in some settings., Patient Summary: When deciding how best to treat patients during the coronavirus disease 2019 (COVID-19) pandemic, urologists are taking into account both expert recommendations and the availability of important local resources., (Copyright © 2020 European Association of Urology. All rights reserved.)

Context: A large number of minimally invasive techniques have been developed for the surgical management of male lower urinary tract symptoms (LUTS) presumed to be secondary to benign prostatic obstruction (BPO) over the last 3 decades. Many have not stood the test of time often because they were overpromoted before there were sufficient data., Objective: The scope of this paper is to consider whether new devices, for the treatment of male LUTS/BPO, have been implemented prematurely in the past. We also examine the relative certainty of evidence (CoE) that is currently available for newer developing technologies and make recommendations about the CoE that should be demanded in the future before widespread implementation., Key Messages: This evidence must provide adequate length of follow-up to allow proper information to be provided for patients before treatment choices are made and to be able to create recommendations in high-quality guidelines such as those of the European Association of Urology. It is not just within the domain of LUTS treatments that this is important, other urological devices, such as mesh devices, have been equally "guilty" and likewise devices in most other (surgical) specialities. We believe that there is a need for a set of requirements built around primary randomised controlled trials (RCTs) looking at both efficacy and safety, and secondary studies to confirm the reproducibility and generalisability of the first pivotal studies. Otherwise, there is a danger that a single pivotal study can be overexploited by device manufacturers. Studies that are needed include (1) proof of concept, (2) RCTs on efficacy and safety, as well as (3) cohort studies with a broad range of inclusion and exclusion criteria to confirm both reproducibility and generalisability of the benefits and harms. It is not the purpose of this paper to make judgements about individual treatments but simply to look at different treatments to provide verification for this debate., Patient Summary: Many new treatment devices have been developed over the last 20-30 yr, often with inadequate medium- to long-term results. Many have not stood the test of time, but were heavily promoted by manufacturers, the press, and some doctors when they were first released, meaning that many patients had unsatisfactory results. This paper proposes minimum standards for the investigation of new treatments before their widespread promotion to patients., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

It is well known that lower urinary tract symptoms (LUTS) have a multifactorial etiology. Therefore, there is an increased need for improved diagnostics for the optimal assessment of patients with LUTS in order to identify the various causes of symptoms and improve disease phenotyping. Research has focused on the development of improved urodynamic technologies and the development of noninvasive tests that could replace urodynamic studies. This mini-review will present the most recently published studies on the topic including new technologies in the diagnosis of bladder outlet obstruction, novel metrics for bladder sensation, analysis of filling phase rhythm, measurement of detrusor wall tension, and brain imaging during urodynamic studies., Patient Summary: Lower urinary tract symptoms (LUTS) have a multifactorial etiology; therefore there is a need for the development of new tests that can help LUTS diagnosis. The present mini-review highlights the new tests and novel concepts in the field., (Copyright © 2018. Published by Elsevier B.V.)