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Purpose: Open simple prostatectomy (OSP) has been a cornerstone in treating large prostate volumes (> 80 ml) in benign prostatic hyperplasia (BPH). With evolving minimally invasive procedures like minimally invasive simple prostatectomy (MISP) and laser enucleation, the role of OSP needs contemporary evaluation. This way, we assessed the efficacy and safety of OSP to understand its current standing in the treatment of BPH, especially in comparison with newer surgical modalities. Methods: A comprehensive search of MEDLINE, Cochrane and EMBASE was conducted to include randomized controlled trials (RCTs) comparing OSP with other treatments for BPH from 1993 to 2023. A total of 10 RCTs were included in the meta-analysis. Data on various outcomes including IPSS, Qmax, PVR, quality of life, perioperative factors, and postoperative complications were analysed. Results: Our meta-analysis, covering 557 patients, confirms OSP's significant improvement in voiding symptoms and objective voiding metrics. However, it also reveals a higher incidence of postoperative complications, such as bleeding and transfusion requirements. The study found moderate to high heterogeneity in perioperative outcomes, indicating variations in surgical techniques and postoperative care. OSP remains a reliable option with an easily accessible and effective approach for managing large prostates, despite advancements in minimally invasive surgeries. Conclusion: OSP continues to be a relevant surgical option for BPH in large prostates, offering significant symptom relief. However, the associated higher morbidity warrants careful patient selection and highlights the need for continued research into optimizing surgical techniques and improving outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Although holmium laser enucleation (HoLEP) is considered a size‐independent procedure for treatment of an enlarged prostate, prostate artery embolization (PAE) is emerging as an alternative modality to treat moderate and large benign prostatic hyperplasia. This study aims to compare the early post‐operative and short‐term efficacy of PAE and HoLEP. Methods PubMed, Cochrane Library and EMBASE databases were searched. Network meta‐analysis was performed following PRISMA‐N‐guidelines. Post‐operative parameters analysed include international prostate symptom score (IPSS), quality of life (QOL), post‐void residual urine (PVR), maximal uroflow rate (Qmax) and serious adverse events (SAE). Random effects model calculated weighted mean differences (WMD). If 95%CI crossed the line of no effect (WMD = 0), evidence indicated no statistically significant difference between treatments compared. Results Qualitative and quantitative syntheses included 20 and 18 studies with 1991 and 1606 patients, respectively. At 3 months, there was no statistically significant difference between PAE and HoLEP in IPSS score improvement [WMD: −2.21: 95%CI: (−10.20, 5.78), favouring PAE], QoL score improvement [WMD: −0.22:95%CI: (−1.75, 1.32), favouring PAE] and PVR improvement [WMD: 26.97: 95%CI: (−59.53, 113.48), favouring HoLEP]. However, PAE was found inferior to HoLEP for Qmax improvement [WMD: 8.47, 95%CI: (2.89, 14.05), favouring HoLEP]. At 1‐year follow‐up, there was no statistically significant was found between PAE and HoLEP for IPSS score improvement [WMD:6.03, 95%CI: (−1.30, 13.35)], QoL score improvement [WMD: 0.03, 95%CI: (−1.19, 1.25)], PVR improvement [WMD:4.11, 95%CI: (−32.31, 40.53)] and Qmax improvement [WMD:2.60, 95%CI: (−2.20, 7.41)] with all differences favouring HoLEP. PAE was superior to HoLEP for SAE [PAE vs. HoLEP‐OR: 0.68, 95%CI: (0.25, 1.37)]. Conclusion HoLEP was superior to PAE at 3 months for Qmax improvement. There was no significant difference in IPSS, QoL, PVR and Qmax improvement at 1 year between PAE and HoLEP. PAE was also associated with lesser SAE compared to HoLEP. Studies on the long‐term outcome of PAE are needed to establish the durability of early outcomes after PAE.

Purpose: MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures. Methods: The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures. Results: We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment. Conclusion: MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process. [ABSTRACT FROM AUTHOR]

Objective We aimed to assess the success rate of the GreenLight laser photoselective vaporization of the prostate (GLL PVP) procedure for enlarged prostates in patients with and without preoperative long-term catheters. Methodology A retrospective data analysis was conducted on 46 patients. Data were collected from clinical health records and radiology images. The parameters studied in this analysis included the patient's age, prostate volume, medical management before surgery, and whether the patient had a catheter or not prior to the surgery. Results A total of 46 GLL PVP surgeries were performed over a 12-month period from May 2023 to May 2024 at West Middlesex University Hospital in London. Patients had a mean age of 73.2 ± 8.12 years, and their prostate volume was 57.7 ± 25.96 cc. Before the surgery, 14 cases (30%) were using long-term catheters, and 32 cases (70%) were not. Additionally, 40 cases (87%) were receiving medical management for lower urinary tract symptoms (LUTS). After the surgery, 39 cases (85%) passed their first trial without catheter (TWOC), and seven cases (15%) failed it, regardless of whether they had used catheters before the surgery. Patients using long-term catheters before the operation had a 71% success rate in passing their first TWOC and a 29% failure rate. Conclusion Our study found that GLL PVP has a significant positive impact on elderly individuals with a large prostate volume, regardless of whether they had long-term catheters or not prior to the operation. Additionally, our findings indicate that patients without preoperative long-term catheters experience significantly better outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Islam et al.)

Prostate gland and its enlargement is a common problem in aging males. Surgery may not be advisable in all cases of enlarged prostate, as the aging people often have other problems such as asthma, diabetes, and blood pressure (BP) and may not often be physically fit to undergo a safe surgery. Case studies were undertaken on two male patients of age 62 and 79 years, respectively. The parameters studied were ultrasonography, pre- and post-void urine volume, and serum prostatic-specific antigen (PSA) along with other physiological and biochemical parameters of BP and diabetes. The patients were tested after 7 days and also after 14 days of yoga practice. In case 1, it was seen that the prostate size, on sonography readings, was reduced from 144 to 37 cc by just 1 month of yoga practice. Prevoid urine volume was 230 ml and postvoid was 180 ml, and after 1 month of yoga practice, it was 694 ml and 19 ml, respectively. Serum PSA initially was 25.24 ng/ml, while at the time of posttesting, it was 0.82 ng/ml. In case 2, the postvoid urine volume was 50 ml initially. On the 14th day of yoga practice, it was nil. Serum PSA was 128.5 ng/ml at the time of pretesting, while on the 14th day, it was 16.35 ng/ml. The prostate size was 91 cc on sonography examination at preyoga testing, while on 14th day of yoga practice, it was 23.6 cc. The yoga module, used in this study, is recommended to be employed to help patients of enlarged prostate.

Background: Despite significant developments in transurethral surgery for benign prostatic hyperplasia, simple prostatectomy remains an excellent option for patients with severely enlarged glands. The objective is to describe our results of robot-assisted simple prostatectomy (RASP) with a modified urethrovesical anastomosis (UVA). Methods: From May 2011 to February 2014, RASP with UVA was performed in 34 patients by a single surgeon (O.C.) using the da Vinci S-HD surgical system. The UVA was performed between the bladder neck and urethral margin using the Van Velthoven technique. Demographic, perioperative, and outcome data were recorded. Complications were recorded with the Clavien–Dindo system. Results: The mean (standard deviation) age was 68 years (62–74 years). The median preoperative prostate volume (interquartile range) was 117 cc (99–146 cc). Operative time was 96 minutes (78–126 minutes), estimate blood loss was 200 mL (100–300 mL), and two (5.8%) patients required a blood transfusion. No conversion to open surgery was needed. The median specimen weight on pathological examination was 76 g (58–100 g). The average hospital stay was 2.2 days (1–4 days) and average Foley catheter time was 4.6 days (4–6 days). No intraoperative complications were recorded. There were seven (20.5%) postoperative complications, most of them Clavien less than or equal to Grade II. Conclusion: The results of our study show that RASP with UVA is a feasible, secure, and reproducible procedure with low morbidity. Additional series with larger patient cohorts are needed to validate this approach.

Background: Although holmium laser enucleation (HoLEP) is considered a size-independent procedure for treatment of an enlarged prostate, prostate artery embolization (PAE) is emerging as an alternative modality to treat moderate and large benign prostatic hyperplasia. This study aims to compare the early post-operative and short-term efficacy of PAE and HoLEP., Methods: PubMed, Cochrane Library and EMBASE databases were searched. Network meta-analysis was performed following PRISMA-N-guidelines. Post-operative parameters analysed include international prostate symptom score (IPSS), quality of life (QOL), post-void residual urine (PVR), maximal uroflow rate (Qmax) and serious adverse events (SAE). Random effects model calculated weighted mean differences (WMD). If 95%CI crossed the line of no effect (WMD = 0), evidence indicated no statistically significant difference between treatments compared., Results: Qualitative and quantitative syntheses included 20 and 18 studies with 1991 and 1606 patients, respectively. At 3 months, there was no statistically significant difference between PAE and HoLEP in IPSS score improvement [WMD: -2.21: 95%CI: (-10.20, 5.78), favouring PAE], QoL score improvement [WMD: -0.22:95%CI: (-1.75, 1.32), favouring PAE] and PVR improvement [WMD: 26.97: 95%CI: (-59.53, 113.48), favouring HoLEP]. However, PAE was found inferior to HoLEP for Qmax improvement [WMD: 8.47, 95%CI: (2.89, 14.05), favouring HoLEP]. At 1-year follow-up, there was no statistically significant was found between PAE and HoLEP for IPSS score improvement [WMD:6.03, 95%CI: (-1.30, 13.35)], QoL score improvement [WMD: 0.03, 95%CI: (-1.19, 1.25)], PVR improvement [WMD:4.11, 95%CI: (-32.31, 40.53)] and Qmax improvement [WMD:2.60, 95%CI: (-2.20, 7.41)] with all differences favouring HoLEP. PAE was superior to HoLEP for SAE [PAE vs. HoLEP-OR: 0.68, 95%CI: (0.25, 1.37)]., Conclusion: HoLEP was superior to PAE at 3 months for Qmax improvement. There was no significant difference in IPSS, QoL, PVR and Qmax improvement at 1 year between PAE and HoLEP. PAE was also associated with lesser SAE compared to HoLEP. Studies on the long-term outcome of PAE are needed to establish the durability of early outcomes after PAE., Competing Interests: Shivank Bhatia reports consulting fees from Embolx Inc. Grant funding and Travel Support from Merit Medical. Stock ownership of East End LLC. The remaining authors report no competing financial interests., (© 2023 The Authors. BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Background: The prostate undergoes gradual growth throughout men’s lives, resulting in development of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH). The aim of this review was to determine whether Thermobalancing could be used for conservative treatment of LUTS/BPH. Methods and Results: Men older than 55 with LUTS derived to BPH used Thermobalancing therapy enabled by therapeutic device as mono-therapy. The main group consisted of 124 patients with the prostate volume (PV) up to 60 ml, however, there were also men with the prostate volume (PV) over 60 ml that were studied separately. Before and after six months Thermobalancing the International Prostate Symptom Score (IPSS) lessened (p

Introduction: We investigated if "thermobalancing" therapy (TT), using Dr Allen's therapeutic device (DATD) in men with benign prostatic hyperplasia (BPH), can aid in understanding the etiology and pathophysiology of BPH.Methods: We compared urinary and other parameters of BPH patients who received TT over 6 months (treatment group) with those of healthy volunteers who had not received the treatment (control group). Dynamics of symptoms and indicators in each group were evaluated in comparison with their data at the beginning and end of the study. Parameters were the International Prostate Symptom Score (IPSS) for urinary symptoms and quality of life (QoL), ultrasound measurement of prostate volume (PV) and uroflowmetry (maximum flow rate, Qmax). TT effectiveness was examined in 124 men with BPH and PV <60 mL. We also investigated the data of five patients with BPH and PV >60 mL.Results: TT decreased urinary symptoms and PV, increased Qmax and improved QoL in men with BPH, PV <60 mL, and in men with BPH, PV >60 mL.Conclusions: The present study demonstrated that TT is effective for BPH, suggesting that blood circulation plays a crucial role in its cause. The continuous heat exposure that does not exceed the normal body temperature terminates the trigger of BPH development, "micro-focus" of hypothermia, and the following spontaneous expansion of capillaries. TT could be considered to be a useful tool in BPH treatment. [ABSTRACT FROM AUTHOR]

Prostate gland and its enlargement is a common problem in aging males. Surgery may not be advisable in all cases of enlarged prostate, as the aging people often have other problems such as asthma, diabetes, and blood pressure (BP) and may not often be physically fit to undergo a safe surgery. Case studies were undertaken on two male patients of age 62 and 79 years, respectively. The parameters studied were ultrasonography, pre- and post-void urine volume, and serum prostatic-specific antigen (PSA) along with other physiological and biochemical parameters of BP and diabetes. The patients were tested after 7 days and also after 14 days of yoga practice. In case 1, it was seen that the prostate size, on sonography readings, was reduced from 144 to 37 cc by just 1 month of yoga practice. Prevoid urine volume was 230 ml and postvoid was 180 ml, and after 1 month of yoga practice, it was 694 ml and 19 ml, respectively. Serum PSA initially was 25.24 ng/ml, while at the time of posttesting, it was 0.82 ng/ml. In case 2, the postvoid urine volume was 50 ml initially. On the 14th day of yoga practice, it was nil. Serum PSA was 128.5 ng/ml at the time of pretesting, while on the 14th day, it was 16.35 ng/ml. The prostate size was 91 cc on sonography examination at preyoga testing, while on 14th day of yoga practice, it was 23.6 cc. The yoga module, used in this study, is recommended to be employed to help patients of enlarged prostate. [ABSTRACT FROM AUTHOR]

Background: The prostate undergoes gradual growth throughout men's lives, resulting in development of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH). The aim of this review was to determine whether Thermobalancing could be used for conservative treatment of LUTS/BPH. Methods and Results: Men older than 55 with LUTS derived to BPH used Thermobalancing therapy enabled by therapeutic device as mono-therapy. The main group consisted of 124 patients with the prostate volume (PV) up to 60 ml, however, there were also men with the prostate volume (PV) over 60 ml that were studied separately. Before and after six months Thermobalancing the International Prostate Symptom Score (IPSS) lessened (p < 0.001), quality of life (QoL) index improved, ultrasound PV reduced (p < 0.001) and uroflowmetry maximum flow rate (Qmax) increased (p < 0.001). The dynamics of the same measurements in the watchful waiting or active surveillance control group have shown negative outcomes. Discussion and Conclusions: The observed positive effect of therapeutic device for BPH has allowed us to recommend this side-effect-free therapy in watchful waiting or active surveillance approach. Therefore, Thermobalancing can be used as safe physiotherapeutic solution for men with enlarged prostate in order to reduce LUTS. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the effect of dutasteride on quality of life of men with lower urinary tract symptoms associated with enlarged prostate or benign prostatic hyperplasia (BPH) as measured by symptom problem index (SPI), BPH-specific interference with activities (BSIA), BPH-specific psychological well-being (BPWB) and BPH-specific lifestyle adaptations (BSLA). Data were derived from three randomized, double-blind studies conducted in 4325 men treated with placebo or dutasteride (0.5 mg/day). Primary analyses included changes from baseline in mean SPI, BSIA, BPWB and BSLA scores. Men treated with dutasteride showed significant improvements in SPI, BSIA, BPWB and BSLA scores compared with placebo.Prostate Cancer and Prostatic Diseases (2008) 11, 129–133; doi:10.1038/sj.pcan.4500990; published online 26 June 2007 [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Both normal and pathological growth of the prostate is dependent on dihydrotestosterone (DHT) synthesis, which is catalysed by two 5α-reductase (5αR) isoenzymes, 5αR1 and 5αR2, of which only 5αR2 has traditionally been viewed as important in the prostate. The objective of this study was to evaluate the role of both isoenzymes during development/progression of prostate cancer. Methods: A thorough literature search was performed with the MEDLINE database to identify studies that have assessed expression of 5αR1/2 in prostate tissue. Results: DHT suppression data for the 5αR2-specific inhibitor, finasteride, and the dual 5αR1/2 inhibitor, dutasteride, show that both isoenzymes are active in benign prostate. Furthermore, immunostaining studies have shown that 5αR1 expression increases and 5αR2 expression decreases in prostatic intraepithelial neoplasia (PIN) and prostate cancer, compared with nonmalignant prostate tissue. Both isoenzymes appear increased in high-grade compared with low-grade localised cancer. Dual inhibition of both isoenzymes with dutasteride may, therefore, be effective in preventing or delaying the growth of prostate cancer. The 4-yr REduction by DUtasteride of prostate Cancer Events (REDUCE) trial is underway to test this hypothesis. Androgen-withdrawal therapy can reverse prostate tumour growth by reducing circulating testosterone. However, 5αR-catalysed DHT synthesis within the prostate can continue and most tumours eventually develop resistance to androgen-deprivation therapy. Full assessment of the role of a 5αR inhibitor in this scenario is warranted. Conclusions: The consensus of evidence to date shows that 5αR1 is present in the prostate, and that levels are higher in malignant compared with benign prostate hyperplasia tissue. [Copyright &y& Elsevier]

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Purpose: Increasingly, men with lower urinary tract symptoms (LUTS) are seeking treatment in the primary care setting. This article reviews the use of α-blockers and 5α-reductase inhibitors (5ARIs) in the management of LUTS and enlarged prostate. Data sources: Information is based on a critical review of the published literature. Relevant studies were identified using MEDLINE and review of reference lists of published studies. Conclusions: Enlargement of the prostate is a common occurrence among aging men. Nurse practitioners (NPs) are in a unique, frontline position to evaluate symptoms and bother and to recommend appropriate treatment of patients with enlarged prostate. Both α-blockers and 5ARIs are effective at reducing symptoms in the short term. However, only the 5ARIs impact disease progression and maintain improvement in symptoms in the long term. Implications for practice: NPs play an important role in assessing and treating LUTS in men with enlarged prostate. When treating men with LUTS, assess the severity of symptoms and the extent of prostate enlargement. For symptomatic men with enlarged prostate, long-term therapy with 5ARIs should be considered to treat symptoms as well as address the disease progression. [ABSTRACT FROM AUTHOR]

Abstract: Background:: Enlargement of the prostate is common among aging men, with an incidence of 90% by the age of 85 years. It is a progressive condition, with growth in prostate size accompanied by lower urinary tract symptoms that can result in long-term complications (eg, acute urinary retention [AUR], need for enlarged prostate-related surgery). Current pharmacologic treatment options include α-blockers (alfuzosin, doxazosin, tamsulosin, and terazosin) and 5α-reductase inhibitors (5ARIs) (finasteride and dutasteride). Objectives:: This article reviews the natural history of enlarged prostate and the data supporting management of this condition with α-blocker and 5ARI therapy, either as monotherapy or combination therapy, for symptomatic relief and a reduction in long-term disease progression. Methods:: Pertinent English-language articles were identified through a search of MEDLINE (1966-week 2, May 2006) using such search terms as 5α-reductase inhibitor, α-blocker, benign prostatic hyperplasia, dutasteride, efficacy, enlarged prostate, finasteride, and safety. Results:: Clinical trials of α-blockers in men with enlarged prostate have reported improvements in total symptom scores of 10% to 20% compared with placebo; however, these agents were not shown to reduce the risk of long-term complications or disease progression. Studies of the 5ARIs have reported significant reductions compared with placebo in the relative risk for AUR and enlarged prostate-related surgery, slowing of disease progression, and relief of symptoms. In studies of dutasteride, improvements in symptom scores were greater after 4 years of therapy compared with 2 years (−6.4 vs −4.3 points, respectively) and flow rates were better (2.6 vs 2.3 mL/sec). Six-year data for finasteride showed maintenance of the decreased risk for AUR and enlarged prostate-related surgery. Use of combination therapy with an α-blocker and a 5ARI may be of benefit in patients who require immediate relief of symptoms, with discontinuation of the α-blocker after several months of therapy. 5ARIs were generally well tolerated, with sexual dysfunction the most frequently reported adverse effect, although in only a small proportion of men (1%–8%). Conclusions:: The use of 5ARI therapy is a rational approach to symptom management and prevention of long-term negative outcomes in men with enlarged prostates.V 3 [Copyright &y& Elsevier]

Assessment and treatment of benign prostatic hyperplasia, or enlarged prostate, has evolved considerably in recent years; clear evidence has accumulated for the progression of disease over time, the association between disease progression and negative outcomes, and the potential for medical management of this condition. Commensurate with the long-term preventive role of primary care, efforts can and should be made to treat the underlying condition of enlarged prostate as well as to manage the symptoms short-term. This review outlines evaluation of men presenting with lower urinary tract symptoms, examines the challenges for medical treatment and suggests how treatment choice can address these challenges. [ABSTRACT FROM AUTHOR]

This US national survey evaluated beliefs and attitudes towards the enlarged prostate (EP) and its treatment among the men of a national sample aged ≥50 years in the US (400 with and 700 without EP), and a national sample of 100 primary care doctors and 100 urologists. The principal risk of EP was considered to be acute urinary retention among the majority of physicians, while the majority of patients believed it to be prostate cancer. In contrast to physicians’ beliefs, the majority of patients with moderate-to-severe symptoms are more concerned with long-term effects of EP than acute symptoms. Furthermore, they are willing to wait up to 3 months for symptom relief if treatment of the underlying condition is achieved. Doctors and patients agree that most patients want to avoid surgery but only 18% of surgery patients were told about drugs that could reduce the risk of surgery. These findings demonstrate significant differences between the beliefs and attitudes of patients and physicians towards EP. [ABSTRACT FROM AUTHOR]

Summary: A 53-year-old man who used growth hormone (GH), anabolic steroids and testosterone (T) for over 20 years presented with severe constipation and hypercalcaemia. He had benign prostatic hyperplasia and renal stones but no significant family history. Investigations showed - (1) corrected calcium (reference range) 3.66 mmol/L (2.2-2.6), phosphate 1.39 mmol/L (0.80-1.50), and PTH 2 pmol/L (1.6-7.2); (2) urea 21.9 mmol/L (2.5-7.8), creatinine 319 mmol/L (58-110), eGFR 18 mL/min (>90), and urine analysis (protein 4+, glucose 4+, red cells 2+); (3) creatine kinase 7952 U/L (40-320), positive anti Jo-1, and Ro-52 antibodies; (4) vitamin D 46 nmol/L (30-50), vitamin D3 29 pmol/L (55-139), vitamin A 4.65 mmol/L (1.10-2.60), and normal protein electrophoresis; (5) normal CT thorax, abdomen and pelvis and MRI of muscles showed 'inflammation', myositis and calcification; (6) biopsy of thigh muscles showed active myositis, chronic myopathic changes and mineral deposition and of the kidneys showed positive CD3 and CD45, focal segmental glomerulosclerosis and hypercalcaemic tubular changes; and (7) echocardiography showed left ventricular hypertrophy (likely medications and myositis contributing), aortic stenosis and an ejection fraction of 44%, and MRI confirmed these with possible right coronary artery disease. Hypercalcaemia was possibly multifactorial - (1) calcium release following myositis, rhabdomyolysis and acute kidney injury; (2) possible primary hyperparathyroidism (a low but detectable PTH); and (3) hypervitaminosis A. He was hydrated and given pamidronate, mycophenolate and prednisolone. Following initial biochemical and clinical improvement, he had multiple subsequent admissions for hypercalcaemia and renal deterioration. He continued taking GH and T despite counselling but died suddenly of a myocardial infarction., Learning Points: The differential diagnosis of hypercalcaemia is sometimes a challenge. Diagnosis may require multidisciplinary expertise and multiple and invasive investigations. There may be several disparate causes for hypercalcaemia, although one usually predominates. Maintaining 'body image' even with the use of harmful drugs may be an overpowering emotion despite counselling about their dangers.