On the natural history, diagnosis and treatment of benign prostatic hyperplasia

Sammanfattning: There are a number of important issues which remain unknown or poorly understood in the natural history of benign prostatic hyperplasia (BPH). The standard investigation of patients with BPH gives controversial results in relation to the severity of lower urinary tract symptoms (LUTS). Choosing an appropriate evaluation tool and effective treatment modality for these patients is a delicate task with several aspects to consider. The aim of the first study was to estimate the relationship between severity of LUTS, age, prostate volume, PSA and uroflowmetry. The natural history of bladder outlet obstruction (BOO) due to BPH is poorly understood as well. Thus, the aim of the second study was to determine whether routine clinical and urodynamic parameters are reliable to diagnose BOO, and we investigated the influence of idiopathic detrusor overactivity (IDO) on this condition. In the third study, the aim was to evaluate the durability of the effect of transurethral microwave thermotherapy (TUMT) in a large sample of men. A total of 323 patients treated with low-energy Program 2.0 and 129 patients treated with high-energy Program 3.5 were included in the analysis. Pressure-flow studies (pQS) have been proposed as a useful instrument for selection of graded treatment of BOO. The aim of the fourth study was to evaluate the long-term outcome of transurethral resection of the prostate (TURP) and low-energy TUMT in men with symptomatic BPH, when allocation to the treatment group was based on urodynamic diagnosis of BOO. In the fifth study we aimed to investigate morphological changes in the hyperplastic prostate tissue following microwave feedback thermotherapy, with use of magnetic resonance imaging (MRI). In addition, we investigated the influence of different structural features of the prostate, detectable with MRI, on the treatment. Prostate volume and serum PSA were significantly correlated and increased with advancing age. However, there was no relationship between symptoms and objective measures of BPE or severity of obstruction. The grade of BOO was more related to prostate volume, postvoid residual volume, and uroflow. BOO and IDO seem to be related conditions. High-energy TUMT in patients with higher grades of obstruction caused appreciable symptom relief with low retreatment rate at 2.5 years follow-up. Low-energy TUMT proved to be safe and effective treatment for symptomatic patients with lower grades of obstruction and showed fair results even at 8.8 years of follow-up. Our results indicate that with durable symptomatic improvement and lowest retreatment rate, TURP still presents a standard treatment option for patients with severe BOO. Coretherm microwave treatment caused significant intraprostatic necrosis, which was detectable with MR imaging both at 1 week and 6 months after the treatment. With MRI, it was possible to identify structural features of the prostate, which may predict the length of treatment and amount of energy needed.