Benign prostatic hyperplasia | Medicina Clínica (English Edition)

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HBP: hiperplasia benigna de próstata; IPSS: International Prostate Symptoms Score; PDE5-I: inhibidores de la fosfodiesterasa 5; PSA: antígeno prostático específico; STUI: síntomas de tracto urinario inferior." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sarelis Infante Hernández, Juan Gómez Rivas, Jesús Moreno Sierra" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Sarelis" "apellidos" => "Infante Hernández" ] 1 => array:2 [ "nombre" => "Juan" "apellidos" => "Gómez Rivas" ] 2 => array:2 [ "nombre" => "Jesús" "apellidos" => "Moreno Sierra" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624004352" "doi" => "10.1016/j.medcle.2024.04.020" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624004352?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324003075?idApp=UINPBA00004N" "url" => "/00257753/0000016300000008/v1_202410210953/S0025775324003075/v1_202410210953/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020624004339" "issn" => "23870206" "doi" => "10.1016/j.medcle.2024.01.044" "estado" => "S300" "fechaPublicacion" => "2024-10-25" "aid" => "6622" "copyright" => "The Author(s)" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2024;163:415-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Trends in authorship in Medicina Clínica: an 11-year analysis of author gender" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "415" "paginaFinal" => "420" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tendencias en la autoría en Medicina Clínica: un análisis de 11 años sobre el género de los autores" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1509 "Ancho" => 2091 "Tamanyo" => 172215 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Flow chart of the articles in the Medicina clínica journal between the years 2012-2022 included in the study." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Xenia Artiga-Solana, Ernesto Muñoz-Mahamud, Andrés Combalia" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Xenia" "apellidos" => "Artiga-Solana" ] 1 => array:2 [ "nombre" => "Ernesto" "apellidos" => "Muñoz-Mahamud" ] 2 => array:2 [ "nombre" => "Andrés" "apellidos" => "Combalia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775324001921" "doi" => "10.1016/j.medcli.2024.01.044" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324001921?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624004339?idApp=UINPBA00004N" "url" => "/23870206/0000016300000008/v1_202410240712/S2387020624004339/v1_202410240712/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020624004340" "issn" => "23870206" "doi" => "10.1016/j.medcle.2024.04.019" "estado" => "S300" "fechaPublicacion" => "2024-10-25" "aid" => "6687" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Med Clin. 2024;163:404-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Editorial" "titulo" => "Early-onset colorectal cancer: should population screening be brought forward to 45 years of age, by when?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "404" "paginaFinal" => "406" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cáncer colorrectal de aparición temprana. ¿Hay que adelantar el cribado poblacional a los 45 años?, ¿para cuándo?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan J. Sebastián Domingo" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Juan J." "apellidos" => "Sebastián Domingo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775324003063" "doi" => "10.1016/j.medcli.2024.04.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324003063?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624004340?idApp=UINPBA00004N" "url" => "/23870206/0000016300000008/v1_202410240712/S2387020624004340/v1_202410240712/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Benign prostatic hyperplasia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "407" "paginaFinal" => "414" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sarelis Infante Hernández, Juan Gómez Rivas, Jesús Moreno Sierra" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Sarelis" "apellidos" => "Infante Hernández" "email" => array:1 [ 0 => "sarelis91@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan" "apellidos" => "Gómez Rivas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Jesús" "apellidos" => "Moreno Sierra" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Cirugía, Sección de Urología, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiperplasia benigna de próstata" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 856 "Ancho" => 1830 "Tamanyo" => 179667 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm of pharmacological treatment and clinical follow-up in males with LUTS/BPH. 5-ARI: 5-alpha reductase inhibitors; BPH: benign prostatic hyperplasia; IPSS: International Prostate Symptoms Score; PDE5-I: phosphodiesterase-5 inhibitors; PSA: prostate-specific antigen; LUTS: lower urinary tract symptoms." ] ] ] "textoCompleto" => "IntroductionBenign prostatic hyperplasia (BPH) is a histopathological definition associated with prostate gland enlargement, which can cause obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that lead a patient to the consultancy room.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>It is a disease associated with ageing and is on an upward trend, due to the increase in life expectancy. It affects 80% of men over 50 years of age, rising to 95% at around 80 years of age.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> This can be extrapolated to the prevalence in Spain, which is 11.8% in those over 40 years of age and up to 30% in those over 75 years of age.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The treatment of BPH complications has a significant impact not only on the individual’s quality of life but also on society’s economy and on the health system.<a class="elsevierStyleCrossRefs" href="#bib0025">5–7</a>Symptoms can be categorised according to the bladder cycle stage that is predominantly affected. This can be voiding (emptying) or storage (filling), with the former being more prevalent and the latter usually having a greater affect on the patients' quality of life (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0030">6</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Advances in medical treatment over the last 20 years have helped to decrease the use of surgical interventions. However, it is important to remember that medication will help to improve the symptoms but not cure the disease, as this can only be achieved by surgery. Therefore, understanding how to diagnose and treat lower urinary tract symptoms (LUTS) associated with BPH has become increasingly important.ObjectiveThe aim of this literature review is to summarise the available evidence on the diagnosis and treatment of BPH.Materials and methodsA literature search was conducted from 1996 to 2021 using a combination of the following Medical Subject Headings (MESH) terms: lower urinary tract symptoms, benign prostatic enlargement, medical treatment, surgical treatment, treatment/intervention. Medline, PubMed and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness to the topic of this review. Only articles published in English and Spanish were selected. Evidence was limited to human data.Synthesis of evidenceBPH is characterised by excessive proliferation of epithelial and stromal tissues, mainly in the prostate gland’s transition zone. Although the precise mechanism is still unclear, probable causes include metabolic, hormonal and inflammatory factors. Systemic vascular damage, such as atherosclerosis, to the vasculature supplying the prostate and bladder is thought to be a common link between cardiovascular risk factors and BPH.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>Patients with metabolic syndrome (MetS) show excessive stimulation of the sympathetic nervous system, leading to smooth muscle contraction via alpha-adrenergic receptors. Hormonally, both testosterone and dihydrotestosterone influence prostate growth, although the serum concentration of these hormones does not differ significantly between men with and without BPH.LUTS related to BPH are a frequent cause of consultation in primary care and urology. The medical evaluation should include obtaining a detailed history to understand the severity and characteristics of the symptoms (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), as well as the patient’s comorbidities, medication and lifestyle. A physical examination, including a digital rectal examination, is also essential during the initial evaluation, to assess prostate size and consistency.The use of validated questionnaires, such as the International Prostate Symptom Score (IPSS) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and the International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms (ICIQ-MLUTS), is recommended by clinical guidelines to assess and monitor symptoms. Voiding diaries are also useful for categorising symptoms and understanding the patient's voiding patterns.<a class="elsevierStyleCrossRef" href="#bib0050">10</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Urinalysis and additional tests, such as ultrasound bladder scanning and uroflowmetry, are useful in the initial evaluation of patients with LUTS. Prostate-specific antigen (PSA) determination is necessary but controversial, as high levels are not necessarily an indication of BPH or prostate cancer. Urethrocystoscopy and urine cytology are reserved for specific cases, such as haematuria or bothersome symptoms refractory to treatment.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>Medical management may include watchful waiting for patients with mild to moderate symptoms and minimal discomfort. This involves lifestyle changes and regular monitoring of symptoms. Patients should be warned about the possible progression of symptoms over time. Factors such as PSA, obstructive symptom score and prostate volume may influence the clinical progression of BPH.In summary, the evaluation and management of LUTS related to BPH requires a comprehensive understanding of the contributing factors and careful evaluation of the symptoms and clinical findings. A multidisciplinary approach that includes collaboration between primary care physicians and urological specialists is essential for effective management of this condition. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> summarises the initial diagnostic algorithm for patients with LUTS/BPH.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Pharmacological treatmentFactors that would indicate starting treatment are multiple and include patient preference, cost, availability of the necessary equipment for surgical procedures, and surgeon training. In general, starting treatment is not necessary as long as the symptoms remain mild and there is no deterioration in quality of life.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Alpha-adrenergic antagonistsAlpha-adrenergic antagonists are considered the first-line treatment for LUTS in men. These drugs decrease smooth muscle tone in the prostate and bladder by inhibiting the action of noradrenaline.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Symptom improvement is typically seen after four weeks of treatment, with a 30–40% reduction in the IPSS score. These drugs have been shown to significantly improve the symptom, quality of life, and the urinary flow rate scores. However, they do not reduce the risk of acute urinary retention or the need for surgery.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>We analysed the results of two open-label, observational studies in patients with LUTS suggestive of BPH that were conducted as part of the post-marketing surveillance of tamsulosin in Germany.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Patients were grouped into <61 years, 61 ±  70, and >70 years and treatment-associated IPSS reduction was measured, with a very similar result in all three age groups, with a mean reduction of nine points, corresponding to 50%. More importantly, 42% of patients had an IPSS 20 and 50% a peak flow achieved during micturition (Qmax) <10 mL/s before treatment, but only 5% and 15%, respectively, remained in that category after four weeks of treatment.Selective alpha-1 blockers, such as tamsulosin and silodosin, have fewer systemic side effects compared to non-selective ones, such as alfuzosin, doxazosin and prazosin, however, they have higher rates of retrograde ejaculation. Common side effects include dizziness, fatigue, orthostatic hypotension and nasal congestion. In 2005, an adverse ocular event known as intraoperative floppy iris syndrome (IFIS) associated with these drugs was reported during cataract surgery.5-alpha-reductase inhibitors5-alpha reductase inhibitors (5-ARIs) block the conversion of testosterone to dihydrotestosterone by inhibiting the type I and type II 5-alpha reductase enzymes. By reducing dihydrotestosterone levels, they result in a 20–25% decrease in prostate volume and a decrease in serum PSA by almost 50% after one year. These drugs significantly improve symptoms and urinary flow, reduce the risk of acute urinary retention and decrease the need for BPH-related surgery.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> However, it may take time to achieve maximal effect, so they are not suitable for short-term use.A 24-month trial of dutasteride in symptomatic men with prostate volumes >30 mL, moderate to severe symptoms, a peak flow rate of ≤15 mL/s and a serum PSA level of 1.5–10.0 ng/mL, showed that dutasteride reduced symptoms at least as much as tamsulosin, as well as improved flow rate, with decreased risk of acute urinary retention and possible surgery.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Side effects include erectile dysfunction, decreased libido, decreased ejaculate volume and gynecomastia. PSA levels should be taken into account when screening for prostate cancer.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Anticholinergics/antimuscarinicsThe action of antimuscarinic drugs is to block acetylcholine-mediated bladder contractions. The frequency and intensity of the bladder contractions thereby decrease.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> Although the detrusor contains five muscarinic receptor subtypes, the M2 and M3 receptors predominate, with M2 outnumbering M3 by a ratio of 3:1. However, detrusor contraction is mainly controlled by M3 receptors.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Available agents include both non-selective antagonists such as oxybutynin and selective antagonists such as solifenacin and tolterodine. In addition, other drugs such as darifenacin, fesoterodine, propiverine and trospium are also approved.Abrams et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> studied the effect of tolterodine in men with evidence of both urinary obstruction and overactive bladder. Inclusion criteria were frequency, urgency and a BOOI of 20 or greater. For 12 weeks, 222 randomised men received tolterodine 2 mg twice daily or placebo. Tolterodine significantly reduced BOOI (−9 vs. 0, p < 0.02) and increased peak cystometric capacity (67 mL, 95% confidence interval [CI] 35–103, p < 0.003) compared with placebo. The change in the postvoid residual (PVR) volume was significantly greater among patients treated with tolterodine (25 mL) than placebo (0 mL, p < 0.004). There was no significant difference in the incidence of adverse events.The European Association of Urology (EAU) recommends the use of anticholinergic drugs in men with moderate to severe LUTS who mainly have bladder storage symptoms and even then they should be prescribed with caution, and avoided in patients with postvoid residual volume greater than 150 mL.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Beta-3 agonistBeta-3 adrenoceptors are the predominant beta receptors expressed in the smooth muscle cells of the detrusor and their stimulation is thought to induce detrusor relaxation.Mirabegron is the first clinically available beta-3 agonist approved for use in adults with overactive bladder. A systematic review and meta-analysis of eight clinical trials involving 10,248 patients (27% male) where the efficacy and safety of 50 mg and 100 mg of mirabegron compared to 4 mg of tolterodine and a placebo was evaluated, concluded that mirabegron at both doses of 50 mg and 100 mg and tolterodine 4 mg were significantly associated with reduction in incontinence episodes, in mean number of micturitions, an improved voided volume, and reduction in urgency episodes per 24 h, compared to placebo.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>The most common treatment-related adverse events are high blood pressure, urinary tract infection (UTI), headache and nasopharyngitis. It is contraindicated in patients with severe uncontrolled hypertension, and it is recommended that blood pressure be measured before starting treatment and monitored regularly during treatment.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Phosphodiesterase 5 inhibitorsPhosphodiesterase 5 inhibitors (PDE5-I) increase intracellular cyclic guanosine monophosphate, which reduces smooth muscle tone of the the detrusor, prostate and urethra. Based on these relaxant effects and the association between LUTS and erectile dysfunction, their use in the treatment of male LUTS has been investigated.Three randomised placebo-controlled trials<a class="elsevierStyleCrossRefs" href="#bib0120">24–26</a> have demonstrated the efficacy of PDE5-I (sildenafil, tadalafil and vardenafil) in BPH-related LUTS, with significant improvements in symptom scores, but no effect on urinary flow rate or postvoid residual volume.To date, there are limited conclusions on efficacy or tolerability beyond one year. There is limited information on reduction of prostate size and no data on disease progression.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>PhytotherapyPhytotherapy involves the use of herbal preparations, which can be single or combined, and contain compounds such as phytosterols, ß-sitosterol, fatty acids and lectins. Although in vitro studies have shown anti-inflammatory, anti-androgenic and oestrogenic effects,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> their in vivo effects and precise mechanisms remain unclear.A meta-analysis compared the efficacy of Serenoa repens (saw palmetto) with and without hexane versus placebo and α1 blockers in men with LUTS.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> It was found that S. repens achieved no clinically significant improvement in short-term follow-up. However, it did show benefits after prolonged treatment, especially with the hexane-containing extract, which showed an improvement in IPSS score.European guidelines recommend the use of hexane-extracted S. repens for men wishing to avoid potential adverse effects, especially those related to sexual function, although it is noted that the magnitude of efficacy may be modest.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Combination therapyα-adrenergic antagonists (alpha-blockers) with 5α-reductase inhibitorsThe ComBAT study,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> a long-term, randomised, double-blind, placebo-controlled trial involving 4,844 men with moderate-severe LUTS (IPSS 12 or greater) and prostate size >30 cc, were randomised to dutasteride, tamsulosin or combination therapy over four years. Combination therapy reduced the relative risks of acute urinary retention by 68%, BPH-related surgery by 71% and symptom deterioration by 41% compared to tamsulosin alone.α-adrenergic antagonists with muscarinic receptor antagonistsFor patients with mixed symptomatology, monotherapy is often incomplete. Combination therapy is more effective in reducing urgency, urge urinary incontinence, voiding frequency, nocturia or IPSS compared with α1-blockers or placebo alone, and improves quality of life.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The EAU guidelines recommend using the drug combination for patients with moderate to severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> A summary of medical and/or conservative treatment of BPH is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Surgical approachThe EAU guidelines recommend a surgical procedure in case of renal failure secondary to outflow tract obstruction, refractory urinary retention secondary to outflow tract obstruction, recurrent UTIs, bladder stones or macroscopic haematuria due to BPH, patients refractory to medical treatment or unwilling to use other therapies.The choice of surgical technique will depend primarily on the size of the prostate, the patient's comorbidities, patient preferences, as well as the availability of surgical equipment and the surgeon's experience with the various surgical techniques.Currently we can divide the surgical approach into five sections: resection, enucleation, vaporisation, alternative ablative techniques, and non-ablative techniques.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Transurethral resectionTransurethral resection of the prostate (TURP) is the treatment of choice in the surgical management of men with a prostate size of 30−80 mL and moderate to severe LUTS secondary to BPH. It aims to remove bulky prostate tissue from the transition zone principally, which causes obstruction, and thus allows better urinary flow.Monopolar TURP delivered durable outcomes over a 22-year follow-up period. According to a systematic review and meta-analysis by Cornu et al.,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> which included a total of 69 clinical trials, no significant differences in terms of short-term efficacy were found between bipolar TURP and monopolar TURP. However, bipolar TURP was associated with a lower rate of peri-operative complications. Surgical time has also been associated with increased likelihood of complications, with longer surgical time significantly increasing the complication rate, and the procedure being safest when performed in under 90 min.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>EnucleationOpen laparoscopic and robotic prostatectomyIt is considered the oldest surgical treatment for patients with moderate to severe LUTS/BPH, especially with a prostate volume greater than 80−100 mL. They should be enucleated using the index finger, approaching from within the bladder (Freyer or suprapubic procedure) or through the anterior prostatic capsule (Millin or retropubic procedure).<a class="elsevierStyleCrossRef" href="#bib0160">32</a>The advantages of the retropubic technique over the suprapubic approach include direct visualisation of the adenoma during enucleation to ensure complete and direct removal, visualisation of the prostatic fossa after enucleation to control bleeding, as well as minimal or no surgical trauma to the bladder. And the most important advantage of the suprapubic approach over the retropubic approach is that it allows better visualisation of the bladder neck and ureteral orifices.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>Perioperative complications and morbidity of up to 42% have been reported, including prolonged catheterisation time, increased estimated blood loss with a transfusion rate of more than 24%, and increased length of hospital stay.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>The EAU guidelines recommend considering and offering open prostatectomy to patients with the aforementioned characteristics and in cases of absence of bipolar/monopolar transurethral enucleation of the prostate and holmium laser enucleation (HoLEP).<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Regarding laparoscopic prostatectomy, it was first described by Mariano et al.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> in 2002. It was performed using a transperitoneal approach, making a longitudinal incision from the prostatic capsule to the bladder neck. A systematic review by Garcia-Segui<a class="elsevierStyleCrossRef" href="#bib0180">36</a> compared the functional results between open and laparoscopic prostatectomy series, concluding that both techniques are equally effective in improving LUTS and voiding flow disturbances caused by BPH.Robotic-assisted prostatectomy was first described by Sotelo et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> in 2008. A systematic review<a class="elsevierStyleCrossRef" href="#bib0190">38</a> concluded that for LUTS patients with prostate glands larger than 80 mL, robotic-assisted prostatectomy is a good alternative, especially when laser systems or surgical skills in other procedures are not available. However, more studies on cost analysis and learning curve are needed.Holmium laser prostate enucleationThe Holmium (Ho:YAG) laser has been explored as an alternative in the treatment of BPH due to its precise cutting ability, immediate symptom relief and good level of haemostasis. It is considered similar to open prostatectomy in that it stays in the plane between the adenoma and the surgical capsule. The resected tissue is removed from the bladder through a morcellator, an endoscopic device that cuts and shreds the tissues. A systematic review of Holmium laser enucleation of the prostate (HoLEP) showed that it was at least as effective as TURP in improving LUTS.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>According to two meta-analyses,<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a> HoLEP has longer operation times, but shorter catheterisation and hospitalisation times, as well as reduced blood loss, hence fewer blood transfusions, but had no significant difference in the urethral strictures and stress urinary incontinence (SUI) rates compared to monopolar TURP.It has a long learning curve, so mentoring programmes are recommended to improve surgical performance, as the experience of the surgeon is the most important factor affecting the occurrence of complications in HoLEP.Aquablation or robotic hydroablation of the prostate glandIt uses the principle of hydro-dissection to ablate the prostatic parenchyma while sparing collageneous structures like blood vessels and the surgical capsule. It is an ablation therapy that combines ultrasound-guided robotics (AQUABEAM®, AquaBeam Robotic System, PROCEPT BioRobotics, San Jose, CA, USA) for selective, heat-free removal of prostate tissue.<a class="elsevierStyleCrossRef" href="#bib0210">42</a>The high-velocity saline stream is emitted from the distal end of the cutting probe and allows selective resection of prostate tissue while preserving blood vessels and the prostatic capsule. These structures contain a high content of collagen and elastin, which have strong intrinsic physical properties, allowing them to withstand resection with the saline stream, and during the procedure, the same device automatically calculates the water pressure according to the programmed resection depth and the position of the probe within the prostate.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>Gilling et al.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> conducted the first randomised, prospective, multicentre, double-blind, randomised control trial known as WATER comparing robotic hydroablation with TURP in patients with prostate sizes between 30 and 80 mL. They found a significantly shorter mean resection time in the robotic hydroablation arm compared to the TURP arm (3.9 min and 27.4 min, respectively, p < 0.001). However, they saw no significant change in total operative time (32.8 min and 35.5 min, respectively, p = 0.275).In terms of complications, haemorrhagic events have been observed in patients with a prostate volume between 80 and 150 mL according to the WATER II trial.<a class="elsevierStyleCrossRef" href="#bib0220">44</a>Alternative ablative techniques under investigation. Convective water vapour energy ablation (WAVE): the Rezum systemThe Rezum system is a transurethral ablative therapy that uses radiofrequency power to create thermal energy in the form of water vapour. This therapy involves employing the convective properties of water vapour, releasing large deposits of stored thermal energy (540 cal/mL H2 O) as the water vapour comes into contact with the tissue. The steam disperses rapidly and evenly through the interstices and condenses back into water, and thus ruptures cell membranes without a perceptible thermal gradient.The EAU guidelines state that randomised controlled trials against a reference technique are needed to confirm the results, and to evaluate mid- and long-term efficacy and safety.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Non-ablative techniquesUroliftIt is a minimally invasive procedure under local or general anaesthesia. It consists of compressing the hypertrophic prostate lobes by means of small permanent implants delivered under cystoscopic vision resulting in an opening of the prostatic urethra. Compression is applied laterally over the prostate lobe to compress it towards the capsule. The compression point is in the upper third between 10 and 2 o'clock.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>According to a systematic review by Jung at al.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> is less effective than TURP in improving LUTS in both the short and long term, but the outcomes on quality of life may be similar. Therefore, European guidelines recommend offering this procedure to men with LUTS interested in preserving ejaculatory function, with prostates <70 mL and no middle lobe.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Follow-upThe need for standardised and regular clinical follow-up is justified due to the clinical progression of BPH (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). According to EAU guidelines, follow-up varies according to the treatment chosen. For active follow-up, it is recommended to see the patient every six months and then annually, unless symptoms worsen or indications for surgery arise. During follow-up, tests such as uroflowmetry and ultrasound may be performed.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>For drug-treated patients, follow-up at four to six weeks is suggested to determine treatment response, followed by reviews every six months, and then annually if there is clinical improvement.For those on 5-ARI treatment, regular monitoring of PSA levels is recommended if life expectancy is greater than 10 years. A new baseline PSA should be determined at six months and any confirmed increase in PSA while taking 5-ARI should be evaluated.Finally, patients undergoing surgical treatment should be reviewed four to six weeks after bladder catheter removal. If there are no complications and they show clinical improvement, they can continue to be followed up in primary care, although any recurrence of symptoms should be referred to urology (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>ConclusionsLUTS in men are common, especially in an ageing population. The diagnosis and the decision as to when and how to treat them depends on the impact on the patient's quality of life, together with objective parameters such as residual volume after urination and uroflowmetry results, as well as the risk of disease progression and the presence of complications.The EAU guidelines recommend an individualised risk-based approach, which may include conservative, pharmacological or surgical management. TURP remains the main surgical option, but may be associated with adverse effects such as bleeding, retrograde ejaculation and post-RTU syndrome. In recent years, new less invasive surgical techniques have been developed, although some of them require further comparative studies for widespread recommendation.Ethical considerationsWe do not require informed consent as this is a review of published articles.FundingThis work has not received any funding.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2281799" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1898246" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2281798" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1898247" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Materials and methods" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Synthesis of evidence" "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Pharmacological treatment" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Alpha-adrenergic antagonists" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "5-alpha-reductase inhibitors" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Anticholinergics/antimuscarinics" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Beta-3 agonist" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Phosphodiesterase 5 inhibitors" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Phytotherapy" ] 7 => array:3 [ "identificador" => "sec0060" "titulo" => "Combination therapy" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "α-adrenergic antagonists (alpha-blockers) with 5α-reductase inhibitors" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "α-adrenergic antagonists with muscarinic receptor antagonists" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Surgical approach" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Transurethral resection" ] 10 => array:3 [ "identificador" => "sec0085" "titulo" => "Enucleation" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Open laparoscopic and robotic prostatectomy" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Holmium laser prostate enucleation" ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Aquablation or robotic hydroablation of the prostate gland" ] 3 => array:2 [ "identificador" => "sec0101" "titulo" => "Alternative ablative techniques under investigation. Convective water vapour energy ablation (WAVE): the Rezum system" ] ] ] 11 => array:3 [ "identificador" => "sec0105" "titulo" => "Non-ablative techniques" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Urolift" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Follow-up" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0120" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Ethical considerations" ] 10 => array:2 [ "identificador" => "sec0130" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0135" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-09" "fechaAceptado" => "2024-04-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1898246" "palabras" => array:3 [ 0 => "Lower urinary tract symptoms" 1 => "Benign prostatic hyperplasia" 2 => "Transurethral resection of prostate" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1898247" "palabras" => array:3 [ 0 => "Hiperplasia prostática benigna" 1 => "Síntomas del tracto urinario inferior" 2 => "Resección transuretral de próstata" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Benign prostatic hyperplasia (BPH) is a histopathologic definition associated with enlargement of the prostate gland that causes obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that are what bring patients for consultation.Urinary tract symptoms are common, especially in an increasingly aging population. Diagnosis and the decision on when and how to treat depend on the patient's quality of life and objective clinical parameters.An individualized, risk-based approach is necessary to guide conservative, pharmacologic, or surgical treatment." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La hiperplasia benigna de próstata (HBP) es una definición histopatológica asociada al crecimiento de la glándula prostática, que genera obstrucción del tracto urinario inferior y se manifiesta clínicamente con síntomas característicos que son los que conducen a los pacientes a la consulta.Los síntomas del tracto urinario son frecuentes, especialmente en una población cada vez más envejecida. Diagnosticarlos y decidir cuándo y cómo tratarlos depende de la afectación de la calidad de vida del paciente, junto con parámetros objetivos clínicos.Es necesario un enfoque individualizado basado en el riesgo para orientar a un tratamiento conservador, farmacológico o quirúrgico." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1118 "Ancho" => 1856 "Tamanyo" => 250311 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm for the initial diagnosis of patients with LUTS/BPH in primary care. BPH: benign prostatic hyperplasia; IPSS: International Prostate Symptoms Score; STI: sexually transmitted infection; UTI: urinary tract infection; PSA: prostate-specific antigen; LUTS: lower urinary tract symptoms." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1146 "Ancho" => 2150 "Tamanyo" => 169881 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Treatment algorithm using medical and/or conservative treatment options. 5-ARI: 5-alpha reductase inhibitors; PDE5-I: phosphodiesterase 5 inhibitors; LUTS: lower urinary tract symptoms." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 856 "Ancho" => 1830 "Tamanyo" => 179667 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm of pharmacological treatment and clinical follow-up in males with LUTS/BPH. 5-ARI: 5-alpha reductase inhibitors; BPH: benign prostatic hyperplasia; IPSS: International Prostate Symptoms Score; PDE5-I: phosphodiesterase-5 inhibitors; PSA: prostate-specific antigen; LUTS: lower urinary tract symptoms." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Filling \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Emptying \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postvoid \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urgency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weak stream \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Feeling of incomplete emptying \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shower urination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postvoid drip \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urgency Urinary Incontinence (UUI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Voiding delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nocturia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Straining \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3699818.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Filling, emptying and postvoid symptoms." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IPSS: International Prostate Symptom Score." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IPSS score \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptomatology \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0−7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scarcely symptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8−19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderately symptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20−35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severely symptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3699817.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Interpretation of the IPSS score." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "5-ARI: 5-alpha reductase inhibitors; BPH: benign prostatic hyperplasia; IPSS: International Prostate Symptoms Score; PSA: prostate-specific antigen; LUTS: lower urinary tract symptoms." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment modality \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up visits \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tests \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1st visit: 6 months2nd visit: 12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anamnesis about worsening symptoms. Fill in IPSSUroflowmetry and postvoid residual ultrasound may be requested. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pharmacological \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1st visit: 4th week-6th week2nd: 6 months3rd visit: 12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anamnesis aimed at tolerance and adverse effects of treatment. Fill in IPSS.In patients with 5-ARI, request PSA at the 2nd visit.Uroflowmetry and postvoid residual ultrasound may be requested. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1st visit: 4th week-6th week (after removal of the bladder catheter) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anamnesis and postoperative care.If there is improvement, there is no need for further follow-up in urology consultations. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3699816.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for patients with LUTS/BPH according to treatment modality." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:45 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathophysiology of benign prostatic hyperplasia and benign prostatic enlargement: a mini-review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. 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Review

Benign prostatic hyperplasia

Hiperplasia benigna de próstata

Sarelis Infante Hernándeza,

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sarelis91@gmail.com

Corresponding author.

, Juan Gómez Rivasa,b, Jesús Moreno Sierraa,b

a Servicio de Urología, Hospital Clínico San Carlos, Madrid, Spain

b Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Cirugía, Sección de Urología, Madrid, Spain

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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Algorithm of pharmacological treatment and clinical follow-up in males with LUTS&#47;BPH&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">5-ARI&#58; 5-alpha reductase inhibitors&#59; BPH&#58; benign prostatic hyperplasia&#59; IPSS&#58; <span class="elsevierStyleItalic">International Prostate Symptoms Score</span>&#59; PDE5-I&#58; phosphodiesterase-5 inhibitors&#59; PSA&#58; prostate-specific antigen&#59; LUTS&#58; lower urinary tract symptoms&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Benign prostatic hyperplasia &#40;BPH&#41; is a histopathological definition associated with prostate gland enlargement&#44; which can cause obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that lead a patient to the consultancy room&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is a disease associated with ageing and is on an upward trend&#44; due to the increase in life expectancy&#46; It affects 80&#37; of men over 50 years of age&#44; rising to 95&#37; at around 80 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> This can be extrapolated to the prevalence in Spain&#44; which is 11&#46;8&#37; in those over 40 years of age and up to 30&#37; in those over 75 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The treatment of BPH complications has a significant impact not only on the individual&#8217;s quality of life but also on society&#8217;s economy and on the health system&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Symptoms can be categorised according to the bladder cycle stage that is predominantly affected&#46; This can be voiding &#40;emptying&#41; or storage &#40;filling&#41;&#44; with the former being more prevalent and the latter usually having a greater affect on the patients&#39; quality of life &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Advances in medical treatment over the last 20 years have helped to decrease the use of surgical interventions&#46; However&#44; it is important to remember that medication will help to improve the symptoms but not cure the disease&#44; as this can only be achieved by surgery&#46; Therefore&#44; understanding how to diagnose and treat lower urinary tract symptoms &#40;LUTS&#41; associated with BPH has become increasingly important&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objective</span><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this literature review is to summarise the available evidence on the diagnosis and treatment of BPH&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A literature search was conducted from 1996 to 2021 using a combination of the following <span class="elsevierStyleItalic">Medical Subject Headings</span> &#40;MESH&#41; terms&#58; lower urinary tract symptoms&#44; benign prostatic enlargement&#44; medical treatment&#44; surgical treatment&#44; treatment&#47;intervention&#46; Medline&#44; PubMed and Scopus databases were searched&#46; Each article title and abstract was reviewed for relevance and appropriateness to the topic of this review&#46; Only articles published in English and Spanish were selected&#46; Evidence was limited to human data&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Synthesis of evidence</span><p id="par0035" class="elsevierStylePara elsevierViewall">BPH is characterised by excessive proliferation of epithelial and stromal tissues&#44; mainly in the prostate gland&#8217;s transition zone&#46; Although the precise mechanism is still unclear&#44; probable causes include metabolic&#44; hormonal and inflammatory factors&#46; Systemic vascular damage&#44; such as atherosclerosis&#44; to the vasculature supplying the prostate and bladder is thought to be a common link between cardiovascular risk factors and BPH&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with metabolic syndrome &#40;MetS&#41; show excessive stimulation of the sympathetic nervous system&#44; leading to smooth muscle contraction via alpha-adrenergic receptors&#46; Hormonally&#44; both testosterone and dihydrotestosterone influence prostate growth&#44; although the serum concentration of these hormones does not differ significantly between men with and without BPH&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">LUTS related to BPH are a frequent cause of consultation in primary care and urology&#46; The medical evaluation should include obtaining a detailed history to understand the severity and characteristics of the symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; as well as the patient&#8217;s comorbidities&#44; medication and lifestyle&#46; A physical examination&#44; including a digital rectal examination&#44; is also essential during the initial evaluation&#44; to assess prostate size and consistency&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The use of validated questionnaires&#44; such as the <span class="elsevierStyleItalic">International Prostate Symptom Score</span> &#40;IPSS&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and the <span class="elsevierStyleItalic">International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms</span> &#40;ICIQ-MLUTS&#41;&#44; is recommended by clinical guidelines to assess and monitor symptoms&#46; Voiding diaries are also useful for categorising symptoms and understanding the patient&#39;s voiding patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Urinalysis and additional tests&#44; such as ultrasound bladder scanning and uroflowmetry&#44; are useful in the initial evaluation of patients with LUTS&#46; Prostate-specific antigen &#40;PSA&#41; determination is necessary but controversial&#44; as high levels are not necessarily an indication of BPH or prostate cancer&#46; Urethrocystoscopy and urine cytology are reserved for specific cases&#44; such as haematuria or bothersome symptoms refractory to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Medical management may include watchful waiting for patients with mild to moderate symptoms and minimal discomfort&#46; This involves lifestyle changes and regular monitoring of symptoms&#46; Patients should be warned about the possible progression of symptoms over time&#46; Factors such as PSA&#44; obstructive symptom score and prostate volume may influence the clinical progression of BPH&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In summary&#44; the evaluation and management of LUTS related to BPH requires a comprehensive understanding of the contributing factors and careful evaluation of the symptoms and clinical findings&#46; A multidisciplinary approach that includes collaboration between primary care physicians and urological specialists is essential for effective management of this condition&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> summarises the initial diagnostic algorithm for patients with LUTS&#47;BPH&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pharmacological treatment</span><p id="par0070" class="elsevierStylePara elsevierViewall">Factors that would indicate starting treatment are multiple and include patient preference&#44; cost&#44; availability of the necessary equipment for surgical procedures&#44; and surgeon training&#46; In general&#44; starting treatment is not necessary as long as the symptoms remain mild and there is no deterioration in quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Alpha-adrenergic antagonists</span><p id="par0075" class="elsevierStylePara elsevierViewall">Alpha-adrenergic antagonists are considered the first-line treatment for LUTS in men&#46; These drugs decrease smooth muscle tone in the prostate and bladder by inhibiting the action of noradrenaline&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Symptom improvement is typically seen after four weeks of treatment&#44; with a 30&#8211;40&#37; reduction in the IPSS score&#46; These drugs have been shown to significantly improve the symptom&#44; quality of life&#44; and the urinary flow rate scores&#46; However&#44; they do not reduce the risk of acute urinary retention or the need for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We analysed the results of two open-label&#44; observational studies in patients with LUTS suggestive of BPH that were conducted as part of the post-marketing surveillance of tamsulosin in Germany&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Patients were grouped into &#60;61 years&#44; 61&#8239;&#177; &#8239;70&#44; and &#62;70 years and treatment-associated IPSS reduction was measured&#44; with a very similar result in all three age groups&#44; with a mean reduction of nine points&#44; corresponding to 50&#37;&#46; More importantly&#44; 42&#37; of patients had an IPSS 20 and 50&#37; a peak flow achieved during micturition &#40;Qmax&#41; &#60;10&#8239;mL&#47;s before treatment&#44; but only 5&#37; and 15&#37;&#44; respectively&#44; remained in that category after four weeks of treatment&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Selective alpha-1 blockers&#44; such as tamsulosin and silodosin&#44; have fewer systemic side effects compared to non-selective ones&#44; such as alfuzosin&#44; doxazosin and prazosin&#44; however&#44; they have higher rates of retrograde ejaculation&#46; Common side effects include dizziness&#44; fatigue&#44; orthostatic hypotension and nasal congestion&#46; In 2005&#44; an adverse ocular event known as intraoperative floppy iris syndrome &#40;IFIS&#41; associated with these drugs was reported during cataract surgery&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">5-alpha-reductase inhibitors</span><p id="par0090" class="elsevierStylePara elsevierViewall">5-alpha reductase inhibitors &#40;5-ARIs&#41; block the conversion of testosterone to dihydrotestosterone by inhibiting the type I and type II 5-alpha reductase enzymes&#46; By reducing dihydrotestosterone levels&#44; they result in a 20&#8211;25&#37; decrease in prostate volume and a decrease in serum PSA by almost 50&#37; after one year&#46; These drugs significantly improve symptoms and urinary flow&#44; reduce the risk of acute urinary retention and decrease the need for BPH-related surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However&#44; it may take time to achieve maximal effect&#44; so they are not suitable for short-term use&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A 24-month trial of dutasteride in symptomatic men with prostate volumes &#62;30&#8239;mL&#44; moderate to severe symptoms&#44; a peak flow rate of &#8804;15&#8239;mL&#47;s and a serum PSA level of 1&#46;5&#8211;10&#46;0&#8239;ng&#47;mL&#44; showed that dutasteride reduced symptoms at least as much as tamsulosin&#44; as well as improved flow rate&#44; with decreased risk of acute urinary retention and possible surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Side effects include erectile dysfunction&#44; decreased libido&#44; decreased ejaculate volume and gynecomastia&#46; PSA levels should be taken into account when screening for prostate cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Anticholinergics&#47;antimuscarinics</span><p id="par0105" class="elsevierStylePara elsevierViewall">The action of antimuscarinic drugs is to block acetylcholine-mediated bladder contractions&#46; The frequency and intensity of the bladder contractions thereby decrease&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Although the detrusor contains five muscarinic receptor subtypes&#44; the M2 and M3 receptors predominate&#44; with M2 outnumbering M3 by a ratio of 3&#58;1&#46; However&#44; detrusor contraction is mainly controlled by M3 receptors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Available agents include both non-selective antagonists such as oxybutynin and selective antagonists such as solifenacin and tolterodine&#46; In addition&#44; other drugs such as darifenacin&#44; fesoterodine&#44; propiverine and trospium are also approved&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Abrams et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> studied the effect of tolterodine in men with evidence of both urinary obstruction and overactive bladder&#46; Inclusion criteria were frequency&#44; urgency and a BOOI of 20 or greater&#46; For 12 weeks&#44; 222 randomised men received tolterodine 2&#8239;mg twice daily or placebo&#46; Tolterodine significantly reduced BOOI &#40;&#8722;9 vs&#46; 0&#44; p &#60;&#8239;0&#46;02&#41; and increased peak cystometric capacity &#40;67&#8239;mL&#44; 95&#37; confidence interval &#91;CI&#93; 35&#8211;103&#44; p&#8239;&#60;&#8239;0&#46;003&#41; compared with placebo&#46; The change in the postvoid residual &#40;PVR&#41; volume was significantly greater among patients treated with tolterodine &#40;25&#8239;mL&#41; than placebo &#40;0&#8239;mL&#44; p&#8239;&#60;&#8239;0&#46;004&#41;&#46; There was no significant difference in the incidence of adverse events&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The European Association of Urology &#40;EAU&#41; recommends the use of anticholinergic drugs in men with moderate to severe LUTS who mainly have bladder storage symptoms and even then they should be prescribed with caution&#44; and avoided in patients with postvoid residual volume greater than 150&#8239;mL&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Beta-3 agonist</span><p id="par0125" class="elsevierStylePara elsevierViewall">Beta-3 adrenoceptors are the predominant beta receptors expressed in the smooth muscle cells of the detrusor and their stimulation is thought to induce detrusor relaxation&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mirabegron is the first clinically available beta-3 agonist approved for use in adults with overactive bladder&#46; A systematic review and meta-analysis of eight clinical trials involving 10&#44;248 patients &#40;27&#37; male&#41; where the efficacy and safety of 50&#8239;mg and 100&#8239;mg of mirabegron compared to 4&#8239;mg of tolterodine and a placebo was evaluated&#44; concluded that mirabegron at both doses of 50&#8239;mg and 100&#8239;mg and tolterodine 4&#8239;mg were significantly associated with reduction in incontinence episodes&#44; in mean number of micturitions&#44; an improved voided volume&#44; and reduction in urgency episodes per 24&#8239;h&#44; compared to placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The most common treatment-related adverse events are high blood pressure&#44; urinary tract infection &#40;UTI&#41;&#44; headache and nasopharyngitis&#46; It is contraindicated in patients with severe uncontrolled hypertension&#44; and it is recommended that blood pressure be measured before starting treatment and monitored regularly during treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Phosphodiesterase 5 inhibitors</span><p id="par0140" class="elsevierStylePara elsevierViewall">Phosphodiesterase 5 inhibitors &#40;PDE5-I&#41; increase intracellular cyclic guanosine monophosphate&#44; which reduces smooth muscle tone of the the detrusor&#44; prostate and urethra&#46; Based on these relaxant effects and the association between LUTS and erectile dysfunction&#44; their use in the treatment of male LUTS has been investigated&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Three randomised placebo-controlled trials<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> have demonstrated the efficacy of PDE5-I &#40;sildenafil&#44; tadalafil and vardenafil&#41; in BPH-related LUTS&#44; with significant improvements in symptom scores&#44; but no effect on urinary flow rate or postvoid residual volume&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">To date&#44; there are limited conclusions on efficacy or tolerability beyond one year&#46; There is limited information on reduction of prostate size and no data on disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Phytotherapy</span><p id="par0155" class="elsevierStylePara elsevierViewall">Phytotherapy involves the use of herbal preparations&#44; which can be single or combined&#44; and contain compounds such as phytosterols&#44; &#223;-sitosterol&#44; fatty acids and lectins&#46; Although in vitro studies have shown anti-inflammatory&#44; anti-androgenic and oestrogenic effects&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> their in vivo effects and precise mechanisms remain unclear&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A meta-analysis compared the efficacy of <span class="elsevierStyleItalic">Serenoa repens</span> &#40;saw palmetto&#41; with and without hexane versus placebo and &#945;1 blockers in men with LUTS&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> It was found that <span class="elsevierStyleItalic">S&#46; repens</span> achieved no clinically significant improvement in short-term follow-up&#46; However&#44; it did show benefits after prolonged treatment&#44; especially with the hexane-containing extract&#44; which showed an improvement in IPSS score&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">European guidelines recommend the use of hexane-extracted <span class="elsevierStyleItalic">S&#46; repens</span> for men wishing to avoid potential adverse effects&#44; especially those related to sexual function&#44; although it is noted that the magnitude of efficacy may be modest&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Combination therapy</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">&#945;-adrenergic antagonists &#40;alpha-blockers&#41; with 5&#945;-reductase inhibitors</span><p id="par0170" class="elsevierStylePara elsevierViewall">The ComBAT study&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> a long-term&#44; randomised&#44; double-blind&#44; placebo-controlled trial involving 4&#44;844 men with moderate-severe LUTS &#40;IPSS 12 or greater&#41; and prostate size &#62;30 cc&#44; were randomised to dutasteride&#44; tamsulosin or combination therapy over four years&#46; Combination therapy reduced the relative risks of acute urinary retention by 68&#37;&#44; BPH-related surgery by 71&#37; and symptom deterioration by 41&#37; compared to tamsulosin alone&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">&#945;-adrenergic antagonists with muscarinic receptor antagonists</span><p id="par0175" class="elsevierStylePara elsevierViewall">For patients with mixed symptomatology&#44; monotherapy is often incomplete&#46; Combination therapy is more effective in reducing urgency&#44; urge urinary incontinence&#44; voiding frequency&#44; nocturia or IPSS compared with &#945;1-blockers or placebo alone&#44; and improves quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The EAU guidelines recommend using the drug combination for patients with moderate to severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A summary of medical and&#47;or conservative treatment of BPH is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Surgical approach</span><p id="par0180" class="elsevierStylePara elsevierViewall">The EAU guidelines recommend a surgical procedure in case of renal failure secondary to outflow tract obstruction&#44; refractory urinary retention secondary to outflow tract obstruction&#44; recurrent UTIs&#44; bladder stones or macroscopic haematuria due to BPH&#44; patients refractory to medical treatment or unwilling to use other therapies&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The choice of surgical technique will depend primarily on the size of the prostate&#44; the patient&#39;s comorbidities&#44; patient preferences&#44; as well as the availability of surgical equipment and the surgeon&#39;s experience with the various surgical techniques&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Currently we can divide the surgical approach into five sections&#58; resection&#44; enucleation&#44; vaporisation&#44; alternative ablative techniques&#44; and non-ablative techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Transurethral resection</span><p id="par0195" class="elsevierStylePara elsevierViewall">Transurethral resection of the prostate &#40;TURP&#41; is the treatment of choice in the surgical management of men with a prostate size of 30&#8722;80&#8239;mL and moderate to severe LUTS secondary to BPH&#46; It aims to remove bulky prostate tissue from the transition zone principally&#44; which causes obstruction&#44; and thus allows better urinary flow&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Monopolar TURP delivered durable outcomes over a 22-year follow-up period&#46; According to a systematic review and meta-analysis by Cornu et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> which included a total of 69 clinical trials&#44; no significant differences in terms of short-term efficacy were found between bipolar TURP and monopolar TURP&#46; However&#44; bipolar TURP was associated with a lower rate of peri-operative complications&#46; Surgical time has also been associated with increased likelihood of complications&#44; with longer surgical time significantly increasing the complication rate&#44; and the procedure being safest when performed in under 90&#8239;min&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Enucleation</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Open laparoscopic and robotic prostatectomy</span><p id="par0205" class="elsevierStylePara elsevierViewall">It is considered the oldest surgical treatment for patients with moderate to severe LUTS&#47;BPH&#44; especially with a prostate volume greater than 80&#8722;100&#8239;mL&#46; They should be enucleated using the index finger&#44; approaching from within the bladder &#40;Freyer or suprapubic procedure&#41; or through the anterior prostatic capsule &#40;Millin or retropubic procedure&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The advantages of the retropubic technique over the suprapubic approach include direct visualisation of the adenoma during enucleation to ensure complete and direct removal&#44; visualisation of the prostatic fossa after enucleation to control bleeding&#44; as well as minimal or no surgical trauma to the bladder&#46; And the most important advantage of the suprapubic approach over the retropubic approach is that it allows better visualisation of the bladder neck and ureteral orifices&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Perioperative complications and morbidity of up to 42&#37; have been reported&#44; including prolonged catheterisation time&#44; increased estimated blood loss with a transfusion rate of more than 24&#37;&#44; and increased length of hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The EAU guidelines recommend considering and offering open prostatectomy to patients with the aforementioned characteristics and in cases of absence of bipolar&#47;monopolar transurethral enucleation of the prostate and holmium laser enucleation &#40;HoLEP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Regarding laparoscopic prostatectomy&#44; it was first described by Mariano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> in 2002&#46; It was performed using a transperitoneal approach&#44; making a longitudinal incision from the prostatic capsule to the bladder neck&#46; A systematic review by Garcia-Segui<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> compared the functional results between open and laparoscopic prostatectomy series&#44; concluding that both techniques are equally effective in improving LUTS and voiding flow disturbances caused by BPH&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Robotic-assisted prostatectomy was first described by Sotelo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> in 2008&#46; A systematic review<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> concluded that for LUTS patients with prostate glands larger than 80&#8239;mL&#44; robotic-assisted prostatectomy is a good alternative&#44; especially when laser systems or surgical skills in other procedures are not available&#46; However&#44; more studies on cost analysis and learning curve are needed&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Holmium laser prostate enucleation</span><p id="par0235" class="elsevierStylePara elsevierViewall">The Holmium &#40;Ho&#58;YAG&#41; laser has been explored as an alternative in the treatment of BPH due to its precise cutting ability&#44; immediate symptom relief and good level of haemostasis&#46; It is considered similar to open prostatectomy in that it stays in the plane between the adenoma and the surgical capsule&#46; The resected tissue is removed from the bladder through a morcellator&#44; an endoscopic device that cuts and shreds the tissues&#46; A systematic review of Holmium laser enucleation of the prostate &#40;HoLEP&#41; showed that it was at least as effective as TURP in improving LUTS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">According to two meta-analyses&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a> HoLEP has longer operation times&#44; but shorter catheterisation and hospitalisation times&#44; as well as reduced blood loss&#44; hence fewer blood transfusions&#44; but had no significant difference in the urethral strictures and stress urinary incontinence &#40;SUI&#41; rates compared to monopolar TURP&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">It has a long learning curve&#44; so mentoring programmes are recommended to improve surgical performance&#44; as the experience of the surgeon is the most important factor affecting the occurrence of complications in HoLEP&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120"><span class="elsevierStyleItalic">Aquablation</span> or robotic hydroablation of the prostate gland</span><p id="par0250" class="elsevierStylePara elsevierViewall">It uses the principle of hydro-dissection to ablate the prostatic parenchyma while sparing collageneous structures like blood vessels and the surgical capsule&#46; It is an ablation therapy that combines ultrasound-guided robotics &#40;AQUABEAM&#174;&#44; AquaBeam Robotic System&#44; PROCEPT BioRobotics&#44; San Jose&#44; CA&#44; USA&#41; for selective&#44; heat-free removal of prostate tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">The high-velocity saline stream is emitted from the distal end of the cutting probe and allows selective resection of prostate tissue while preserving blood vessels and the prostatic capsule&#46; These structures contain a high content of collagen and elastin&#44; which have strong intrinsic physical properties&#44; allowing them to withstand resection with the saline stream&#44; and during the procedure&#44; the same device automatically calculates the water pressure according to the programmed resection depth and the position of the probe within the prostate&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Gilling et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> conducted the first randomised&#44; prospective&#44; multicentre&#44; double-blind&#44; randomised control trial known as WATER comparing robotic hydroablation with TURP in patients with prostate sizes between 30 and 80&#8239;mL&#46; They found a significantly shorter mean resection time in the robotic hydroablation arm compared to the TURP arm &#40;3&#46;9&#8239;min and 27&#46;4&#8239;min&#44; respectively&#44; p&#8239;&#60;&#8239;0&#46;001&#41;&#46; However&#44; they saw no significant change in total operative time &#40;32&#46;8&#8239;min and 35&#46;5&#8239;min&#44; respectively&#44; p&#8239;&#61;&#8239;0&#46;275&#41;&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In terms of complications&#44; haemorrhagic events have been observed in patients with a prostate volume between 80 and 150&#8239;mL according to the WATER II trial&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0101" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0121">Alternative ablative techniques under investigation&#46; Convective water vapour energy ablation &#40;WAVE&#41;&#58; the Rezum system</span><p id="par0275" class="elsevierStylePara elsevierViewall">The Rezum system is a transurethral ablative therapy that uses radiofrequency power to create thermal energy in the form of water vapour&#46; This therapy involves employing the convective properties of water vapour&#44; releasing large deposits of stored thermal energy &#40;540&#8239;cal&#47;mL H<span class="elsevierStyleInf">2</span> O&#41; as the water vapour comes into contact with the tissue&#46; The steam disperses rapidly and evenly through the interstices and condenses back into water&#44; and thus ruptures cell membranes without a perceptible thermal gradient&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">The EAU guidelines state that randomised controlled trials against a reference technique are needed to confirm the results&#44; and to evaluate mid- and long-term efficacy and safety&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Non-ablative techniques</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Urolift</span><p id="par0285" class="elsevierStylePara elsevierViewall">It is a minimally invasive procedure under local or general anaesthesia&#46; It consists of compressing the hypertrophic prostate lobes by means of small permanent implants delivered under cystoscopic vision resulting in an opening of the prostatic urethra&#46; Compression is applied laterally over the prostate lobe to compress it towards the capsule&#46; The compression point is in the upper third between 10 and 2 o&#39;clock&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">According to a systematic review by Jung at al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> is less effective than TURP in improving LUTS in both the short and long term&#44; but the outcomes on quality of life may be similar&#46; Therefore&#44; European guidelines recommend offering this procedure to men with LUTS interested in preserving ejaculatory function&#44; with prostates &#60;70&#8239;mL and no middle lobe&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Follow-up</span><p id="par0295" class="elsevierStylePara elsevierViewall">The need for standardised and regular clinical follow-up is justified due to the clinical progression of BPH &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; According to EAU guidelines&#44; follow-up varies according to the treatment chosen&#46; For active follow-up&#44; it is recommended to see the patient every six months and then annually&#44; unless symptoms worsen or indications for surgery arise&#46; During follow-up&#44; tests such as uroflowmetry and ultrasound may be performed&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0300" class="elsevierStylePara elsevierViewall">For drug-treated patients&#44; follow-up at four to six weeks is suggested to determine treatment response&#44; followed by reviews every six months&#44; and then annually if there is clinical improvement&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">For those on 5-ARI treatment&#44; regular monitoring of PSA levels is recommended if life expectancy is greater than 10 years&#46; A new baseline PSA should be determined at six months and any confirmed increase in PSA while taking 5-ARI should be evaluated&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Finally&#44; patients undergoing surgical treatment should be reviewed four to six weeks after bladder catheter removal&#46; If there are no complications and they show clinical improvement&#44; they can continue to be followed up in primary care&#44; although any recurrence of symptoms should be referred to urology &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0315" class="elsevierStylePara elsevierViewall">LUTS in men are common&#44; especially in an ageing population&#46; The diagnosis and the decision as to when and how to treat them depends on the impact on the patient&#39;s quality of life&#44; together with objective parameters such as residual volume after urination and uroflowmetry results&#44; as well as the risk of disease progression and the presence of complications&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">The EAU guidelines recommend an individualised risk-based approach&#44; which may include conservative&#44; pharmacological or surgical management&#46; TURP remains the main surgical option&#44; but may be associated with adverse effects such as bleeding&#44; retrograde ejaculation and post-RTU syndrome&#46; In recent years&#44; new less invasive surgical techniques have been developed&#44; although some of them require further comparative studies for widespread recommendation&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Ethical considerations</span><p id="par0325" class="elsevierStylePara elsevierViewall">We do not require informed consent as this is a review of published articles&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0330" class="elsevierStylePara elsevierViewall">This work has not received any funding&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of interest</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Alpha-adrenergic antagonists"
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              "titulo" => "5-alpha-reductase inhibitors"
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                  "titulo" => "&#945;-adrenergic antagonists with muscarinic receptor antagonists"
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              "titulo" => "Enucleation"
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                  "titulo" => "Open laparoscopic and robotic prostatectomy"
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                  "titulo" => "Aquablation or robotic hydroablation of the prostate gland"
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                  "titulo" => "Alternative ablative techniques under investigation&#46; Convective water vapour energy ablation &#40;WAVE&#41;&#58; the Rezum system"
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              "titulo" => "Non-ablative techniques"
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    "fechaRecibido" => "2023-10-09"
    "fechaAceptado" => "2024-04-03"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Benign prostatic hyperplasia &#40;BPH&#41; is a histopathologic definition associated with enlargement of the prostate gland that causes obstruction of the lower urinary tract and manifests clinically with characteristic symptoms that are what bring patients for consultation&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Urinary tract symptoms are common&#44; especially in an increasingly aging population&#46; Diagnosis and the decision on when and how to treat depend on the patient&#39;s quality of life and objective clinical parameters&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">An individualized&#44; risk-based approach is necessary to guide conservative&#44; pharmacologic&#44; or surgical treatment&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La hiperplasia benigna de pr&#243;stata &#40;HBP&#41; es una definici&#243;n histopatol&#243;gica asociada al crecimiento de la gl&#225;ndula prost&#225;tica&#44; que genera obstrucci&#243;n del tracto urinario inferior y se manifiesta cl&#237;nicamente con s&#237;ntomas caracter&#237;sticos que son los que conducen a los pacientes a la consulta&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas del tracto urinario son frecuentes&#44; especialmente en una poblaci&#243;n cada vez m&#225;s envejecida&#46; Diagnosticarlos y decidir cu&#225;ndo y c&#243;mo tratarlos depende de la afectaci&#243;n de la calidad de vida del paciente&#44; junto con par&#225;metros objetivos cl&#237;nicos&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Es necesario un enfoque individualizado basado en el riesgo para orientar a un tratamiento conservador&#44; farmacol&#243;gico o quir&#250;rgico&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Filling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Urgency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Weak stream&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Feeling of incomplete emptying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Shower urination&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postvoid drip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgency Urinary Incontinence &#40;UUI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Voiding delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nocturia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Straining&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab3699818.png"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Filling&#44; emptying and postvoid symptoms&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptomatology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#8722;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Scarcely symptomatic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#8722;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderately symptomatic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#8722;35&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Interpretation of the IPSS score&#46;</p>"
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                  \t\t\t\t">Anamnesis aimed at tolerance and adverse effects of treatment&#46; Fill in IPSS&#46;In patients with 5-ARI&#44; request PSA at the 2nd visit&#46;Uroflowmetry and postvoid residual ultrasound may be requested&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Surgical&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1st visit&#58; 4th week-6th week &#40;after removal of the bladder catheter&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Anamnesis and postoperative care&#46;If there is improvement&#44; there is no need for further follow-up in urology consultations&#46;&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:45 [
            0 => array:3 [
              "identificador" => "bib0005"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology of benign prostatic hyperplasia and benign prostatic enlargement&#58; a mini-review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Madersbacher"
                            1 => "N&#46; Sampson"
                            2 => "Z&#46; Culig"
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                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1159/000496289"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gerontology&#46;"
                        "fecha" => "2019"
                        "volumen" => "65"
                        "paginaInicial" => "458"
                        "paginaFinal" => "464"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30943489"
                            "web" => "Medline"
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hiperplasia benigna de pr&#243;stata&#58; una afecci&#243;n de elevada prevalencia en el paciente de edad avanzada"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Fern&#225;ndez Arjona"
                            1 => "I&#46; Pereira Sanz"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0211-139x(08)71148-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Geriatr Gerontol&#46;"
                        "fecha" => "2008"
                        "volumen" => "43"
                        "paginaInicial" => "44"
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                            "web" => "Medline"
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              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de s&#237;ntomas del tracto urinario inferior relacionados con la hiperplasia benigna de pr&#243;stata&#46; Estudio de 1804 hombres de 40 a&#241;os o m&#225;s residentes en Madrid durante 1999-2000"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; Fern&#225;ndez P&#233;rez"
                            1 => "J&#46; Moreno Sierra"
                            2 => "S&#46; Cano Escudero"
                            3 => "M&#46;E&#46; Fuentes Ferrer"
                            4 => "G&#46; Bocardo Fajardo"
                            5 => "A&#46; Silmi Moyano"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0210-4806(09)74001-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Urol Esp&#46;"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "43"
                        "paginaFinal" => "51"
                        "link" => array:1 [
                          0 => array:2 [
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                        "titulo" => "Hipertrofia Benigna de Pr&#243;stata &#40;HBP&#41; Frecuencia&#44; comorbilidad y uso de f&#225;rmaco&#44; datos procedentes de BDCAP-Base de Datos Cl&#237;nicos de Atenci&#243;n Primaria"
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                      "titulo" => "The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms&#58; prevalence and incident rates"
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                    0 => array:2 [
                      "doi" => "10.1016/j.ucl.2016.04.001"
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                        "paginaInicial" => "289"
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                      "titulo" => "Vascular damage as a risk factor for benign prostatic hyperplasia and erectile dysfunction"
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Article information

ISSN: 23870206
Original language: English

DOI:10.1016/j.medcle.2024.04.020

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