Tag Archive for: BPH

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Ejaculatory Function and Treatment for Male LUTS due to BPH

This month’s twitter-based international urology journal club discussed “Impact of Medical Treatments for Male LUTS due to BPH on Ejaculatory Function: A Systematic Review and Meta-analysis”, published online in the Journal of Sexual Medicine. The discussion was enriched by the participation of Asst. Prof. Giacomo Novara (@giacomonovara) of the University of Padua, the senior author of the paper.

There was general consensus that this was a well constructed paper addressing an important and sometimes neglected side-effect of a group of medications that most urologists use commonly. The principal messages of the paper were:

  1. Ejaculatory dysfunction (EjD) was significantly more common with alphablockers (ABs) in general than placebo
  2. This effect was mainly seen with selective ABs (tamsulosin and sildosin). Non-selective ABs (doxazosin and terazosin) had similar rates of EjD to placebo.
  3. Finasteride and dutasteride both cause EjD, and to a similar extent as each other.
  4. Combination therapy (5ARI + AB) resulted in a three-fold increase in EjD compared to either monotherapy

The authors were congratulated on the amount of work that had obviously gone into the analysis. There was a discussion of some of the technical aspects of how to conduct a systematic review (SR) and meta-analysis. The PRISMA guidelines are a mandatory standard, and are recommended to anyone considering undertaking one. @LoebStacy also recommended the Cochrane handbook as a useful source of info. @DrHWoo asked whether Jadad scores had been used to rate RCT quality. They were not used in this study, but are one method of assessing RCT quality for an SR. @chrisfilson and @jleow advocated the Cochrane Collaboration’s tool for risk of bias assessment (found in Section 8.5 of the handbook), as an alternative.

After the technical aspects, discussion focussed on how best to avoid EjD in men who are concerned about it. @linton_kate asked whether PDE5 inhibitors were an option in this regard. General consensus was that they are an option, especially where LUTS and erectile dysfunction (ED) coexist, but concerns were expressed about the cost (which varied country by country, but is generally far in excess of the cost of ABs) and by @nickbrookMD about the uncertainty surrounding their mechanism of action for LUTS improvement.

Several correspondants were using PDE5Is in clinical practice for this indication however, including @VMisrai. It was pointed out however, that alfuzosin also offers a reduced risk of EjD compared to other ABs, and is substantially less expensive than PDE5Is. Alfuzosin was not evaluated in this paper, however @giacomonovara agreed that it was an option in men with LUTS who wish to avoid EjD, especially where ED is not a concern. @DrHWoo pointed out the Rosen data demonstrating the correlation between increasing LUTS and decreasing erectile function, but indeed (as suggested by @JCLinMD) treatment of LUTS, e.g. with an AB, may in itself improve erectile function.

Discussion moved on to 5ARIs. @giacomonovara stated that these agents had a broad spectrum of potential effects on ejaculatory/erectile function. @shomik_S raised the issue of whether 5ARIs could cause irreversible sexual side-effects. This is certainly a medicolegal concern, and undoubtedly some men report persistent effects on libido and sexual function, although a firm causal link has not been established.

The medicolegal theme was further explored with a discussion on what to warn patients of when commencing these medications. All were agreed that patients commencing ABs/5ARIs, including those undergoing medical expulsive therapy for stones should be warned about EjD. There was some discussion however, about whether patients commencing a 5ARI should be warned about the increased rates of high-grade prostate cancer seen in the PCPT and REDUCE trials. This increase may be an artefact of more effective cancer detection, but none-the-less @loebStacy was of the opinion that it should be included in pre-treatment counselling.

 

But is all the concern about sexual side-effects justified? It was pointed out that many patients are prepared to tolerate sexual side-effects in return for improvement in their LUTS.

Regardless, this paper from @giacomonovara and co-authors provided useful insight and stimulated a valuable discussion. Undoubtedly, some patients are very concerned about EjD and this paper will help all urologists who treat male LUTS to address these concerns.

Winner of the Best Tweet Prize was David Gillatt for his response to the discussion regarding the needs of various nationalities for PDE5I. Special thanks to the SIU for offering a prize of free registration to the 2014 SIU Congress in Glasgow. Also special thanks to Wiley for allowing open access of the article for the May #urojc discussion.

Ben Jackson has completed urological training in the East Midlands, and is now undertaking a fellowship at St. Vincent’s Hospital, Sydney. His principal clinical interest is urologic oncology.
Twitter @Ben_L_Jackson

 

UroLift Takes Off From Down Under. The Potential Rewards When Engineers Bring You Into Their Inner Circle

At the American Urological Association meeting in San Antonio in May 2005, I was introduced to a four engineers from a small start up company called NC2 (New Company 2).  It had at that time been recently spun off from the medical device incubator company Exploramed.  They had no product and not even a prototype of a product that could possibly be used in humans but what they did have was a passion to make a difference, incredible ideas and a laptop computer. 

They had thought about the failings of existing mechanical treatments for LUTS/ BPH and the first that comes to your mind is prostatic stents.  No stent conforms perfectly to the shape of the prostatic urethra and there were the issues of encrustation of any elements of stent material that were exposed to the urine.  Rather than throw the baby out with the bathwater, they harnessed what was good about stents, which was the potentially immediate effects they could have on urinary function without associated destruction of tissue and that perhaps tailoring the radial expansion to just a few critical points rather than the entire length of the prostatic urethra could do the trick.

The original idea was that some sort of metallic disc could be placed outside the prostate capsule and one on the urethral side and between them, a non absorbable suture could be placed under tension and therefore draw open the prostatic urethra and defined sites.  How these engineers were to find a way of designing a delivery tool to do this had me a little skeptical at first but there seemed to be no doubt in their minds, even thought they had not yet worked it out, were going to find a way.  Their confidence, intellect and enthusiasm was infectious and you just felt like you wanted to be a part of this project.  It so turned out that the metallic discs would be replaced by linear metallic tabs which logically make for easier delivery.

So why involve Australians?  It is difficult to keep things under the radar and one way of doing so is to take the idea where it is less likely to be visible. Additionally, the data needed to be trustworthy and in a place where strong ethic committee governance structures exist. We make no illusion that for once, being Australian, gave us a clinical research opportunity from a company based in the US that would rarely be directed our way.

My Australian colleague, Dr Peter Chin was also brought in on the project.  Over the next few months, we did not hear anything but there was then an urgent call that ‘California was the place we ought to be’ so we literally dropped everything and headed over to Silicon Valley where we had the opportunity to use the first prototype of the device on human cadavers.  Whilst our travel costs were covered by NC2, we received no payment for our time spent during these exercises but remuneration was the last thing on our minds given the exciting path that the idea could potentially take.  Simultaneously, animal studies were being conducted and these demonstrated that the internal metallic tabs of the prosthesis would become covered by urothelium and in combination with the cadaveric work, provided a convincing argument to move forward with human clinical trials.

Putting on a brave face doing the first human Urolift case at Westmead Hospital in Sydney in December 2005

By December 2005, we were ready to conduct the first human trials.  We measured everything that could possibly move and it probably took close to 2 hours to perform the first case.  The initial prototype device used looked like it was literally built in somebody’s garage workshop but it was functional and confirmed proof in principle that a transurethral delivery system could deploy metallic tabs on the capsular side of the prostate and within the urethra that was connected by a tensioned suture. Through this, it created mechanical alteration to the anatomy of the prostatic urethra with positive influence on lower urinary tract symptoms.  From here, multiple clinical trials have been performed by the company that became known as Neotract Inc and as of 13 September 2013, the device received FDA approval.

It is enormous privilege to have played a role in product development from inception of an idea through to FDA approval.  These opportunities are rare and whilst healthy skepticism and caution should be applied to all ideas presented to you, if you are offered such an opportunity to take a side project, it could be a rewarding diversion from your daily clinical practice.  Financially, you will never recoup your time investment but the rewards of making a difference is priceless.

Shared passion for a project can go a long way.   This experience emphasizes the value of engineers interacting with clinicians to achieve a desired outcome and there is certainly room for of such interactions. Opportunities to embrace these relationships are out there and perhaps a good place to start is to become active in the Engineering and Urology Society which as a section of the Endourological Society meets each year at the AUA Annual Meeting.

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

Disclosure: Henry Woo has formerly been an investigator and advisor to Neotract Inc. He holds a small stock investment in the company.

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