Urology

Treating the elderly: challenges and prospects

Professors Dirk De Ridder and Francesco Montorsi chaired a plenary session covering the problems associated with the treatment and diagnosis of urological disorders in elderly patients.1

An overview of pathophysiological age-related changes affecting the lower urinary tract was presented by Professor Alan Weir. These included changes in morphology, metabolism, hormonal environment, physiology and cerebral control.1

Appropriate medications for the treatment or palliative care of elderly patients with LUT dysfunction were discussed by Dr Adrian Wagg. The Fit fOR The Aged (FORTA) classification scheme was also introduced: FORTA provides guidance on harmful or inappropriate drug choices for older patients.1

Dr Jean-Nicolas Cornu presented a state-of-the-art lecture on current surgical treatments for benign prostatic obstruction with a focus on elderly patients. The aims, tools and supporting evidence associated with the invasive treatment of men >75 years of age were discussed.

Elderly patients may have existing morbidities and can be more vulnerable to post-surgery changes in blood pressure, thromboembolism and loss of muscle mass.

Caution was advised when considering surgical options in elderly patients.1

Photovaporisation benefits elderly with prostate hyperplasia

Data from 2 different studies presented at EAU 2016 suggest that laser photovaporisation is effective and safe in patients ≥80 years of age with BPH.2

French researchers lead by Dr Pradère investigated 369 patients with BPH between 2005 and 2014. Of these, 147 were ≥80 years of age and 222 were <80 years of age. Following surgery, International Prostate Symptom Score (IPSS) was significantly lower in the younger men at 6 months compared with the older men, however by 12 months post-surgery, no difference in IPSS scores was found between the groups.2

The authors concluded that photovaporisation was both safe and effective in patients aged over 80 years.2

A British study lead by Dr Savvas Omorphos investigated 181 patients (mean age 74.8 years) who underwent photovaporisation for urinary retention over a 2-year period. In total, 59 (32.6%) of the patients were >80 years of age.2

Despite the relatively aged study population, deobstruction was achieved in 94.5% of cases.2

The authors propose that laser photovaporisation is highly suited for elderly patients, due to positive urinary functional outcomes and low risk of peri- and post-operative bleeding.2

Understanding personalised medical management for BPH patients at risk of progression

Chaired by Professor Peter Hammerer, this session focussed on individualised therapies and highlighted the importance of evidence-based approaches of BPH management, dependent on patient symptoms and needs.3

BPH is considered one of the most important contributing factors to the pathophysiology of LUTS in older men. LUTS can have a significant impact on patient quality of life in those with moderate-to-severe symptoms. However, each patient experiences his symptoms differently, and the degree to which the patients are bothered by their symptoms may vary. When a patient presents with LUTS, it is important to consider differential diagnoses, as there may be other causes besides BPH.3

There are a number of risk factors for progressive BPH, including increasing age, severity of LUTS, decreased urinary flow, prostate volume of 30–40 mL and prostate-specific antigen (PSA) level ≥1.6 ng/mL.3

Appropriate management can significantly decrease the risk of and delay progression of BPH.

To achieve optimal management of patients with BPH, it is important to listen to patients’ concerns, and to explain to and reassure them regarding their condition and how it can be best managed according to their individual needs. Importantly, appropriate patient expectations should be set from the outset and counselling is critical.3

Treatment adherence to BPH medical management is approximately 30%.

Patient counselling is particularly important, as adherence to BPH medical treatment is approximately 30%. The reasons for lack of adherence are varied, with 30% of patients discontinuing therapy because symptoms resolved, 24% due to lack of improvement in symptoms and 20% due to adverse drug reactions. Low adherence levels are associated with increased hospitalisation and need for surgery. In order to improve adherence, it is important to council patients to stay on therapy even if symptoms improve and to regularly follow up with patients to review their medical therapy.3

α-blockers (AB), 5α-reductase inhibitors (5ARIs) and their combination are the standard medical treatment for patients with bothersome LUTS due to BPH. Monotherapy with AB has been associated with a greater risk of hospitalisation versus 5ARI alone or in combination. There are also differences in the degree of efficacy between individual therapies. In the long term, ABs do not decrease the risk of acute urinary retention and need for surgery, as they have no effect on prostate volume, which continues to increase at a rate of around 4–5%/year. Therefore, combination therapy with a 5ARI should be considered.3

In the CombAT trial, AB/5ARI combination therapy resulted in significant improvements in LUTS and quality of life, and a reduction in the risk of acute urinary retention or BPH-related surgery compared with AB monotherapy at 4 years in patients with BPH, regardless of baseline PSA levels.3

In the CONDUCT trial, which enrolled treatment-naïve patients with moderate BPH, AB/5ARI combination therapy resulted in rapid and significant symptom improvement, and reduced the risk of clinical progression over a 2-year period versus watchful waiting with a step up to AB monotherapy. There was no symptom improvement with watchful waiting and lifestyle advice.3

Patients who are less bothered by their BPH symptoms respond better to watchful waiting and lifestyle advice.

Further analysis of the study population found that patients with a lower BPH impact index (BII) score before treatment, i.e. those who were less bothered by their symptoms, had better responses with watchful waiting and lifestyle advice. Over the long term, BII scores influence patient perception of symptomatic improvement, so change from baseline in IPSS with combination therapy was most pronounced in patients with the highest baseline BII. The results from CONDUCT are aligned with guideline recommendations that conservative management should be considered for men with mild LUTS and those with moderate LUTS who are not bothered by their symptoms.3

Evidence from the CombAT and CONDUCT trials support the use of AB plus 5ARI in combination for BPH patients at risk of progression to improve symptoms, slow disease progression and improve quality of life.3

New diagnostic tools in male LUTS

In this dedicated poster and short presentation session, chaired by Matthias Oelke and Andrea Tubaro, researchers from around the world explored the latest development of new LUTS diagnostic tools.4Highlights included:

A Cocci from the University of Florence, Italy, presented data from the European Male Ageing Study investigating the link between LUTS, adverse life events and depression. MG Park from Seoul, South Korea, discussed the effect of metabolic status on the correlation of serum vitamin D levels and BPH and hypogonadism. The predictive value of intravesical prostatic protrusion on post-operative outcomes of transurethral resection of the prostate for patients with BPH was presented by T Nur Budaya from Surabaya, Indonesia. SM Choi from Jinju, South Korea, presented a large-scale cohort study of the relationship between BPH and body mass index.

Reference list

1. EAU News. Treating the elderly: challenges and prospects. Uroweb. [Online] 14 March 2016.
2. Johnson K. Photovaporization benefits elderly with prostate hyperplasia. Medscape. [Online] 18 March 2016.
3. Understanding personalised medical management for BPH patients at risk of progression. Session at the Annual European Association of Urology 2016 Congress. [Online] 2016.
4. New diagnostic tools in male LUTS. Session at the Annual European Association of Urology 2016 Congress. [Online] 2016.