Aktuelle Aspekte zur Epidemiologie, Diagnostik und Therapie des Benignen Prostatasyndroms

Zusammenfassung

Hintergrund: Nach Veröffentlichung neuer nationaler und internationaler Leitlinien zur Diagnostik und Therapie des benignen Prostatasyndroms (BPS) wurde eine Neubewertung von etablierten Untersuchungen und Therapien vorgenommen. Dieser Artikel beschreibt die aktuellen Tendenzen und deren Stellenwert hinsichtlich Epidemiologie, Diagnostik und Therapie des BPS. Material und Methoden: Die Diagnostik- und Therapieleitlinien zum BPS der DGU, EAU, AUA, NICE wurden hinsichtlich Schlüsselartikel und neuesten Erkenntnissen analysiert. Ergebnisse: Die einzige deutsche epidemiologische Untersuchung zum BPS zeigte, dass alle Komponenten (Symptomatik, Prostatavergrößerung, Blasenauslassobstruktion) altersabhängig zunehmen. 27 % der deutschen Männer werden innerhalb von 5 Jahren eine Krankheitsprogres­sion haben. Risikofaktoren hierfür sind höheres Lebensalter, Symptomatik, Prostatavergrößerung bzw. PSA, Harnstrahlstärke und Restharn. Ziel der empfohlenen Diagnostik besteht in der Abgrenzung des BPS von anderen Erkrankungen mit ähnlicher Symptomatik, Quantifizierung der Teilkomponenten sowie Abschätzung des individuellen Progressionsrisikos. Das BPS wird durch keine Untersuchung direkt nachgewiesen, sondern ist eine Ausschlussdiagnose. Die Ultraschallmessung der Detrusordicke bei ≥ 250 ml ist eine Zusatzuntersuchung, die bei ≥ 2 mm sicher eine Blasenauslassobstruktion nachweist. Kontrolliertes Zuwarten und Verhaltenstherapie kommen für Männer mit milder Symptomatik und geringem Progressionsrisiko in Frage. Alle Medikamente reduzieren die Symptomatik, aber haben keinen Einfluss auf die Obstruktion. α-Blocker sind Medikamente der ersten Wahl und können bei irrita­tiven Symptomen mit Anticholinergika oder bei erhöhtem Progressionsrisiko mit 5α-Reduk­tase-Inhibitoren kombiniert werden. Die Kombinationstherapie ist effektiver als die Monotherapie. Bei Versagen der medikamentösen Therapie, absoluten Operationsindikationen oder starker Blasenauslassobstruktion sollte Prostatagewebe zur effektiven Beseitigung der Obstruktion abladiert werden. Standardoperationen sind die TURP bei geringem und die offene Adenomenukleation bei großem Prostatavolumen. Alternative operative Verfahren können bei ausgewählten Patienten eingesetzt werden und weisen Vorteile hinsichtlich Blutungsrisiko, Katheterliegedauer oder Sexualfunktion auf. Schlussfolgerungen: Aktuelle Leitlinien liefern eine effektive Grundlage zur verbesserten Abklärung und Behandlung von Patienten mit BPS. 

Abstract

Background: A re-evaluation of established tests and treatments has become necessary after publication of several new guidelines on BPH during the past two years. This article describes the latest developments concerning epidemiology, diagnosis, and treatment of BPH. Material and Methods: Diagnostic and treatment guidelines on BPH of the German, European, or North American urologists as well as UK doctors were reviewed according to key articles and latest modifications. Results: The only German epidemiological trial on BPH demonstrated that all components of the BPH disease (symptoms – prostate enlargement – bladder outlet obstruction) increase with ageing. 27 % of German men will have disease progression within the next 5 years. Risk factors for disease progression are: age, symptoms, prostate size, PSA, urinary flow rate, and postvoiding residual urine. Diagnosis aims to distinguish BPH from other diseases with similar symptoms, quantify the BPH components, and estimate the individual risk of disease progression. BPH is an exclusion diagnosis. Ultrasonic measurement of detrusor wall thickness at the anterior wall of bladders filled with ≥250 mL can securely detect bladder outlet obstruction if the value is ≥ 2 mm. Watchful waiting and lifestyle modifications are suitable for men with mild symptoms and low disease progression risk. All drugs used in BPH treatment reduce symptoms but have no influence on bladder outlet obstruction. α-blockers are first-line drugs and may be combined with muscarinic receptor antagonists or 5α-reductase inhibitors to further increase efficacy. Prostate surgery is indicated when drug treatment is insufficient, the patient develops complications in the upper or lower urinary tract (absolute indications), or has severe bladder outlet obstruction. Standard operations are TURP in small (≤ 80 mL) or open prostatectomy in large prostates (> 80 mL). Minimally invasive, alter­native surgeries may be considered in selected men and ­offer advantages with regard to the risk of bleeding, duration of catheterisation, or maintenance of sexual function. Conclusions: Current guidelines have integrated the latest knowledge and developments on BPH and are likely to improve assessment and treatment. 

Schlüsselwörter

benignes Prostatasyndrom - Symptome des unteren Harntraktes - Risikoabklärung - Diagnose - Therapie

Key words

benign prostatic hyperplasia - lower urinary tract symptoms - risk assessment - diagnosis - therapy

Literatur

• 1 Berry S J, Coffey D S, Walsh P C et al. The development of human benign prostatic hyperplasia with age.  J Urol. 1984;  132 474-479
• 2 Berges R R, Pientka L, Höfner K et al. Male lower urinary tract symptoms and related health care seeking in Germany.  Eur Urol. 2001;  39 682-687
• 3 Berges R, Oelke M. Age-stratified normal values for prostate volume, PSA, maximum urinary flow rate, IPSS, and other LUTS / BPH indicators in the German male community-dwelling population aged 50 years or older.  World J Urol. 2011;  29 171-178
• 4 Berges R. Epidemiology of benign prostatic syndrome. Associated risks and management data in German men over age 50.  Der Urologe. 2008;  47 141-148
• 5 Jimenez-Cruz F. Identifying patients with lower urinary tract symptoms / benign prostatic hyperplasia (LUTS / BPH) at risk for progression.  Eur Urol. 2003;  6-12
• 6 McConnell J D, Roehrborn C G, Bautista O et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia.  N Engl J Med. 2003;  349 2387-2398
• 7 Hutchison A, Farmer R, Chapple C et al. Characteristics of patients presenting LUTS / BPH in six European countries.  Eur Urol. 2006;  50 555-562
• 8 Kok E, Groeneveld F, Gouweloos J et al. Determinants of seeking of primary care for lower urinary tract symptoms: The Krimpen Study in community-dwelling men.  Eur Urol. 2006;  50 811-817
• 9 Berges R, Dreikorn K, Höfner K et al. Diagnostik und Differenzialdiagnostik des benignen Prostatasyndroms (BPS). Leitlinie der Deutschen Urologen.  Urologe. 2009;  48 1356-1365
• 10 Roehrborn C G. BPH progression: concept and key learning from MTOPS, ALTESS, COMBAT, and ALF-ONE.  BJU Int. 2008;  101 17-21
• 11 Oelke M, Höfner K, Jonas U et al. Diagnostic accuracy of noninvasive tests to evaluate bladder outlet obstruction in men: detrusor wall thickness, uroflowmetry, postvoid residual urine, and prostate volume.  Eur Urol. 2007;  52 827-835
• 12 Rule A D, Jacobson D J, McGree M E et al. Longitudinal changes in post void residual and voided volume among community dwelling men.  J Urol. 2005;  174 1317-1321
• 13 Brookman-May S, Burger M, Hoschke B et al. Assoziation zwischen Restharnvolumen und Harnwegsinfektion. Prospektive Studie an 225 Männern.  Urologe. 2010;  49 1163-1168
• 14 Fitzpatrick J M. The natural history of benign prostatic hyperplasia.  BJU Int. 2006;  97 3-6
• 15 Pinto F, Racioppi M, Sacco E et al. Progression, risk factors and sub­sequent medical management of symptomatic benign prostatic hyperplasia.  Arch Ital Urol Androl. 2009;  81 1-8
• 16 Oelke M, Höfner K, Wiese B et al. Increase in detrusor wall thickness ­indicates bladder outlet obstruction (BOO) in men.  World J Urol. 2002;  19 443-452
• 17 Berges R, Dreikorn K, Höfner K et al. Therapie des benignen Prostatasyndroms (BPS). Leitlinien der Deutschen Urologen.  Urologe. 2009;  48 1503-1516
• 18 Yamanishi T, Mizuno T, Tatsumiya K et al. Urodynamic effect of silodosin, a new alpha 1A-adrenoreceptor selective antagonist, for the treatment of benign prostatic hyperplasia.  Neurourol Urodyn. 2010;  29 558-562
• 19 Djavan B, Marberger M. A meta-analysis of efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.  Eur Urol. 1999;  36 1-13
• 20 Lukacs B, Grane J C, Comet D et al. History of 7093 patients with lower urinary tract symptoms related to benign prostatic hyperplasia treated with alfuzosin in general practice up to 3 years.  Eur Urol. 2000;  37 183-190
• 21 Michel M C, Bressel H U, Mehlburger L et al. Tamsulosin: real life clinical experience in 19 365 patients.  Eur Urol. 1999;  34 37-45
• 22 Kortmann B B, Floratos D L, Kiemeny L A et al. Urodynamic effects of ­alpha-adrenoceptor blockers: a review of clinical trials.  Urology. 2003;  62 1-9
• 23 Oelke M, Bachmann A, Descazeaud A et al. EAU Guidelines on the management of non-neurogenic Male LUTS. http://www.uroweb.org/gls/pdf/BPH%202010.pdf
• 24 Djavan B, Chapple C, Milani S et al. State of the art on efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower ­urinary tract symptoms suggestive of benign prostatic hyperplasia.  ­Urology. 2004;  64 1081-1088
• 25 Nickel J C, Sander S, Moon T D. A meta-analysis of the vascular-related safety profile and efficacy of alpha-adrenergic blockers for symptoms related to benign prostatic hyperplasia.  Int J Clin Pract. 2008;  62 1547-1559
• 26 Roehrborn C G, Siami P, Barkin J et al. The effects of dutasteride, tam­sulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study.  J Urol. 2008;  179 616-621
• 27 Boyle P, Gould A L, Roehrborn C G. Prostate volume predicts outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analy­sis of randomized clinical trials.  Urology. 1996;  48 398-405
• 28 Tammela T LJ, Kontturi M J. Long-term effects of finasteride on invasive urodynamics and symptoms in the treatment of patients with bladder outflow obstruction due to benign prostatic hyperplasia.  J Urol. 1995;  154 1466-1469
• 29 Roehrborn C G, Siami P, Barkin J et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study.  Eur Urol. 2010;  57 123-131
• 30 Roehrborn C G, Kaplan S A, Kraus S R et al. Effects of serum PSA on efficacy of tolterodine extended release with or without tamsulosin in men with LUTS, including OAB.  Urology. 2008;  72 1061-1067
• 31 Barkin J, Guimarães M, Jacobi G et al. Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5alpha-reductase inhibitor dutasteride.  Eur Urol. 2003;  44 461-466
• 32 Athanasopoulols A, Gyftopoulos K, Giannitsas K et al. Combination treatment with an alpha–blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized, controlled study.  J Urol. 2003;  169 2253-2256
• 33 Kaplan S A, Roehrborn C G, Rovner E S et al. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and over­active bladder: a randomized controlled trial.  JAMA. 2006;  296 2319-2328
• 34 Kerrebroek van P, Oelke M, Katona F et al. Efficacy of tamsulosin OCAS™ plus solifenacin (TOCAS + Soli) in male LUTS: results from a ran­domised, dose-ranging, phase II trial (SATURN).  Urology. 2010;  76 S12-S13
• 35 Muschter R. Lasertherapie der benignen Prostatahyperplasie.  Akt Urol. 2008;  39 359-368
• 36 Varkarakis I, Kyriakis Z, Delis A et al. Long-term results of open trans­vesical prostatectomy from a contemporary series of patients.  Urology. 2004;  62 306-310
• 37 Gratzke C, Schlenker B, Seitz M et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study.  J Urol. 2007;  177 1419-1422
• 38 Reich O, Gratzke C, Bachmann A et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective ­multicenter evaluation of 10 654 patients.  J Urol. 2008;  180 246-249
• 39 Descazeaud A, Robert G, Azzousi A R et al. Laser treatment of benign prostatic hyperplasia in patients on oral anticoagulant therapy: a review.  BJU Int. 2009;  103 1162-1165
• 40 Reich O, Bachmann A, Siebels M et al. High power (80 W) potassium-titanyl-phosphat laser vaporization of the prostate in 66 high risk patients.  J Urol. 2005;  173 158-160
• 41 Bruyère F, Puichaud A, Pereira H et al. Influence of photoselective vaporization of the prostate on sexual function: results of a prospective analysis of 149 patients with long-term follow-up.  Eur Urol. 2010;  58 207-211
• 42 Bouchier-Hayes D M, Van Appledorn S, Bugeja P et al. A randomized trial of photoselective vaporization of the prostate using the 80-W potassium-titanyl-phosphate laser vs transurethral prostatectomy, with 1 year follow-up.  BJU Int. 2010;  105 964-969
• 43 Ruszat R, Wyler S F, Seitz M et al. Comparison of potassium-titanyl-phosphate laser vaporization of the prostate and transurethral resection of the prostate: update of a prospective non-randomized two-centre study.  BJU Int. 2008;  102 1432-1438
• 44 Herrmann T, Bach T, Imkamp F et al. Thulium laser enucleation of prostate (ThuLEP): transurethral anatomical prostatectomy with laser support. Introduction of a novel technique for treatment of benign prostatic obstruction.  World J Urol. 2010;  28 45-51
• 45 Lourenco T, Armstrong N, N’Dow J et al. Systematic review and economic modeling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement.  Health Technol Assess. 2008;  12 1-146
• 46 Hoffmann R M, Monga M, Elliot S et al. Microwave thermotherapy for benign prostatic hyperplasia.  Cochrane Database Syst Rev. 2007;  17
• 47 Kaye J D, Smith A D, Badlani G H et al. High-energy transurethral thermotherapy with CoreTherm approaches transurethral prostate resection in outcome efficacy: a meta-analysis.  J Endourol. 2008;  22 713-718
• 48 Zlotta A R, Giannakopoulus X, Maehlum O et al. Long-term evaluation of prostate needle ablation of the prostate (TUNA) for treatment of symptomatic benign prostatic hyperplasia: Clinical outcome up to five years from three centers.  Eur Urol. 2003;  44 89-93
• 49 Mattiasson A, Wagrell L, Schelin S et al. Five-year follow-up of feedback microwave thermotherapy versus TURP for clinical BPH: a prospective randomized multicenter study.  Urology. 2007;  69 91-96
• 50 Lourenco T, Shaw M, Fraser C et al. The clinical effectiveness of trans­urethral incision of the prostate: a systematic review of randomised controlled trials.  World J Urol. 2010;  28 23-32