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EDITORIAL COMMENT

The authors use preoperative AUA symptom scores, and other variables perhaps reflecting BPH severity, to predict postoperative decreases in symptom score. Preoperative symptom burden ap- peared to be the best predictor o f symptom response. For example approximately 87% of men with a preoperative symptom score of at least 17 points improved substantially (at least 7 points) with pros- tatectomy, while only 29% with lower preoperative scores responded as dramatically. This prognostic stratification based on symptom severity appears much more powerful than for some other predictors of surgical outcome examined in the literature, such as the preoper- ative presence or seventy of urodynamic obstruction. Treatment guidelines have emphasized that surgical treatment (or any treat- ment for that matter) should be avoided for men with symptom scores of less than 8 points.

Perhaps the threshold symptom level before prostatectomy is rec- ommended should be even greater, although by how much depends on whether it is worse to operate on a man who will not improve substantially or to deny operative treatment to a man who will indeed improve substantially. The worse the former outcome is than the latter, the greater the symptom threshold should be for recom- mending surgery. An interesting caveat to this analysis is to note that the 11 men with symptom scores of 8 or less had a group mean improvement quality of life score of approximately 2 points, while the 48 with severe symptoms had a group mean improvement of approx- imately 3 points, which is not much greater. While the small sample size argues against overinterpreting this finding, one wonders what the former group of men were responding to when they rated the postoperative quality of life better even with no symptom improve- ment.

Michael J. Barty Medical Practices Evaluation Center Massachusetts General Hospital Boston. Massachusetts