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vin T. McVary,* Claus G. Roehrborn, Andrew L. Avins, Michael J. Barry,ginald C. Bruskewitz, Robert F. Donnell, Harris E. Foster, Jr., Chris M. Gonzalez,even A. Kaplan, David F. Penson, James C. Ulchaker and John T. Weim the American Urological Association Education and Research, Inc., Linthicum Maryland

rpose: To revise the 2003 version of the American Urological AssociationsUA) Guideline on the management of benign prostatic hyperplasia (BPH).aterials and Methods: From MEDLINE searches of English language publi-tions (January 1999 through February 2008) using relevant MeSH terms,ticles concerning the management of the index patient, a male45 years of ageo is consulting a healthcare provider for lower urinary tract symptoms (LUTS)re identified. Qualitative analysis of the evidence was performed. Selected

udies were stratified by design, comparator, follow-up interval, and intensity oftervention, and meta-analyses (quantitative synthesis) of outcomes of random-d controlled trials were planned. Guideline statements were drafted by anpointed expert Panel based on the evidence.sults: The studies varied as to patient selection; randomization; blinding

echanism; run-in periods; patient demographics, comorbidities, prostate char-teristics and symptoms; drug doses; other intervention characteristics; com-rators; rigor and intervals of follow-up; trial duration and timing; suspectedck of applicability to current US practice; and techniques of outcomes measure-ent. These variations affected the quality of the evidence reviewed makingmal meta-analysis impractical or futile. Instead, the Panel and extractors

viewed the data in a systematic fashion and without statistical rigor. Diagnosisd treatment algorithms were adopted from the 2005 International Consulta-n of Urologic Diseases. Guideline statements concerning pharmacotherapies,tchful waiting, surgical options and minimally invasive procedures were eitherdated or newly drafted, peer reviewed and approved by AUA Board of Directors.nclusions: New pharmacotherapies and technologies have emerged whichve impacted treatment algorithms. The management of LUTS/BPH continuesevolve.

Key Words: prostatic hyperplasia, urinary retention, adrenergic alpha-antagonists, 5-alpha-reductase inhibitors, behavior therapy, transurethral

resection of prostate

The complete guideline is available at www.AUAnet.org/BPH2010.This document is being reprinted as submitted without independent editorial or peer review by the Editors of The Journal of Urology.* Correspondence: Tarry Building, 16th Floor, 303 E. Chicago Ave., Chicago, Illinois 60611-3008 (telephone: 312- 908-1987; FAX: 312-908-7275;ail: [email protected]).

Abbreviationsand Acronyms

5-ARIs 5-alpha-reductaseinhibitors

BOO bladder outlet obstruction

BPH benign prostatichyperplasia

CAM complementary andalternative medications

ED erectile dysfunction

HoLRP/HoLEP/HoLAP holmiumlaser resection/enucleation/ablation of the prostate

IFIS intraoperative floppy irissyndrome

LUTS lower urinary tractsymptoms

PSA prostate specific antigen

QoL quality of life

TUIP transurethral incision ofthe prostate

TUMT transurethral microwavethermotherapy

TUNA transurethral needleablation of the prostate

TURP transurethral resection ofthe prostate

TUVP transurethral vaporizationof the prostate

UTI urinary tract infection

NIGN prostatic hyperplasia is a his-logic diagnosis that refers to smoothuscle and epithelial cell prolifera-

tion within the prostatic transitionzone.1 The enlarged gland has beenproposed to contribute to lower uri-

2-5347/11/1855-1793/0 Vol. 185, 1793-1803, May 2011E JOURNAL OF UROLOGY Printed in U.S.A.011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. DOI:10.1016/j.juro.2011.01.074

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA1794ry tract symptom via at least two routes (1) directdder outlet obstruction (static component) and (2)

creased smooth muscle tone and resistance (dy-mic component). In the management of bothersomeTS, it is important that healthcare providers recog-

ze the complex interactions of the bladder, bladderck, prostate and urethra, and that symptoms maysult from interactions of these organs as well as thentral nervous system. The 2010 BPH Guidelinetempts to acknowledge that LUTS represents aoad spectrum of etiologies, and focuses on theanagement of such symptoms.LUTS in the aging male can have a marked im-ct on individual health and society at large.2,3

though LUTS secondary to BPH (LUTS/BPH) ist often life-threatening, the impact of LUTS/BPHquality of life can be significant. Traditionally,

e primary treatment goal has been to alleviatethersome LUTS. More recently, treatment has ad-essed the prevention of disease progression.4 Thisideline reviews a number of important aspects in

e management of LUTS/BPH including diagnosticsts to identify the underlying pathophysiology andmptom management. Complementary and alter-tive medications, watchful waiting, and lifestyleues are addressed. The current literature on the

andard surgical options and on minimally invasiveocedures is also reviewed.Recently, the association between LUTS and erec-e dysfunction has been clarified. Lifestyle factors ch as exercise, weight gain and obesity alsopear to have an impact on LUTS. We expect thesek factors to grow in importance with the aging ofe male population and the obesity epidemic. Thepected increase in prevalence will place increasedmands on the health system and put a premium

efficient, evidence-based management in bothimary and specialty care.

FINITIONS AND TERMINOLOGYr the 2010 Guideline, the Index Patient is aale 45 years of age who is consulting a qualifiedalthcare provider for his LUTS. He does not havehistory suggesting non-BPH causes of LUTS ands LUTS may or may not be associated with anlarged prostate gland, BOO, or histological BPH.wer urinary tract symptoms include storaged/or voiding disturbances common in aging mend can be due to structural or functional abnormal-es in one or more parts of the LUT or abnormali-s of the peripheral and/or central nervous systems

at provide neural control of the LUT. LUTS mayso be secondary to cardiovascular, respiratory ornal disease.ETHODOLOGYe 2010 guideline statements were based on a sys-

matic review and synthesis of the literature onrrent therapies for the treatment of BPH. Theethodology followed the same process used in thevelopment of the 2003 Guideline and, as such, didt include an evaluation of the strength of the bodyevidence as will be instituted in future Guidelinesoduced by the American Urological Association.e full Guideline document including methodologyn be accessed at http://www.auanet.org/content/idelines-and-quality-care/clinical-guidelines.cfm.The guideline statements (indicated as bolded

xt in this paper) were drafted by the Panel basedevidence and tempered by the Panels expert

inion. As in the previous Guideline, these state-ents were graded using three levels of flexibility ineir application. A standard has the least flexibil-

as a treatment policy; a recommendation hasnificantly more flexibility; and an option is even

ore flexible.

AGNOSTIC EVALUATIONF THE INDEX PATIENTter review of the recommendations for diagnosisblished by the 2005 International Consultation ofologic Diseases5 and reiterated in 20096, thenel unanimously agreed that the contents remainlid and reflected best practices. The diagnosticidelines can be found at www.AUAnet.org/H2010.

sic Managemente algorithm describing basic management classi-s diagnostic tests as either recommended (shouldperformed on every patient during the initial

aluation) or optional (test of proven value in thealuation of select patients) (fig. 1). In general,tional tests are performed during a detailed eval-tion by a urologist. If the initial evaluation revealse presence of LUTS associated with results of agital rectal exam suggesting prostate cancer, he-aturia, abnormal prostate-specific antigen levels,current urinary tract infection, palpable bladder,story/risk of urethral stricture, and/or a neurolog-l disease raising the likelihood of a primary blad-r disorder, the patient should be referred to aologist for appropriate evaluation before treat-ent. Baseline renal insufficiency appears to be noore common in men with BPH than in men of theme age group in the general population.Not Recommended: The routine measure-ment of serum creatinine levels is not in-dicated in the initial evaluation of menwith LUTS secondary to BPH.

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 1795[Based on review of the data and Panelconsensus.]

The physician can discuss the benefits and riskstreatment alternatives with the patient based one results of the initial evaluation with no furthersting (See Figure 1). The treatment choice isached in a shared decision-making process be-een the clinician and patient. If treatment is suc-ssful and the patient is satisfied, yearly follow-upth re-evaluation will detect progressive disease.

Figure 1. Basic management of lowtailed Managementthe patients LUTS are being managed by a pri-ary care giver and the patient has persistent both-

froinmsome LUTS after basic management, a urologistould be consulted. The urologist may use testingyond that recommended for basic evaluationg. 2). If drug therapy is considered, decisions willinfluenced by coexisting overactive bladder symp-

ms and prostate size or serum PSA levels (fig. 2).e decision for choice of therapy should be in con-

rt with the patients preferences.If storage symptoms predominate, an overactive

adder due to idiopathic detrusor overactivity is theost likely cause if there is no indication of BOO

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA1796ugs) should be discussed with the patient. It ise expert opinion of the Panel that some maynefit using a combination of all three modal-es. Should improvement be insufficient andmptoms severe, then newer modalities canconsidered. It is recommended that the patientfollowed to assess treatment outcome.

terventional Therapythe patient elects interventional therapy and

ere is sufficient evidence of obstruction, patientd urologist should discuss the benefits and risks ofe various interventions. Transurethral resectionstill the gold standard but, when available, newerapies could be discussed.

Figure 2. Detailed management of persistent, bothersomIf the patients condition does not suggest ob-ruction (e.g., maximum flow rate 10 mL/sec)essure flow studies are optional as treatment fail-e rates are higher in the absence of obstruction. Iferapy is planned without evidence of obstruction,e patient needs to be informed of possible higherocedure failure rates.

eatment Alternativese patient must be informed of all treatment alter-tives applicable to his clinical condition and thelated benefits and risks so that he may participatedecision making. The treatment choices listed inble 1 are discussed in this article with the sup-rting evidence presented in Chapter 3 of theideline (www.AUAnet.org/BPH2010).

Standard: Information on the benefits and

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 1797toms (AUA-SI score >8) who are botheredenough to consider therapy.

[Based on Panel consensus.]atchful Waiting. Watchful waiting (active surveil-nce) is the preferred strategy for mild symptoms.is also an appropriate option for men with mod-ate-to-severe symptoms who have no complica-ns of LUTS and BOO (e.g., renal insufficiency,inary retention or recurrent infection). Watchfuliting patients usually are reexamined yearly, re-ating the initial evaluation (Figure 1). As prostatelume predicts the natural history of symptoms,w rate, risk for AUR (acute urinary retention) andrgery, patients may be advised as to their individ-l risk based on these measures.

Standard: Patients with mild symptoms ofLUTS secondary to BPH (AUA-SI score8) who are notbothered by their LUTS should be man-aged using a strategy of watchful waiting

atment alternatives for patients with moderate to severeptoms of benign prostatic hyperplasia

Watchful Waiting

edical Therapiespha-adrenergic blockersAlfuzosinDoxazosinTamsulosinTerazosinSilodosin*Alpha-reductase inhibitorsDutasterideFinasteridembination therapyAlpha blocker and 5-alpha-reductase inhibitorAlpha blocker and anticholinergicsticholinergic Agentsmplementary and Alternative Medicines (CAM)inimally Invasive TherapiesTransurethral needle ablation (TUNA)Transurethral microwave heat treatments (TUMT)rgical TherapiesOpen prostatectomyTransurethral holmium laser ablation of the prostate (HoLAP)Transurethral holmium laser enucleation of the prostate (HoLEP)Holmium laser resection of the prostate (HoLRP)Photoselective vaporization of the prostate (PVP)Transurethral incision of the prostate (TUIP)Transurethral vaporization of the prostate (TUVP)Transurethral resection of the prostate (TURP)

ilodosin was approved by the US Food and Drug Administration but there werepublished articles in the peer reviewed literature prior to the cut-off date forliterature search.(active surveillance).[Based on review of the data and Panel

consensus.]pha-Adrenergic Blockers (Alpha-Blockers). In stud-, rates for specific alpha-blocker-associated ad-rse events were similar between treatment andacebo groups. Dizziness, the most common adverseent, was reported in 2% and 14% of patients ander rates with placebo. The 10% risk of ejacula-

ry disturbance cited in 2003 Guideline associatedth tamsulosin was lower in recent studies thated alternate metrics to gauge dysejaculation.7

Although doxazosin and terazosin require doseration and blood pressure monitoring, they areexpensive, dosed once daily, and equally effective asmsulosin and alfuzosin. In addition, they have gen-ally similar side effect profiles, except ejaculatorysfunction which has been reported less frequentlyth alfuzosin.Data from the long-term Medical Therapy of Pros-tic Symptoms study suggest that while AUR andrgery rates were lower with doxazosin comparedplacebo in the early years of follow-up, by five

ars, rates were similar in both groups.4 The time-ited effect noted for doxazosin is likely a class

ect. The second major combination therapy studys the four-year Combination Therapy with Avo-rt and Tamsulosin trial comparing tamsulosin,tasteride and their combination; at present, onlyo-year data are published.7

Option: Alfuzosin, doxazosin, tamsulosin,and terazosin are appropriate and effec-tive treatment alternatives for patientswith bothersome, moderate to severeLUTS secondary to BPH (AUA-SI score>8). Although there are slight differencesin the adverse event profiles of theseagents, all four appear to have equal clin-ical effectiveness. As stated in the 2003Guideline, the effectiveness and efficacyof the four alpha-blockers under consid-eration appear to be similar. Althoughstudies directly comparing these agentsare currently lacking, the available datasupport this contention.

(Silodosin was approved by the US Food and DrugAdministration but there were no publishedarticles in the peer-reviewed literature prior tothe cut-off date for the literature search.)

[Based on review of the data and Panel con-sensus.]

Option: The older, less costly, generic alpha-blockers remain reasonable choices. Theserequire dose titration and blood pressuremonitoring.[Based on Panel consensus.]Recommendation: As prazosin and the nonse-

lective alpha-blocker phenoxybenzamine

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA1798were not reviewed in the course of thisGuideline revision, the 2003 Guideline state-ment indicating that the data were insuffi-cient to support a recommendation for theuse of these two agents as treatment alterna-tives for LUTS secondary to BPH has beenmaintained.

[Based on Panel consensus.]Option: The combination of an alpha-blocker

and a 5-alpha-reductase inhibitor (combi-nation therapy) is an appropriate andeffective treatment for patients withLUTS associated with demonstrableprostatic enlargement based on volumemeasurement, prostate-specific antigenlevel as a proxy for volume, and/or en-largement on DRE.

[Based on review of the data and Panelconsensus.]

The intraoperative floppy iris syndrome is a triadintraoperative miosis despite preoperative dila-n, and billowing and prolapse of a flaccid iris,ring phacoemulsification for cataracts. Complica-ns have included posterior capsule rupture with

treous loss and postoperative intraocular pressureikes, though acuity outcomes appeared preserved.e original report linked this condition with thee of tamsulosin; iris dilator smooth muscle inhibi-n has been suggested as a potential mecha-sm.8,9 The evidence review supports the followingnclusions:

Risk of IFIS was substantial with tamsulosin in 10retrospective and prospective studies.919

The risk of IFIS appears to be lower with older,generic alpha-blockers.9,13,18,19

Data to estimate the risk of IFIS with alfuzosinare insufficient.Whether the dose/duration or cessation of treat-ment preoperatively affects IFIS is unclear.Ophthalmologists aware of preoperative alpha-blocker use can take intraoperative precautions toreduce IFIS complications.8,14

Recommendation: Men with LUTS second-ary to BPH for whom alpha-blocker ther-apy is offered should be asked aboutplanned cataract surgery. Men withplanned cataract surgery should avoidthe initiation of alpha blockers until theircataract surgery is completed.

[Based on review of the data and Panel con-sensus.]Recommendation: In men with no plannedcataract surgery, there are insufficientdata to recommend withholding or dis-

instrecontinuing alpha-blockers for bother-some LUTS secondary to BPH.


Alpha-reductase Inhibitors. Finasteride (5 mgily) inhibits the 5-AR type II isoenzyme whiletasteride (0.5 mg daily) inhibits both types I andThere are no data from direct comparator trialsother sources to suggest that the clinical efficacythe two 5-ARIs is different. Comparisons are dif-ult due to differences in study design and varia-ns in the definition of prostate enlargement.

Option: 5-ARIs may be used to prevent pro-gression of LUTS secondary to BPH andto reduce the risk of urinary retentionand future prostate-related surgery.


Recommendation: 5-ARIs should not be usedin men with LUTS secondary to BPHwithout prostatic enlargement.


Option: The 5-ARIs are appropriate and ef-fective treatment alternatives for menwith LUTS secondary to BPH who havedemonstrable prostate enlargement.


lpha-Reductase Inhibitors for Hematuria. Finas-ide suppresses prostatic vascular endothelialowth factor (VEGF). Prostate-related bleedings found to respond to finasteride; bleeding was

duced or ceased completely and recurrent bleedingcreased.20,21

Option: Finasteride is an appropriate andeffective treatment alternative in menwith refractory hematuria presumablydue to prostatic bleeding (i.e., after exclu-sion of any other causes of hematuria). Asimilar level of evidence concerning du-tasteride was not reviewed; it is the ex-pert opinion of the Panel that dutasteridelikely functions in a similar fashion.


Alpha-Reductase Inhibitors for Prevention ofeeding During Transurethral Resection of theostate. Several investigators studied the effect ofesurgical treatment with a 5-ARI on TURP bleed-

g.2227 One randomized and two nonrandomizedudies found a reduction in blood loss or transfusionquirements.2527

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ticholinergic Agents. Three randomized trialsaluating the use of tolterodine as monotherapy orcombination with an alpha blocker in men withTS/BPH were identified.2830 Although these tri-

s do not sufficiently demonstrate the efficacy orectiveness of tolterodine, the Panel concludedat the use of anticholinergics could benefit sometients.

Option: Anticholinergic agents are appro-priate and effective treatment alterna-tives for themanagement of LUTS second-ary to BPH in men without an elevatedpost void residual (PVR) urine and whenLUTS are predominantly irritative.

[Based on Panel consensus.]Recommendation: Prior to initiation of antich-

olinergic therapy, baselinePVRurine shouldbe assessed. Anticholinergics should be usedwith caution in patients with a PVR greaterthan 250 to 300 mL.

[Based on Panel consensus.]mplementary and Alternative Medicines. Non-

nventional approaches to the management ofTS/ BPH are of interest to patients. Of particular

peal are dietary supplements, which include ex-cts of the saw palmetto plant (Serenoa repens)d stinging nettle (Urtica dioica). Since the publi-tion of the 2003 Guideline, higher-quality evi-nce has appeared concerning the commonly-stud-

saw palmetto plant extract. Previous reviewsggested that saw palmetto may have modest effi-cy. More rigorous studies showed no effects.31,32

ore definitive evidence regarding the use of sawlmetto is forthcoming.

Recommendation: No dietary supplement,combination phytotherapeutic agent, orother nonconventional therapy is recom-mended for the management of LUTS sec-ondary to BPH.


Recommendation: At this time, the availabledata do not suggest that saw palmetto has aclinically meaningful effect on LUTS sec-

ondary to BPH. Further clinical trials arein progress and the results of these studieswill elucidate the potential value of saw

caopwipalmetto extract in the management of pa-tients with BPH.


Recommendation: The paucity of publishedhigh quality, single extract clinical trialsof Urtica dioica do not provide a sufficientevidence base with which to recommendfor or against its use for the treatment ofLUTS secondary to BPH.


inimally Invasive Therapies

Standard: Safety recommendations for theuse of transurethral needle ablation ofthe prostate and transurethral micro-wave thermotherapy published by theUnited States Food and Drug Administra-tion should be followed: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/default.htm.

[Based on review of the data.]ansurethral Needle Ablation of the Prostate.NA is safe with low peri-operative complications

aking this therapy attractive. The Panel concludedat a degree of uncertainty remains regardingNA because of a paucity of high-quality studies.

Option: TUNA is an appropriate and effec-tive treatment alternative for bothersomemoderate or severe LUTS secondary toBPH.


ansurethral Microwave Thermotherapy (TUMT).MT is the least operator dependant of the inter-

ntions yet predicting responders is difficult. Thestematic review of TUMT data revealed a mix ofudies with different sample sizes, outcome mea-res, and follow-up durations leading to conflictingsults. Thus, there is no compelling evidence tonclude that one device is superior to another.

Option: TUMT is effective in partially reliev-ing LUTS secondary to BPH and may beconsidered in men with moderate or se-vere symptoms.


rgical Proceduresrgical intervention is appropriate for moderate-

-severe LUTS, AUR or other BPH-related compli-

tions. By definition, surgery is the most invasivetion for BPH management and generally, patientsll have failed medical therapy before proceeding

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA1800th surgery. However, some patients may pursueis therapy as a primary treatment. The decision

surgery may be based upon the patients risk/nefit assessment. The 2003 Guideline recognizedRP as the benchmark therapy. Alternative tech-

logies are reported to offer lower morbidity bute typically still performed in the operating roomth anesthesia.

Recommendation: Surgery is recommendedfor patients who have renal insufficiencysecondary to BPH, who have recurrenturinary tract infections (UTIs), gross he-maturia due to BPH, or bladder stones,and who have LUTS refractory to othertherapies. The presence of a bladder di-verticulum is not an absolute indicationfor surgery unless associated with recur-rent UTI or progressive bladder dysfunc-tion.


en Prostatectomy. Open prostatectomies mayneeded only for men with very enlarged prostate

ands, may be more effective than TURP in reliev-g BOO, and for men with bladder diverticula orones.

Option: Open prostatectomy is an appropri-ate and effective treatment alternativefor men with moderate to severe LUTSand/or who are significantly bothered bythese symptoms. The choice of approachshould be based on the patients individ-ual presentation including anatomy, thesurgeons experience, and discussion ofthe potential benefits and risks for com-plications. The Panel noted that there isusually a longer hospital stay and a largerloss of blood associated with open proce-dures.


ser Therapies. Generally, transurethral laser ap-oaches have been associated with shorter cathe-rization time and length of stay with comparableprovements in LUTS. There is a decreased risk ofe perioperative complication of TUR syndrome.formation concerning certain outcomes includingtreatment and urethral strictures is limited due toort follow-up. As with all new devices, comparisonoutcomes between studies should be consideredutiously given the rapid evolution in technolo-

es. Emerging evidence suggests a possible role ofansurethral enucleation and laser vaporizationoptions even for men with very large prostates100 g). There are insufficient data on which tose comments on bleeding.

Option: Transurethral laser enucleation (hol-mium laser resection of the prostate[HoLRP], holmium laser enucleation ofthe prostate [HoLEP]), transurethral sidefiring laser ablation (holmium laser abla-tion of the prostate [HoLAP], and photose-lective vaporization [PVP]) are appropri-ate and effective treatment alternativesto transurethral resection of the prostateand open prostatectomy inmenwithmod-erate to severe LUTS and/or who are sig-nificantly bothered by these symptoms.The choice of approach should be basedon the patients presentation, anatomy,the surgeons level of training and experi-ence, and discussion of the potential ben-efits and risks for complications.


ansurethral Incision of the Prostate. TUIP is antpatient endoscopic procedure limited to the treat-ent of smaller prostates (30 mL). TUIP results ingrees of symptomatic improvement equivalent toose attained after TURP.3336 TUIP results in aduced risk of ejaculatory disturbance and a higherte of secondary procedures.

Option: TUIP is an appropriate and effectivetreatment alternative in men with moder-ate to severe LUTS and/or who are signif-icantly bothered by these symptoms whenprostate size is less than 30 mL. Thechoice of approach should be based on thepatients individual presentation includ-ing anatomy, the surgeons experienceand discussion of the potential benefitsand risks for complications.


ansurethral Vaporization of the Prostate. Com-red to TURP, TUVP results in equivalent, short-rm improvements in symptoms, flow rate, andL. Risk of TUR syndrome is reduced comparedth monopolar TURP. However, the rates of post-erative irritative voiding symptoms, dysuria, uri-ry retention, and re-catheterization, appeargher. Reoperation rates were higher with TUVPan with TURP. Long-term comparative trials areeded to determine if TUVP is equivalent to stan-rd TURP.

Option: TUVP is an appropriate and effec-

tive treatment alternative in men withmoderate to severe LUTS and/or who aresignificantly bothered by these symptoms.

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ansurethral Resection of the Prostate. TURPs the most common treatment for BPH but mor-

dities, desire to shorten catheterization and lengthstay issues have stimulated the development of

ternatives. The VA Cooperative Study found a 1%k of urinary incontinence (similar to that reportedth watchful waiting) and an overall decline inxual function identical to patients randomized totchful waiting.37

Bipolar TURP utilizes a resectoscope loop thatcorporates both active and return electrodes which

its current flow dispersal and reduces stray cur-nt flow. Because the bipolar resectoscope uses nor-al saline for irrigation, the risk of TUR syndromeeliminated.

Option: TURP is an appropriate and effec-tive primary alternative for surgical ther-apy in men with moderate to severe LUTSand/or who are significantly bothered bythese symptoms. The choice of a monopo-lar or bipolar approach should be basedon the patients presentation, anatomy,the surgeons experience and discussionof the potential risks and likely benefits.


Option: Overall, there is insufficient evi-dence to recommend using 5-ARIs in thesetting of a pre-TURP to reduce intraop-erative bleeding or reduce the need forblood transfusions.


paroscopic and Robotic Prostatectomy. Lapa-scopic and robotic prostatectomies are currentlysociated with the treatment of prostate cancert a single cohort study has reported on patientsdergoing laparoscopic simple prostatectomy.38

e operation takes longer than traditional sur-ry.

Option: Men with moderate to severe LUTSand/or who are significantly bothered bythese symptoms can consider a laparo-

scopic or robotic prostatectomy. Thereare insufficient published data on whichto base a treatment recommendation.

co

no[Based on review of the data and Panelconsensus.]

TURE RESEARCHven the aging population, BPH will be a majorena for research. There is a substantial need for ag-range vision to promote a better understandingthe etiology and management of BPH.39 High

iority research areas include:

Obesity and lifestyle interventionsPreventive strategies aimed at the underlyingpathophysiology of BPHStudies that assess disease phenotypes and leadto better disease definitionsStudy of primary prevention for LUTS/BPHPlan for a multidisciplinary working group to de-velop a specific research agenda for symptom andhealth status measurement related to male LUTSCollaborative network to standardize treatmentassessment

These topics illustrate the pressing need for im-oved methods to diagnose LUTS due to BPH and toedict progression; to develop new drug therapies;ntify and test prevention strategies; and developw non- or minimally invasive interventions. Prog-ss in these areas has the potential to advance clinicalre for BPH patients beyond symptom management,ich in many cases are not uniformly effective across

tients classified as having the same disorder.

KNOWLEDGMENTS AND DISCLAIMERSis document was written by the BPH Guidelinenel of the American Urological Association Educa-n and Research, Inc., which was created in 2006.e Practice Guideline Committee (PGC) of the AUA

lected the committee chair. Panel members werelected by the chair. Membership of the committeecluded urologists and other physicians with specificpertise in this disorder. The mission of the commit-was to develop recommendations that are analysis-

sed or consensus-based, depending on Panel pro-sses and available data for optimal clinical practicesthe diagnosis and surgical treatment of BPH. Thiscument was submitted for peer review to 69 urolo-ts and other healthcare professionals. After the fi-l revisions were made, based upon the peer reviewocess, the document was submitted to and approvedthe PGC and the Board of Directors of the AUA.nding of the committee was provided by the AUA.mmittee members received no remuneration foreir work. Each member of the committee provided a

nflict of interest disclosure to the AUA.AUA Guidelines provide guidance only, and dot establish a fixed set of rules or define the legal

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sclosures. Those marked with (Cmpensation was received; relatted by (U) indicate no compensatixpands andements willents repre-

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onducted byalie Jacuzzi,eronica Ivey,lth Sciencesvided by Di-es.t of Interestdicate thathips desig-as received.

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AUA GUIDELINE ON MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA 1803

Update on AUA Guideline on the Management of Benign Prostatic HyperplasiaDEFINITIONS AND TERMINOLOGYMETHODOLOGYDIAGNOSTIC EVALUATION OF THE INDEX PATIENTBasic ManagementDetailed ManagementInterventional TherapyTreatment AlternativesWatchful WaitingAlpha-Adrenergic Blockers (Alpha-Blockers)5-Alpha-reductase Inhibitors5-Alpha-Reductase Inhibitors for Hematuria5-Alpha-Reductase Inhibitors for Prevention of Bleeding During Transurethral Resection of the ProstateComplementary and Alternative Medicines

Minimally Invasive TherapiesTransurethral Needle Ablation of the ProstateTransurethral Microwave Thermotherapy (TUMT)

Surgical ProceduresOpen ProstatectomyLaser TherapiesTransurethral Incision of the ProstateTransurethral Vaporization of the ProstateTransurethral Resection of the ProstateLaparoscopic and Robotic Prostatectomy

FUTURE RESEARCHACKNOWLEDGMENTS AND DISCLAIMERSREFERENCES

guideline aua utk bph.pdf

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