LUTS after TURP: How come and how to manage? Matthias Oelke

LUTS after TURP: How come and how to manage? Matthias Oelke Department of Urology Global Congress on LUTD, Rome, 26 th June 2015

Disclosures Consultant, speaker, trial participant and/or research grants from: Allergan Apogepha Astellas Bayer Ferring GSK Lilly Mundipharma Pfizer Recordati

LUTS After Prostatic Operations General misconception that patients are symptom-free after prostatic surgery for LUTS/BPO (not necessarily associated with bother) Please ask you colleguages and compare their answers with results of RCTs or real-life data Real-life practice data from France: medical prescriptions for LUTS after prostatic surgery are common (primarily by GP [72%] or urologist [24%]) prostate drugs (plants, 5ARI, α-blocker, combination therapy): 6% at month 4 14% at year 1 25% at year 5 Cumulative incidence of prescriptions bladder drugs (antimuscarinics): 4% at month 4 9% at year 1 14% at year 5 Lukacs B et al. Eur Urol. 2013; 64: 493 501.

Which LUTS Persist After Prostatic Surgery? Limited data on the type of LUTS which persist after prostatic surgery No high-quality data (RCTs or prospective studies) In retrospective case series, residual/recurrent LUTS after TURP were found in approx. 15-20% of patients (mean time from TURP 3.5 years), of those Prevalence [%] Storage LUTS Voiding LUTS Stress incontinence Urgency incontinence Retention Frequency Poor Stream Urgency Nocturia 11% 32% 33% 40% 42% 52% 68% 0 10 20 30 40 50 60 70 80 90 100 n = 129 men (consecutive series, age 46-90 y, mean 72 y) Seaman EK et al. J Urol. 1994; 152: 935 937.

Urodynamic Diagnoses Behind Residual LUTS Limited data on the pathophysiology of residual/recurrent LUTS after prostatic surgery 76% n = 129 men Only retrospective case series with urodynamic evaluation 50% 35% of patients had signs of neurogenic bladder dysfunction Patients with neurogenic bladder dysfunction were more frequently affected by detrusor overactivity urgency incontinence 38% 37% 30% 26% 10% 4% 4% 0% Seaman EK et al. J Urol. 1994; 152: 935 937.

Reasons for LUTS after Prostatic Surgery Possibilities: 1. Wrong surgical technique: one technique may be better than other techniques 2. Poor surgical skills: urological surgeon does not adequately remove prostatic tissue 3. Insufficient assessment of LUTS and differential diagnosis 4. LUTS may (also) derive from other concomittant diseases (co-morbidities as contributor, LUTS as a multi-causal problem) and are not diagnosed before prostatic surgery

Reasons for LUTS after Prostatic Surgery Possibilities: 1. Wrong surgical technique: one technique may be better than other techniques 2. Poor surgical skills: urological surgeon does not adequately remove prostatic tissue 3. Insufficient assessment of LUTS and differential diagnosis 4. LUTS may (also) derive from other concomittant diseases (co-morbidities as contributor, LUTS as a multi-causal problem) and are not diagnosed before prostatic surgery

IPSS IPSS Comparison of Surgical Techniques (IPSS) 1 2 3 n.s. n.s. n.s. n.s. 4 5 6 n.s. n.s. n.s. n.s. 1. Mamoulakis C et al. Eur Urol. 2013; 63: 667-76; 2. Tkocz M and Prajsner A. Neuroruol Urodyn. 2002; 21: 112-6, 3. Simforoosh N et al. Urol J. 2010; 7: 262-9; 4. Kuntz RM et al. Eur Urol. 2008; 53: 160-6; 5. Bachmann A et al. Eur Urol. 2014; 65: 931-42; 6. Cimentepe E et al. J Endourol. 2003; 17: 103-7.

Reasons for LUTS After Prostatic Surgery Possibilities: 1. Wrong surgical technique: one technique may be better than other techniques 2. Poor surgical skills: urological surgeon does not adequately remove prostatic tissue 3. Insufficient assessment of LUTS and differential diagnosis 4. LUTS may (also) derive from other concomittant diseases (co-morbidities as contributor, LUTS as a multi-causal problem) and are not diagnosed before prostatic surgery

Poor Surgical Skills similiar and reproducible results in experienced surgeons Similar % improvement of IPSS in RCTs with experienced surgeons learning curves for the individual techniques should be considered SUI in patients with sufficient and anatomically intact external urethral sphincter before prostatic surgery is likely to be a surgical mistake (chance approx. 2%) Marszalek M et al. Eur Urol. 2009; Suppl. 8; 504 512.

Reasons for LUTS After Prostatic Surgery Possibilities: 1. Wrong surgical technique: one technique may be better than other techniques 2. Poor surgical skills: urological surgeon does not adequately remove prostatic tissue 3. Insufficient assessment of LUTS and differential diagnosis 4. LUTS may (also) derive from other concomittant diseases (co-morbidities as contributor, LUTS as a multi-causal problem) and are not diagnosed before prostatic surgery

Indications For Prostatic Surgery Prostate should have caused LUTS; therefore, prostate treatment is likely to resolve LUTS/BPO or LUTS/BPE LUTS which have not been directly or indirectly caused by the prostate will most likely not respond to prostatic surgery Relative indications for prostate operations: insufficient relief of LUTS or PVR after conservative or medical treatments Absolute indications for prostate operations: recurrent or refractory urinary retention, overflow incontinence recurrent UTI due to PVR/BPO bladder stones or diverticula due to BPO treatment-resistant macroscopic haematuria due to BPH/BPE dilatation of the upper urinary tract ± renal insufficiency due to BPO Oelke M et al. Eur Urol. 2013; 64: 118 140.

LUTS are unspecific for: age, gender and diseases, are overlapping, have a multifactorial aetiology. LUTS can originate from: Origin of Pre- or Postoperative LUTS bladder, prostate, urethra, pelvic floor, ureter central or peripheral nervous system, bowel Oelke M et al. Eur Urol. 2013; 64: 118 140.

Insufficient Assessment Assessment helps to indentify the underlying pathophysiology of LUTS Adherence to Guidelines (AUA-BPH) reduces the number of prostate operations (evaluated 12 months after initial patient visit) 5% random sample analysis of Medicare claims data (n = 10,248 patients aged >65 years treated 1999-2007) 675 patients (6.7%) had surgery: x 5.5 2% of patients with highest adherance vs. 11% of patients with lowest adherance to the guidelines 91% decrease of the adjusted odds in patients who were assessed according to the guidelines -82% Strope SA et al. Urology 2012; 80: 84-89.

Reasons for LUTS After Prostatic Surgery Possibilities: 1. Wrong surgical technique: one technique may be better than other techniques 2. Poor surgical skills: urological surgeon does not adequately remove prostatic tissue 3. Insufficient assessment of LUTS and differential diagnosis 4. LUTS may (also) derive from other concomittant diseases (co-morbidities as contributor, LUTS as a multi-causal problem) and are not diagnosed before prostatic surgery

Other Diagnoses Than LUTS/BPO Detrusor overactivity, with or without urgency incontinence, is the main urodynamic diagnosis 76% n = 129 men reflecting the clinical symptoms of urgency, frequency, nocturia, and urgency incontinence 35% had undetected neurogenic bladder dysfunction 50% 38% 37% 30% 26% Nocturia is the main symptom persistent detrusor overactivity does not fully explain the high prevalence other causes of nocturia 10% 4% 4% 0% Seaman EK et al. J Urol. 1994; 152: 935 937.

Other Pathophysiology: Detrusor Overactivity Involuntary detrusor contractions (detrusor overactivity) may be primary (=no detectable cause) or secondary (detectable cause, e.g. BPO) 1,418 men with LUTS suggestive of BPH, age 40 89 years (mean 63) Urodynamic investigation (filling speed 25 ml/min, body-warm saline solution) * * * * * increasing probability of detrusor overactivity with increasing BOO-grade Schäfer 0: 51% Schäfer VI: 83% with increasing BOO-grade: earlier appearance of detrusor overactivity higher amplitude of detrusor overactivity Oelke M et al. Eur Urol. 2008; 54: 419-426.

Consequences After Prostatic Surgery 1,2 2 27% 73% 60% 40% Increased chance of urgency incontinence! 3 1 Roehrborn CG et al. ICUD-BPH Guidelines 1996: 167 254. 2 Machino R et al. Neurourol Urodyn. 2002; 21: 444 449. 3 Knutson T et al. Neurourol Urodyn. 2001; 20: 237 247.

Pathophsiology of Nocturia Many causes of nocturia which may occur independently or concurrently with other LUTS van Kerrebroeck P et al. Int J Clin Pract. 2010; 64: 807-816.

Multiple Factors May Result In Nocturia In Individual Patients van Kerrebroeck P et al. Int J Clin Pract. 2010; 64: 807-816.

Nocturnal Polyuria (ICS Definition) Is Present In A Large Proportion Of Patients With Nocturia Europe n=846 USA n=917 24% 12% 76% 88% Nocturnal polyuria Without nocturnal polyuria (other causes) Weiss JP et al. J Urol. 2011; 186: 1358 63.

BPO Is Only One Cause Of Nocturia MANAGEMENT OF NOCTURIA Bladder problems Inappropriate fluid intake Excessive diuresis Diuretic substances Behavioural anatomical capacity Anticholinergics Botulinum toxin Bladder augmentation Bladder replacement functional capacity Primary: OAB symptoms: anticholinergics botulinum toxin Male LUTS: α-blocker 5ARI Secondary: treat underlying disease, e.g. BPO Too much fluid Reduce fluid intake if no diabetes insipidus or mellitus Wrong time of fluid intake Change time of fluid intake, e.g. >2 hrs before bedtime in patients with nocturnal polyuria Hormone disorder AVP (Diabetes insipidus Nocturnal polyuria) Desmopressin Glucose (Diabetes mellitus) Treat diabetes ANP disorder treat cardiac insufficiency (cardiologist) treat sleep apnoea (pulmonologist) van Kerrebroeck P and Oelke M. In Oelke M and van Kerrebroeck (eds.) Current Aspects on Diagnosis and Treatment of Nocturia. Uni-Med Science 2012. Oelke M et al. World J Urol. 2014; 32: 1109 1117.

How To Avoid Persistant LUTS After Prostatic Surgery? Recommendations: Careful assessment of the patient Use assessment algorithm of the EAU-Guidelines on Male LUTS use frequency-volume charts, especially when your patient has nocturia do rough neurological examination or ask your neurologist to diagnose/exclude neurogenic components perform urodynamic investigation in selected cases

Assessment Path History (+ sexual function) Symptom Score Questionnaire Physical Examination Urinalysis PSA (if diagnosis of Pca will change the management discuss with patient) Measurement of PVR No Bothersome Symptoms? Yes Abnormal DRE Suspicion of neurological disease High PSA Hematuria, nitrites, pyuria, glucose Significant PVR US of kidneys +/- renal function assessment FVC with predominant storage LUTS/nocturia US assessment of prostate Uroflowmetry Evaluate according to relevant Guidelines or clinical standard Treat underlying condition (if any, otherwise return to initial assessment) Medical Treatment according to Treatment Algorithm Endoscopy (if test alters the choice of surgical modality) Pressure Flow Studies (see text for specific indications) Benign Conditions of Bladder and/or Prostate with baseline values PLAN TREATMENT Surgical Treatment according to Treatment Algorithm Gratzke C et al. Eur Urol. 2015; 67: 1099 1109.

Indications For Urodynamic Investigations (prior) To Prostate Operations Urodynamic investigation because BPO is less likely in these patients after previous unsuccessful (invasive) treatment for LUTS with suspicion of neurogenic bladder dysfunction or after pelvic surgery in patients who cannot void > 150 ml in patients who have PVR > 300 ml in men aged > 80 years in men aged < 50 years Gratzke C et al. Eur Urol. 2015; 67: 1099 1109.

How To Manage LUTS After Prostatic Surgery? Follow the accepted indications for prostatic surgery; in cases when LUTS/BPO is present, symptomatic success of the operation is likely (patients with BPO have higher success rate than patients without BPO) Perform computer or mentor training at the beginning of your learning curve to improve your surgical skills Treat residual LUTS according to the pathophysiology, e.g.: detrusor overactivity: behavioural strategies, pelvic floor muscle exercises, antimuscarinics, botulinum toxin nocturia: behavioural strategies, desmopressin in case of nocturnal polyuria