Living with a 100 ml prostate: Outcomes over a decade

Abstract

Objective:

The objective of this article is to determine outcomes and guide the management of patients with a prostate volume of 100 ml or greater.

Patients and methods:

A database of patients undergoing transrectal ultrasound (TRUS)-guided biopsy from 1994 to 1999 was analysed. Records of those with a prostate of 100 ml or greater were reviewed.

Results:

A total of 63 patients were included in the study with a mean follow-up of 11 years. Initial TRUS-guided biopsy yielded prostate cancer (CaP) in six of 63 (10%). Twenty-six of 63 (41%) underwent repeat biopsies. CaP was ultimately diagnosed in 13/63 (21%). Prostate-specific antigen (PSA) levels were erratic over time, making monitoring difficult. The PSA coefficient of variation in benign prostates ranged from 8.9% to 48.6% in the year following biopsy.

Twenty-one of 50 (42%) with benign prostates experienced acute urinary retention (AUR), 31/50 (62%) haematuria and 43/50 (86%) received treatment for lower urinary tract symptoms (LUTS). Twenty-six of 50 (52%) received 5-alpha reductase inhibitors (5ARI), 11/50 (22%) α-blockers and 28/50 (56%) surgery. Thirteen of 15 (87%) experienced further symptoms when treated for less than two years with 5ARI versus five of 16 (31%) receiving long-term treatment (mean duration 8.1 years). Fifteen of 25 (60%) experienced haematuria following TURP and 14/25 (56%) required further treatment.

Conclusion:

Large prostates cause considerable symptoms prompting multiple medical consultations and investigations. PSA monitoring in this group is difficult, leading to repeated biopsies of benign prostates. Long-term 5ARI treatment should be considered to reduce progression to AUR, the incidence of haematuria and to facilitate PSA monitoring. Newer treatment modalities such as holmium laser enucleation (HoLEP) should be considered ahead of TURP. When TURP is performed, 5ARI treatment should be considered post-operatively. This group of men should have close urological follow-up.

Keywords

Prostate finasteride acute urinary retention haematuria TURP HoLEP

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References

Berry

Coffey

Walsh

. The development of human benign prostatic hyperplasia with age. J Urol 1984; 132: 474–479.

Roehrborn

McConnell

Lieber

. Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia. PLESS Study Group. Urology 1999; 53: 473–480.

Later life in the United Kingdom. Age UK, http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/Later_life_UK_factsheet.pdf?dtrk=true (accessed February 2014).

2011 Census: Population and household estimates for the United Kingdom. Usual resident population by five-year age group and sex, local authorities in the United Kingdom. Office for National Statistics, www.ons.gov.uk (accessed February 2014).

Marberger

. The MTOPS Study: New findings, new insights, and clinical implications for the management of BPH. Eur Urol Supp 2006; 5: 628–633.

McConnell

Bruskewitz

Walsh

. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med 1998; 338: 557–563.

Roehrborn

. Reducing the risk of benign prostatic hyperplasia progression. Rev Urol 2002; 4 (Suppl 5): S29–S38.

Oelke

Bachmann

Descazeaud

. Guidelines on the management of male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). Uroweb 2012, http://www.uroweb.org/gls/pdf/13_Male_LUTS_LR.pdf (accessed September 2013).

Vaughan

Imperato-McGinley

McConnell

. Long-term (7 to 8-year) experience with finasteride in men with benign prostatic hyperplasia. Urology 2002; 60: 1040–1044.

10.

Roehrborn

Marks

Fenter

. Efficacy and safety of dutasteride in the four-year treatment of men with benign prostatic hyperplasia. Urology 2004; 63: 709–715.

11.

Lin

Liao

Kuo

. Progression of lower urinary tract symptoms after discontinuation of 1 medication from 2-year combined alpha-blocker and 5-alpha-reductase inhibitor therapy for benign prostatic hyperplasia in men – a randomized multicenter study. Urology 2014; 83: 416–421.

12.

Foley

Soloman

Wedderburn

. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. J Urol 2000; 163: 496–498.

13.

Boddy

Dev

Pike

. Intra-individual variation of serum prostate specific antigen levels in men with benign prostate biopsies. BJU Int 2004; 93: 735–738.

14.

Thompson

Jr Goodman

Tangen

. Long-term survival of participants in the Prostate Cancer Prevention Trial. N Engl J Med 2013; 369: 603–610.

15.

Andriole

Bostwick

Brawley

. Effect of dutasteride on the risk of prostate cancer (for the REDUCE Study Group). N Engl J Med 2010; 362: 1192–1202.

16.

Kuntz

Lehrich

Ahyai

. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008; 53: 160–166.

17.

Tan

Gilling

Kennett

. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40–200 grams). J Urol 2003; 170 (4 Pt 1): 1270–1274.

18.

National Institute for Health and Care Excellence. The management of lower urinary tract symptoms in men. Costing report. Implementing NICE guidance. May 2010, http://guidance.nice.org.uk/CG97/CostingReport/pdf/English (accessed September 2013).