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Editorial: Symptom Scores, Watchful Waiting and Prostate Specific Antigen Levels in Benign Prostatic Hyperplasia
~-5347/!36/1563-1040$03.00/0
voi. 156,1040-1041,September 1996 Printed in U S A .
THE JOWRh'AL OF UROLOGY
Copyright 6 1996 by AMERICAN
UROuXjlCAL Assoc~TIoN,INC
EDITORIAL: SYMPTOM SCORES, WATCHFUL WAITING AND PROSTATE SPECIFIC ANTIGEN LEVELS IN BENIGN PROSTATIC HYPERPLASIA The differentiation of patients according to various grades A number of significant articles have been reported during recent years on the correlation between American Urological of obstruction on the basis of linear passive urethral resisAssociation and international prostatic (I-PSS) symptom tance relation shows the different effects of watchful waiting. scores and urodynamics for benign prostatic hyperplasia It remains unclear why patients with mild obstruction had (BPHl.1-4 This issue of the Journal presents another impor- more obstruction and patients with severe obstruction had tant study compiled by Ezz El Din et a1 (page 1020) on less obstruction &er 6 months of watchful waiting. This comparison of bladder outlet obstruction and lower urinary phenomenon was discussed extensively by the authors, tract symptoms in 803 patients classified into groups with which resulted in more questions than answers. The main mild, moderate and severe symptoms according to scores of 8, question appears to focus on the extent to which the change 19 and more than 19.Outlet obstruction was classified based in outlet obstruction may be observed due to the fluctuation on pressure-flow studies, and the corresponding analyses of the biological system or dynamic components of the obusing linear passive urethral resistance relation and ure- struction, or if there is a true spontaneous improvement in thral resistant factor. Due to the large number of patients mechanical bladder outlet obstruction. The problem arises with varying I-PSS in groups demonstrating mild, moderate when comparing changes in pressure-flow measurements in and severe obstruction, a merely modest statistically signif- placebo controlled studies with a-blockers or finasteride, or icant correlation could be determined between I-PSS and with reported effects of treatment with high focused ultraobstruction parameters, which again confirmed the missing sound, laser or thermotherapy. Reported effects of a-blockers connection between symptoms and the underlying outlet ob- indicating similar changes compared to 6 months of watchful struction. The fact that, on average, more symptoms are waiting are not to be interpreted as a physiological variabilevident with a greater degree of obstruction was not entirely ity in the case of determining significant effects compared to relevant for the individual due to the huge overlap of symp- placebo effects. This finding does not present a logical argutom scores. The results indicate that symptoms of BPH dem- ment, since in the placebo group a similar physiological varionstrate a specific pathophysiological category, and well val- ability must be assumed if the groups are not different before idated symptom scores may quantify symptoms in patients therapy. but do not confirm any underlying obstruction. The study A comparison of the results to the study of Rosier et al, who presented is most interesting in that of this large group of investigated the physiological variability of obstruction by 2 patients 31% had no obstruction according to the linear pas- voiding sessions during the same urodynamic measurement, sive urethral resistance relation. Nevertheless, 31% of these seems to be problematk6 A different group is being examnonobstructive patients demonstrated severe symptoms. On ined in this case. The statement on biological variability in the other hand, 15% of patients with severe bladder outlet the watchful waiting group would be valid only if comparaobstruction had only mild symptoms. The authors inferred tive values from 2 voiding sessions were made available for logically that, judging from symptoms only, no indication the same group during the same urodynamic measurement. could be made as to whether surgical treatment was reMarks et a1 (page 1035) question the extent to which sequired. Several analyses revealed that the patient with se- rum prostate specific antigen (PSA) changes after transurevere symptoms would most likely undergo surgery, whereas thral prostatectomy or enucleation. The importance of this a patient with moderate symptoms would be more suited for study is based on the fact that 82 patients were reviewed for conservative treatment.5 With this fact in mind, it would 5 years, demonstrating possible postoperative changes in appear rather problematic for the patient to decide which PSA during this period by PSA velocity. The authors showed form of therapy would be most beneficial. that serum PSA decreased in direct relationship to the Witjes et a1 (page 1026)dealt mainly with the variability of amount of resected tissue. For each gram of resected prosclinical and urodynamic data 6 months after watchful wait- tatic tissue mean serum PSA plus or minus standard deviaing in patients with BPH. This study is of particular interest, tion decreased by 0.11 5 0.02 ng./ml. Postoperatively, the since it investigates a relatively large group of 178 patients values remained low independent of the resected tissue. Acundergoing watchful waiting, as well as assesses thoroughly cording to the results, it appears essential that other normal the effect on subjective symptoms and objective outlet ob- values for serum PSA may be valid for patients after transstruction. Pressure-flow measurements were used to analyze urethral prostatectomy. It remains to be determined whether outlet obstruction. The 178 patients in the watchful waiting the postoperative value of 0.85 ng./ml. given by the authors group constituted 24% of all BPH cases treated between is, in fact, feasible since the value obtained depends on the January 1992 and November 1994.It may be assumed from radicality of the transurethral prostatectomy performed. For the study by Ezz El Din et al that most of these patients did future investigations it would appear more beneficial to cornot have obstruction (31% of 750). However, 36% of the relate PSA decrease with amount of resected tissue in relawatchful waiting group had moderate and 20% had severe tion to total prostate volume preoperatively. As in the case of obstruction. Different grades of obstruction enable the au- nonoperated patients, the extent to which serum PSA inthors to investigate the influence of watchful waiting on crease indicates the probability of carcinoma formation rethese various groups. Overall, the results revealed that the mains to be determined. At least 6 of 82 patients demonI-PSS improved significantly in 64% of patients. However, strated the unlikelihood of predicting an invasive carcinoma changes in objective parameters of bladder outlet obstruction by PSA or PSA velocity. were not as clearly demonstrated, which were to be expected. The discrepancy shown between subjective and objective Udo Jonas and Klaus Hofner data after 6 months of watchful waiting showed that a missDepartment of Urology ing correlation between changes in the subjective and objecHannover Medical School tive data may exist in the outcome of a specific treatment. Hannover, Germany 1040
BENIGN PROSTATIC HYPERPLASIA REFERENCES
1. Yalla, S. V., Sullivan, M. P., Lecamwasam, H. S., DuBeau, C. E., Vickers, M. A. and Cravalho, E. G.: Correlation of American Urological Association symptom index with obstructive and nonobstructive prostatism. J. Urol., 153: 674, 1995. 2. van Venrooij, G. E. P. M., Boon, T. A. and de Gier, R. P. E.: International prostate symptom score and quality of life assessment versus urodynamic parameters in men with benign prostatic hyperplasia symptoms. J . Urol., 153: 1516,1995. 3. Nitti, V. W., Kim, Y. and Combs, A. J.: Correlation of the AUA symptom index with urodynamics in patients with suspected benign prostatic hyperplasia. Neurourol. Urodynam., 1 3 521, 1994. 4. KO,D.S., Fonster, H. N., Chambers, K., Sullivan, L. D., Jens, M.
1041
and Goldenberg, S. L.: The correlation of multichannel urodynamic pressure-flow studies and American Urological Association symptom index in the evaluation of benign prostatic hyperplasia. J. Urol., 151:396,1995. 5. McConnell, J. D.,Barry, M. J. and Bruskewitz, R. C.: Benign prostatic hyperplasia: diagnosis and treatment. In: Quick Reference Guide for Clinicians. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, United S t a t e s Department of Health a n d H u m a n Services, AHCPR Publication No. 94-0583,February, 1994. 6. Rosier, P. F.W. M., de la Rosette, J. J. M. C. H., Koldewijn, E. L., Debruyne, F. M. J. and Wijkstra, H.: Variability of pressureflow analysis parameters in repeated cystometry in patients with benign prostatic hyperplasia. J. Urol., 153 1520, 1995.
voi. 156,1040-1041,September 1996 Printed in U S A .
THE JOWRh'AL OF UROLOGY
Copyright 6 1996 by AMERICAN
UROuXjlCAL Assoc~TIoN,INC
EDITORIAL: SYMPTOM SCORES, WATCHFUL WAITING AND PROSTATE SPECIFIC ANTIGEN LEVELS IN BENIGN PROSTATIC HYPERPLASIA The differentiation of patients according to various grades A number of significant articles have been reported during recent years on the correlation between American Urological of obstruction on the basis of linear passive urethral resisAssociation and international prostatic (I-PSS) symptom tance relation shows the different effects of watchful waiting. scores and urodynamics for benign prostatic hyperplasia It remains unclear why patients with mild obstruction had (BPHl.1-4 This issue of the Journal presents another impor- more obstruction and patients with severe obstruction had tant study compiled by Ezz El Din et a1 (page 1020) on less obstruction &er 6 months of watchful waiting. This comparison of bladder outlet obstruction and lower urinary phenomenon was discussed extensively by the authors, tract symptoms in 803 patients classified into groups with which resulted in more questions than answers. The main mild, moderate and severe symptoms according to scores of 8, question appears to focus on the extent to which the change 19 and more than 19.Outlet obstruction was classified based in outlet obstruction may be observed due to the fluctuation on pressure-flow studies, and the corresponding analyses of the biological system or dynamic components of the obusing linear passive urethral resistance relation and ure- struction, or if there is a true spontaneous improvement in thral resistant factor. Due to the large number of patients mechanical bladder outlet obstruction. The problem arises with varying I-PSS in groups demonstrating mild, moderate when comparing changes in pressure-flow measurements in and severe obstruction, a merely modest statistically signif- placebo controlled studies with a-blockers or finasteride, or icant correlation could be determined between I-PSS and with reported effects of treatment with high focused ultraobstruction parameters, which again confirmed the missing sound, laser or thermotherapy. Reported effects of a-blockers connection between symptoms and the underlying outlet ob- indicating similar changes compared to 6 months of watchful struction. The fact that, on average, more symptoms are waiting are not to be interpreted as a physiological variabilevident with a greater degree of obstruction was not entirely ity in the case of determining significant effects compared to relevant for the individual due to the huge overlap of symp- placebo effects. This finding does not present a logical argutom scores. The results indicate that symptoms of BPH dem- ment, since in the placebo group a similar physiological varionstrate a specific pathophysiological category, and well val- ability must be assumed if the groups are not different before idated symptom scores may quantify symptoms in patients therapy. but do not confirm any underlying obstruction. The study A comparison of the results to the study of Rosier et al, who presented is most interesting in that of this large group of investigated the physiological variability of obstruction by 2 patients 31% had no obstruction according to the linear pas- voiding sessions during the same urodynamic measurement, sive urethral resistance relation. Nevertheless, 31% of these seems to be problematk6 A different group is being examnonobstructive patients demonstrated severe symptoms. On ined in this case. The statement on biological variability in the other hand, 15% of patients with severe bladder outlet the watchful waiting group would be valid only if comparaobstruction had only mild symptoms. The authors inferred tive values from 2 voiding sessions were made available for logically that, judging from symptoms only, no indication the same group during the same urodynamic measurement. could be made as to whether surgical treatment was reMarks et a1 (page 1035) question the extent to which sequired. Several analyses revealed that the patient with se- rum prostate specific antigen (PSA) changes after transurevere symptoms would most likely undergo surgery, whereas thral prostatectomy or enucleation. The importance of this a patient with moderate symptoms would be more suited for study is based on the fact that 82 patients were reviewed for conservative treatment.5 With this fact in mind, it would 5 years, demonstrating possible postoperative changes in appear rather problematic for the patient to decide which PSA during this period by PSA velocity. The authors showed form of therapy would be most beneficial. that serum PSA decreased in direct relationship to the Witjes et a1 (page 1026)dealt mainly with the variability of amount of resected tissue. For each gram of resected prosclinical and urodynamic data 6 months after watchful wait- tatic tissue mean serum PSA plus or minus standard deviaing in patients with BPH. This study is of particular interest, tion decreased by 0.11 5 0.02 ng./ml. Postoperatively, the since it investigates a relatively large group of 178 patients values remained low independent of the resected tissue. Acundergoing watchful waiting, as well as assesses thoroughly cording to the results, it appears essential that other normal the effect on subjective symptoms and objective outlet ob- values for serum PSA may be valid for patients after transstruction. Pressure-flow measurements were used to analyze urethral prostatectomy. It remains to be determined whether outlet obstruction. The 178 patients in the watchful waiting the postoperative value of 0.85 ng./ml. given by the authors group constituted 24% of all BPH cases treated between is, in fact, feasible since the value obtained depends on the January 1992 and November 1994.It may be assumed from radicality of the transurethral prostatectomy performed. For the study by Ezz El Din et al that most of these patients did future investigations it would appear more beneficial to cornot have obstruction (31% of 750). However, 36% of the relate PSA decrease with amount of resected tissue in relawatchful waiting group had moderate and 20% had severe tion to total prostate volume preoperatively. As in the case of obstruction. Different grades of obstruction enable the au- nonoperated patients, the extent to which serum PSA inthors to investigate the influence of watchful waiting on crease indicates the probability of carcinoma formation rethese various groups. Overall, the results revealed that the mains to be determined. At least 6 of 82 patients demonI-PSS improved significantly in 64% of patients. However, strated the unlikelihood of predicting an invasive carcinoma changes in objective parameters of bladder outlet obstruction by PSA or PSA velocity. were not as clearly demonstrated, which were to be expected. The discrepancy shown between subjective and objective Udo Jonas and Klaus Hofner data after 6 months of watchful waiting showed that a missDepartment of Urology ing correlation between changes in the subjective and objecHannover Medical School tive data may exist in the outcome of a specific treatment. Hannover, Germany 1040
BENIGN PROSTATIC HYPERPLASIA REFERENCES
1. Yalla, S. V., Sullivan, M. P., Lecamwasam, H. S., DuBeau, C. E., Vickers, M. A. and Cravalho, E. G.: Correlation of American Urological Association symptom index with obstructive and nonobstructive prostatism. J. Urol., 153: 674, 1995. 2. van Venrooij, G. E. P. M., Boon, T. A. and de Gier, R. P. E.: International prostate symptom score and quality of life assessment versus urodynamic parameters in men with benign prostatic hyperplasia symptoms. J . Urol., 153: 1516,1995. 3. Nitti, V. W., Kim, Y. and Combs, A. J.: Correlation of the AUA symptom index with urodynamics in patients with suspected benign prostatic hyperplasia. Neurourol. Urodynam., 1 3 521, 1994. 4. KO,D.S., Fonster, H. N., Chambers, K., Sullivan, L. D., Jens, M.
1041
and Goldenberg, S. L.: The correlation of multichannel urodynamic pressure-flow studies and American Urological Association symptom index in the evaluation of benign prostatic hyperplasia. J. Urol., 151:396,1995. 5. McConnell, J. D.,Barry, M. J. and Bruskewitz, R. C.: Benign prostatic hyperplasia: diagnosis and treatment. In: Quick Reference Guide for Clinicians. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, United S t a t e s Department of Health a n d H u m a n Services, AHCPR Publication No. 94-0583,February, 1994. 6. Rosier, P. F.W. M., de la Rosette, J. J. M. C. H., Koldewijn, E. L., Debruyne, F. M. J. and Wijkstra, H.: Variability of pressureflow analysis parameters in repeated cystometry in patients with benign prostatic hyperplasia. J. Urol., 153 1520, 1995.