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CUA guideline: LUTS/BPH
large volume of urine during sleep. More specifically, 33% erectile dysfunction (6.5%), and need for surgical retreat-
of the total daily urine volume occurs at night, while the ment (2%/year). 51,52
daily total urine output remains normal. Desmopressin is
a synthetic analogue of the antidiuretic hormone, arginine We recommend M-TURP as a standard first-line surgical
vasopressin (AVP). Desmopressin reduces total nocturnal therapy for men with moderate-to-severe LUTS/BPH with
voids and increases hours of undisturbed sleep by reducing prostate volume of 30–80 cc (strong recommendation, evi-
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urine production in men with NP. While the risk of hypo- dence level A).
natremia is low in men with normal baseline serum sodium,
sodium must be checked at baseline in all men, as well as Bipolar TURP (including bipolar plasma kinetic vaporization)
4–8 days and 30 days after initiation of treatment in men tak- Bipolar TURP (B-TURP) offers a resection alternative to
ing desmopressin melts or men ≥65 years taking 50 μg oral M-TURP in men with moderate to-severe LUTS secondary
disintegrating tablet. In men whose predominant symptom is to BPH with similar efficacy, but lower perioperative mor-
bothersome nocturia and who do not respond to conserva- bidity. 52-54 The predominant difference between M-TURP
tive measures or other monotherapies, desmopressin should and B-TURP is the decreased risk of perioperative bleed-
be considered. ing and TUR syndrome. The choice of B-TURP should be
based on equipment availability, surgeon experience, and
We recommend desmopressin as a therapeutic option in patient preference.
men with LUTS/BPH with nocturia as result of NP (condi-
tional recommendation, evidence level B). We recommend B-TURP as a standard first-line surgical
therapy for men with moderate-to-severe LUTS/BPS with
2.3.8. Phytotherapies prostate volume of 30–80 cc (strong recommendation, evi-
Plant-based herbal preparations may appeal to some dence level B).
patients. Common formulations include Serenoa repens
(saw palmetto), Pygeum africanum (African plum bark), and 2.4.2. Open simple prostatectomy
Urtica dioica (stinging nettle). Phytotherapies lack consistent Open simple prostatectomy (OSP) is an effective treatment
formulation, predictable pharmacokinetics, and regulatory alternative for men with moderate-to-severe LUTS with sub-
oversight. Numerous studies and Cochrane meta-analyses stantially enlarged prostates >80 cc and who are signifi-
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report no significant difference between phytotherapies and cantly bothered by symptoms. Other indications for OSP
placebo, as measured by AUA-SI, peak flow rates, prostate include plans for concurrent bladder procedure, such as
volume, residual urine volume, PSA, or quality of life. 45-48 diverticulectomy or cystolithotomy (for very large bladder
There are few side effects associated with phytotherapies but calculi) and in men who are unable to be placed in dorsal
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there are important potential drug interactions. lithotomy position due to severe hip disease. OSP is the
most invasive surgical method requiring longer hospitaliza-
We do not recommend phytotherapies as standard treat- tion and catheterization. The estimated transfusion rate has
ment for MLUTS/BPH (strong recommendation, evidence been reported as 7–14%. 55,56 Complications include transient
level B). urinary incontinence (8–10%), bladder neck contracture,
and urethral stricture (5–6%). 55,56
2.4. Surgical therapy
We recommend OSP as a first-line surgical therapy when
2.4.1. TURP anatomic endoscopic enucleation of the prostate (AEEP)
(see below) is unavailable for men with moderate-to-severe
Monopolar TURP LUTS/BPS and enlarged prostate volume >80 cc (strong
Monopolar TURP (M-TURP) remains the primary, stan- recommendation, evidence level A).
dard-reference surgical treatment option for moderate-to-
severe LUTS due to BPH in patients with prostate volume 2.4.3. Minimally invasive simple prostatectomy
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30–80 cc. Perioperative mortality has decreased over time With the advent of minimally invasive surgery, starting with
and is currently approximately 0.1%, while morbidity is relat- laparoscopy and proceeding to robotic-assisted laparoscopy,
ed to prostate volume (particularly >60 cc). Contemporary the natural evolution came to the OSP as well. These tech-
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series have reported the following complications: bleeding niques are still relatively new.
(2–9%), capsule perforation with significant extravasation Laparoscopic simple prostatectomy (LSP) and robot-assist-
(2%), TUR syndrome (0.8%), urinary retention (4.5–13%), ed simple prostatectomy (RASP), like OSP, are indicated in
infection (3–4%; sepsis 1.5%), incontinence (<1%), blad- patients with significantly enlarged prostates (>80–100cc)
der neck contracture (3–5%), retrograde ejaculation (65%), and bothersome LUTS. 57,58 They are also beneficial when
CUAJ • August 2022 • Volume 16, Issue 8 249