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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-
       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-
       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
       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
       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-
       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
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