**7.4 Surgical treatment**

Men who develop serious complications from BPH should be treated surgically in most of the cases. Both Agency for Health Care Policy and Research and International Consensus

finasteride and dutasteride and are more effective in prostates larger than 40 mL (Boyle, Gould et al. 1996). According to some trials, finasteride significantly reduced acute urinary

5-ARIs are the only pharmacologic treatment that may be used to prevent progression of LUTS secondary to BPH and to reduce the risk of urinary retention and future prostaterelated surgery. Therefore, indirectly, it may be useful in preventing BPH complications such as chronic kidney failure. However, they can't revert CKD related to BPH after

**Inhibitor Dosage Side-effects** 

gynecomastia **Dutasteride** 1 mg once a day May increase up to 8 mg once daily

Finasteride inhibits exclusively the 5-AR type II isoenzyme, while dutasteride inhibits both types I and II. This difference in activity leads to a reduction in serum levels of dihydroxytestosterone (DHT) by approximately 70% with finasteride compared to

Finasteride (and probably dutasteride) is an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding (Foley, Soloman et

The Medical Therapy of Prostate Symptoms (MTOPS) Study demonstrated that in the long term, among men with larger prostates, combination therapy is superior to either alphablocker or 5-ARI therapy in preventing progression and improving symptoms (McConnell,

The use of plant-derived agents (*Serenoa repens* or Saw palmetto, *Pygeum africanum*) on LUTS and BPH has been popular in Europe for many years and has recently spread in the USA. Their mechanism of action is still unclear. However they seem to improve urinary symptoms without important side effects. In some studies the efficacy of these compounds was found to be equivalent to 5-ARIs and alpha-blockers (Lowe 2001; Debruyne, Koch et al. 2002). The most widely studied and used, *Serenoa repens*, has no effect on prostate volume or the PSA test, but slightly decreases the prostate epithelium. It does not cause erectile dysfunction, but the herb may aggravate chronic gastrointestinal disease such as peptic

Men who develop serious complications from BPH should be treated surgically in most of the cases. Both Agency for Health Care Policy and Research and International Consensus

**Finasteride** 5 mg once a day Erectile dysfunction, decreased

libido, decreased serum PSA,

retention and the need for surgical treatment in men with BPH.

Table 4. 5 alpha-reductase inhibitors used, dosage and side-effects.

approximately 95% with dutasteride (Clark, Hermann et al. 2004).

al. 2000; Kearney, Bingham et al. 2002; Perimenis, Gyftopoulos et al. 2002).

installed.

**5-Alpha-Reductase** 

**7.3.3 Combination therapy** 

ulcer (Bent, Kane et al. 2006).

**7.4 Surgical treatment** 

Roehrborn et al. 2003).

**7.3.4 Phytotherapy** 

Guidelines recommend surgery if the patient has refractory or recurrent urinary retention (failing at least one attempt of catheter removal) or any of the following conditions clearly secondary to BPH: recurrent UTI, recurrent gross hematuria, bladder stones, renal insufficiency, or large bladder diverticula (McConnell, Barry et al. 1994) (Denis et al., 1998). Studies suggest that dialysis dependent patients may recover renal function up to a year after prostatic surgery. In this setting, efforts should be made to identify and treat BPH in patients under dialysis.

Surgeries are associated with postoperative risks such as erectile dysfunction (4% to 10% incidence) and urinary incontinence (0.5% to 1.5%) (Flanigan, Reda et al. 1998) (McConnell, Bruskewitz et al. 1998). The 5-year recurrence rate of BPH following surgery is 2% to 10%(Flanigan, Reda et al. 1998). Proper therapy can be offered to the right men and the costs of long-term renal damage and post-surgical complications can be avoided.
