**7.3.1 Alpha-blockers**

Alpha-blockers address the dynamic component of prostatic obstruction by antagonizing the adrenergic receptors responsible for smooth muscle tone within the stroma, prostate capsule and bladder neck, providing the most rapid symptom relief. They include: terazosin, doxazosin, alfuzosin, tamsulosin and silodosin. These drugs have similar efficacy but different patterns of side-effects:


Table 3. Alpha blockers used, dosage and side-effects.

The older, less costly, generic alpha blockers remain reasonable choices. However, these require dose titration and blood pressure monitoring. Alpha-blockers are the most prescribed medications for BPH as long as they have a rapid (symptoms may improve in 48 hours) and significant improvement on LUTS.

#### **7.3.2 5-alpha-reductase inhibitors**

5-Alpha-Reductase Inhibitors (5-ARI) are anti-androgenic hormonal agents that address the static component of BPH by reducing the prostate volume (up to 20-30%). They include

Benign Prostate Hyperplasia and Chronic Kidney Disease 367

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

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

TURP (transurethral resection of the prostate) is the hallmark of the urologist, the one against which other therapeutic measures are compared. It takes 20 to 30 minutes to resects an average gland weighing of 30 g and carry risks complications like bleeding, infections,

In patients presenting with renal failure due to bladder outflow obstruction, TURP restores normal voiding pattern in many cases. However renal failure due to bladder outflow obstruction tends to be more refractory and 57% of patients in Thomas *et* al. study were dialysis dependent after surgery. Only 3 of 14 patients experienced return to normal renal

Mortality following prostatectomy has decreased significantly within the past two decades and is less than < 0.25% in contemporary series (Holman, Wisniewski et al. 1999; Hahn, Farahmand et al. 2000). The risk of a TUR-syndrome (fluid intoxication, serum Na+<130 nmol/L) is in the range of 2%. Risk factors for the development of the TUR-syndrome are excessive bleeding with opening of venous sinuses, prolonged operation time, large glands

Open prostatectomy is the treatment of choice for large glands (>80-100 mL), bladder stones or if resection of bladder diverticula is indicated. Open prostatectomy involves the surgical removal (enucleation) of the inner portion of the prostate via a suprapubic or retropubic

Standard operations are *TURP* in small (≤80-100mL) or open prostatectomy in large prostates (>80-100mL). Minimally invasive, alternative surgeries may be considered in selected men and offer advantages regarding risk of bleeding, duration of catheterization, or

*Transurethral incision of the pro*state (TUIP) or bladder neck incision is recommended for smaller gland (weigh <25g) and has been found to be less invasive than TURP (Orandi 1990). TUIP has several advantages over TURP, such as a lower incidence of complications,

of long-term renal damage and post-surgical complications can be avoided.

retrograde-ejaculation, hospital stay, impotence and incontinence.

function post TURP (Thomas, Thomas et al. 2009).

**7.6 Minimally invasive surgical therapies** 

maintenance of sexual function. (Gabuev and Oelke 2011).

patients under dialysis.

**7.5 Standard surgical procedures** 

and past or present smoking.

prostatectomy.

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

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 installed.


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

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

Finasteride (and probably dutasteride) is an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding (Foley, Soloman et al. 2000; Kearney, Bingham et al. 2002; Perimenis, Gyftopoulos et al. 2002).

### **7.3.3 Combination therapy**

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, Roehrborn et al. 2003).
