How do new data from clinical trials allow us to optimise the assessment and treatment of patients with benign prostatic hyperplasia?

Current guidelines for the management of benign prostatic hyperplasia (BPH) provide clear guidance on the use of surgery in men with absolute indications; however, less advice is given on the optimal use of surgical versus minimally invasive versus medical therapies for remaining patients. Minimally invasive therapies (MITs) differ in their efficacy, durability, and adverse event profiles. The less invasive nature of MIT must be weighed against the greater need for secondary procedures compared with surgery. Of the available medical therapies, alpha-blockers provide rapid symptom relief but evidence demonstrates that they do not significantly affect the long-term risks of acute urinary retention (AUR) and surgery. In contrast, the 5 alpha-reductase (5-AR) inhibitors provide less rapid symptom relief but reduce prostate volume. They also reduce long-term risks of AUR and surgery. Combination therapy with 5-AR inhibitor therapy and an alpha-blocker may provide greater benefits in selected patients. The ongoing phase 3 Combination of Avodart (R) and Tamsulosin (CombAT) study is examining combination therapy using the dual 5-AR inhibitor dutasteride in a high-risk group. The choice of medical versus minimally invasive or surgical therapy should therefore be thoroughly discussed with patients, and the magnitude and durability of benefits and adverse events individualised to allow them to make a considered choice. Selection of medical therapy should include an assessment of the likelihood of BPH progression based on prostate volume and/or serum prostate-specific antigen level. (c) 2007 Published by Elsevier B.V. on behalf of European Association of Urology.