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EAU Guidelines on the Management of Non-Neurogenic Male LUTS 2019

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EAU Guidelines on the Management of Non-Neurogenic Male LUTS 2019 EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO) S. Gravas (Chair), J.N. Cornu, M. Gacci, C. Gratzke, T.R.W. Herrmann, C. Mamoulakis, M. Rieken, M.J. Speakman, K.A.O. Tikkinen Guidelines Associates: M. Karavitakis, I. Kyriazis, S. Malde, V. Sakalis, R. Umbach © European Association of Urology 2019 TABLE OF CONTENTS PAGE 1. INTRODUCTION 4 1.1 Aim and objectives 4 1.2 Panel composition 4 1.3 Available publications 4 1.4 Publication history 4 2. METHODS 4 2.1 Introduction 4 2.2 Review 5 2.3 Patients to whom the guidelines apply 5 3. EPIDEMIOLOGY, AETIOLOGY AND PATHOPHYSIOLOGY 5 4. DIAGNOSTIC EVALUATION 6 4.1 Medical history 6 4.2 Symptom score questionnaires 7 4.2.1 The International Prostate Symptom Score (IPSS) 7 4.2.2 The International Consultation on Incontinence Questionnaire (ICIQ-MLUTS) 7 4.2.3 Danish Prostate Symptom Score (DAN-PSS) 7 4.3 Frequency volume charts and bladder diaries 7 4.4 Physical examination and digital-rectal examination 8 4.4.1 Digital-rectal examination and prostate size evaluation 8 4.5 Urinalysis 8 4.6 Prostate-specific antigen (PSA) 9 4.6.1 PSA and the prediction of prostatic volume 9 4.6.2 PSA and the probability of PCa 9 4.6.3 PSA and the prediction of BPO-related outcomes 9 4.7 Renal function measurement 9 4.8 Post-void residual urine 10 4.9 Uroflowmetry 10 4.10 Imaging 11 4.10.1 Upper urinary tract 11 4.10.2 Prostate 11 4.10.2.1 Prostate size and shape 11 4.10.3 Voiding cysto-urethrogram 11 4.11 Urethrocystoscopy 11 4.12 Urodynamics 12 4.12.1 Diagnosing bladder outlet obstruction 12 4.12.2 Videourodynamics 12 4.13 Non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS 13 4.13.1 Prostatic configuration/intravesical prostatic protrusion (IPP) 13 4.13.2 Bladder/detrusor wall thickness and ultrasound-estimated bladder weight 13 4.13.3 Non-invasive pressure-flow testing 13 4.13.4 The diagnostic performance of non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS compared with pressure-flow studies 14 5. DISEASE MANAGEMENT 15 5.1 Conservative treatment 15 5.1.1 Watchful waiting (WW) 15 5.1.2 Behavioural and dietary modifications 16 5.1.3 Practical considerations 16 5.2 Pharmacological treatment 17 5.2.1 α1-Adrenoceptor antagonists (α1-blockers) 17 5.2.2 5α-reductase inhibitors 18 5.2.3 Muscarinic receptor antagonists 19 5.2.4 Phosphodiesterase 5 inhibitors 20 5.2.5 Plant extracts - phytotherapy 22 5.2.6 Beta-3 agonist 22 2 MANAGEMENT OF NON-NEUROGENIC MALE LOWER URINARY TRACT SYMPTOMS (LUTS) - UPDATE MARCH 2019 5.2.7 Combination therapies 24 5.2.7.1 α1-blockers + 5α-reductase inhibitors 24 5.2.7.2 α1-blockers + muscarinic receptor antagonists 25 5.3 Surgical treatment 26 5.3.1 Transurethral resection of the prostate and transurethral incision of the prostate 26 5.3.1.1 Modifications of TURP: bipolar TURP 27 5.3.1.1.1 Modifications of B-TURP: bipolar transurethral vaporisation of the prostate 28 5.3.2 Open prostatectomy 30 5.3.3 Laser treatments of the prostate 30 5.3.3.1 Holmium laser enucleation and holmium laser resection of the prostate 30 5.3.3.1.1 Summary of evidence and recommendations for HoLEP and HoLRP 32 5.3.3.2 532 nm (‘Greenlight’) laser vaporisation of the prostate 32 5.3.3.2.1 Summary of evidence and recommendations for 532 nm (‘Greenlight’) laser vaporisation of prostate 33 5.3.3.3 Diode laser treatment of the prostate 34 5.3.3.3.1 Summary of evidence and recommendations for diode laser treatment of the prostate 35 5.3.3.4 Thulium:yttrium-aluminium-garnet laser (Tm:YAG) 35 5.3.3.4.1 Summary of evidence and recommendations for the use of the Thulium:yttrium-aluminium-garnet laser (Tm:YAG) 36 5.3.4 Prostatic stents 36 5.3.5 Prostatic urethral lift 37 5.3.6 Intra-prostatic injections 38 5.3.7 Techniques under investigation 39 5.3.7.1 Minimal invasive simple prostatectomy 39 5.3.7.2 (i)TIND 39 5.3.7.3 Aquablation – image guided robotic waterjet ablation: AquaBeam 40 5.3.7.4 Convective water vapour energy (WAVE) ablation: The Rezum system 40 5.3.7.5 Prostatic artery embolisation 41 5.4 Patient selection 42 5.5 Management of Nocturia in men with lower urinary tract symptoms 44 5.5.1 Diagnostic assessment 45 5.5.2 Medical conditions and sleep disorders Shared Care Pathway 46 5.5.3 Treatment for Nocturia 47 5.5.3.1 Antidiuretic therapy 47 5.5.3.2 Medications to treat LUTD 48 5.5.3.3 Other medications 48 6. FOLLOW-UP 49 6.1 Watchful waiting (behavioural) 49 6.2 Medical treatment 49 6.3 Surgical treatment 50 7. REFERENCES 50 8. CONFLICT OF INTEREST 78 9. CITATION INFORMATION 78 MANAGEMENT OF NON-NEUROGENIC MALE LOWER URINARY TRACT SYMPTOMS (LUTS) - UPDATE MARCH 2019 3 1. INTRODUCTION 1.1 Aim and objectives Lower urinary tract symptoms (LUTS) are a common complaint in adult men with a major impact on quality of life (QoL), and have a substantial economic burden. The present Guidelines offer practical evidence-based guidance on the assessment and treatment of men aged 40 years or older with various non-neurogenic benign forms of LUTS. The understanding of the LUT as a functional unit, and the multifactorial aetiology of associated symptoms, means that LUTS now constitute the main focus, rather than the former emphasis on Benign Prostatic Hyperplasia (BPH). It must be emphasised that clinical guidelines present the best evidence available to the experts. However, following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care. 1.2 Panel composition The EAU Non-neurogenic Male LUTS Guidelines Panel consists of an international group of experts with urological and clinical epidemiological backgrounds. All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/. 1.3 Available publications A quick reference document, the Pocket Guidelines, is available in print and as an app for iOS and Android devices. These are abridged versions which may require consultation together with the full text version. All documents are accessible through the EAU website Uroweb: http://www.uroweb.org/guideline/treatment-of- non-neurogenic-male-luts/. 1.4 Publication history The Non-neurogenic Male LUTS Guidelines was first published in 2000. The standard procedure for EAU Guidelines includes an annual assessment of newly published literature in the field to guide future updates. The 2019 document presented a comprehensive update of the 2017 publication; the next update of the Non- neurogenic Male LUTS Guidelines will be presented in 2020. 2. METHODS 2.1 Introduction For the 2019 Management of Non-Neurogenic Male LUTS Guidelines, new and relevant evidence was identified, collated and appraised through a structured assessment of the literature. A broad and comprehensive literature search, covering all sections of the Non-Neurogenic Male LUTS Guidelines was performed. The search was limited to studies representing high levels of evidence, i.e. systematic reviews with meta-analysis, randomised controlled trials (RCTs), and prospective non-randomised comparative studies, published in the English language. Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 31st 2016 and April 30th 2018. A total of 2,357 unique records were identified, retrieved and screened for relevance. A detailed search strategy is available online: http://www. uroweb.org/guideline/ treatment-of-non-neurogenic-male-luts/supplementary-material. For each recommendation within the guidelines there is an accompanying online strength rating form, the bases of which is a modified GRADE methodology [1, 2]. Each strength rating form addresses a number of key elements namely: 1. the overall quality of the evidence which exists for the recommendation, references used in this text are graded according to a classification system modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence [3]; 2. the magnitude of the effect (individual or combined effects); 3. the certainty of the results (precision, consistency, heterogeneity and other statistical or study related factors); 4. the balance between desirable and undesirable outcomes; 5. the impact of patient values and preferences on the intervention; 6. the certainty of those patient values and preferences. 4 MANAGEMENT OF NON-NEUROGENIC MALE LOWER URINARY TRACT SYMPTOMS (LUTS) - UPDATE MARCH 2019 These key elements are the basis which panels use to define the strength rating of each recommendation. The strength of each recommendation is represented by the words ‘strong’ or ‘weak’ [4]. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including certainty of estimates), and nature and variability of patient values and preferences. The strength rating forms will be available online. Additional information can be found in the general Methodology section of this print, and online at the EAU website; http://www.uroweb.org/guideline/. A list of associations endorsing the EAU Guidelines can also be viewed online at the above address.
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