Profile of Prostatectomy Cases

ORİJİNAL ARAŞTIRMA Profile of Prostatectomy Cases Turgut ALKİBAY, a Serhat GÜROCAK, a İyimser ÜRE, b Seçil ÖZKAN, c Amirali FARAHVASH, a Bora KÜPELİ, a Sinan SÖZEN, a Sevim İNAL a Departments of a Urology, c Public Health, Gazi University Faculty of Medicine, Ankara, b Bolvadin State Hospital, Afyonkarahisar Ge liş Ta ri hi/re ce i ved: 02.04.2013 Ka bul Ta ri hi/ac cep ted: 14.11.2013 Abstract of this study was presented as a poster at 1 st National Congress of Urological Surgery, October 3-7, 2012, Antalya Ya zış ma Ad re si/cor res pon den ce: Turgut ALKİBAY Gazi University Faculty of Medicine, Department of Urology, Ankara, TÜRKİYE/TURKEY alkibay@yahoo.com doi: 10.5336/medsci.2013-35571 Cop yright 2014 by Tür ki ye Kli nik le ri ABS TRACT Objective: To define the clinical and demographic features of the patients who underwent prostatectomy and find out current trends in treatment of lower urinary tract symptoms (LUTS) before prostatectomy. Material and Methods: Data were collected using questionnaires filled by hospitalized patients and urologists. Data of 102 primary cases were analyzed and presented in this study. Results: Median age of the patients was 68 (46-90) years. Among all, 49% of the patients underwent surgery in the first 4 years after the beginning of LUTS. Acute urinary retention (AUR) was the indication for surgery in 34.3% of the cases, and the rest were operated due to high International Prostate Symptom Score (IPSS). Preoperatively, nocturia (34.3%) was the most bothersome symptom followed by frequency (29.4%). Although 58.8% of the cases had a preoperative prostate specific antigen (PSA) value above 2.5 ng/ml, only 27.3% of the patients had a biopsy. Prescription history of α-blockers, 5α-reductase inhibitors (5ARI) and combination of them at any time before surgery were 74.6%, 12.8% and 4.9%, respectively. In the statistical analysis; AUR was found to be correlated with a large prostate volume (Vp), high PSA, and combination of prostatic inflammation with benign prostatic hyperplasia in the prostatectomy pathology report (p<0.05). According to the International Index of Erectile Function (IIEF-5) questionnaire, only 15.6% of the cases had no erectile disfunction (ED) (score 22-25) preoperatively. Age had a negative correlation with IIEF-5 scores (p<0.05). Conclusion: The leading indication for prostatectomy was high IPSS. Most bothersome symptom was nocturia. Preoperative rates for biopsy, prescription of 5ARI, and combination treatments was lower than expected. ED was common, and increased with age. Large Vp, high PSA, and prostatic inflammation were related with AUR. Key Words: Lower urinary tract symptoms; prostatectomy; therapy ÖZET Amaç: Alt üriner sistem semptomları nedeniyle prostatektomi yapılan olguların klinik ve demografik özelliklerini ve prostatektomi öncesi bu olguların tedavisindeki güncel yaklaşımları saptamak. Gereç ve Yöntemler: Hastalar ve servis doktorları tarafından doldurulan formlar aracılığı ile veri toplanmıştır. Bu çalışmada 102 primer olgunun verileri analiz edilmiştir. Bulgular: Olguların median yaşları 68 (46-90) yıldır. Olguların %70 inin yakınmalar başladıktan sonra ilk dört yıl içinde opere edildiği gözlenmiştir. Olguların %34,3 ünün tekrarlayan akut üriner retansiyon, diğerlerinin ise yüksek Uluslararası Prostat Semptom Skoru (IPSS) nedeni ile opere edildiği görülmüştür. En çok yakınılan semptomlar %34,3 ile noktüri ve %29,4 ile pollaküridir. Preoperatif 2,5 ng/ml üzerinde prostat spesifik antijen (PSA) değeri olan olgu oranı %58,83 iken, preoperatif biyopsi yapılan olgu oranı %27,3 te kalmıştır. Özgeçmişinde sırası ile α-bloker, 5α redüktaz inhibitörü ve kombine tedavi kullanımı öyküsü olan olgu oranı sırasıyla %74,6, %12,8 ve %4,9 olarak bulunmuştur. Yapılan istatistiksel analizde, AUR; büyük prostat hacmi, yüksek PSA ve patolojik incelemede benigh prostat hiperplazisi ve inflamasyonun birlikteliği ile ilişkili bulunmuştur (p<0,05). Preoperatif değerlendirmede, Uluslararası Erektil Fonksiyon İndeksine (IIEF-5) göre olguların sadece %15,6 sının erektil disfonksiyonu (ED) yoktur. Yaş ile IIEF-5 skoru arasında negatif korelasyon saptanmıştır (p<0,05). Sonuç: Önde gelen prostatektomi endikasyonu yüksek IPSS skorudur. En çok yakınılan semptom noktüridir. Preoperatif biopsi oranı, 5α redüktaz inhibitörü ve kombine tedavi kullanım oranı beklenenden düşüktür. ED bu hasta grubunda yaygındır ve yaşla artmaktadır. Büyük prostat, yüksek PSA ve prostatik inflamasyon, AUR ile ilişkilidir. Anah tar Ke li me ler: Alt üriner sistem semptomları; prostatektomi; tedavi Turkiye Klinikleri J Med Sci 2014;34(1):53-9 Turkiye Klinikleri J Med Sci 2014;34(1) 53

Alkibay ve ark. Lo wer uri nary tract symptoms (LUTS) are com mon in aging men. Be nign pros ta tic hyperp la si a (BPH) is one of the fac tors that contri bu te to LUTS. Cur rently, tre at ment of LUTS sug ges ti ve of BPH is al most uni qu ely de fi ned, and re com men da ti ons by se ve ral gu i de li nes ha ve only mi nor dif fe ren ces. 1-3 Tre at ment in di ca ti ons and opti ons are mostly re com men ded ac cor ding to tri als and/or stu di es on LUTS, rat her than tra di ti o nal prac ti ces. 1-3 On the ot her hand, the da ta from re al li fe prac ti ce are li mi ted, and the ef fect of ge og rap - hi cal and cul tu ral dif fe ren ces on tre at ment prac ti - ces and gu i de li ne comp li an ces are not cle arly known. 4,5 In ad di ti on, symptoms and deg re e of suffe ring from LUTS may vary con si de rably bet we en cul tu res and co un tri es. 6-8 The aim of this study was to de fi ne the cli ni - cal and de mog rap hic fe a tu res of the pa ti ents who un der went pros ta tec tomy, and to find out cur rent trends in tre at ment of LUTS be fo re pros ta tec tomy by exa mi ning the da ta of a re fer ral cen ter of a Tur - kish uni ver sity hos pi tal. MA TE RI AL AND MET HODS The study gro up con sis ted of 102 con se cu ti ve pa ti - ents hos pi ta li zed for pros ta tec tomy in Ga zi Uni versity hos pi tal du e to LUTS, sug ges ti ve of BPH. Only pri mary ca ses we re inc lu ded to the study. Da ta we re col lec ted by qu es ti on na i res fil led by hos pi ta li zed pa ti ents, un der the su per vi si on of uro logists and nur ses in the re la ted de part ments. Along with In ter na ti o nal Pros ta te Symptom Sco re (IPSS) and In ter na ti o nal In dex of Erec ti le Func ti on (II EF-5) qu es ti on na i res, a stan dard form cre a ted for this study was used to re cord his tory, symptoms, physi - cal exa mi na ti on, la bo ra tory and ra di o lo gi cal fin dings, co mor bi di ti es, pre vi o us drugs used for LUTS, and most dis tres sing symptom as sta ted by the pa ti ents. 9,10 Only pre o pe ra ti ve da ta was pre sen ted in this study. Ten uro lo gists tre a ted the se pa ti ents. As the re we re so me mis sing da ta du e to unans we red qu es ti ons and un re cor ded pa ra me ters, percen ta ges we re used for pre sen ting the da ta. The num bers in the brac kets are the ac tu al num ber of the events that are used in cal cu la ti ons. Des crip ti ve sta tis tics we re pre sen ted by fre qu - en ci es, per cent and me di an (mi ni mum, ma xi mum) va lu es. Ca te go ri cal da ta we re com pa red using Pe arson Chi-squ a re test. Con ti nu o us da ta we re tes ted for nor ma lity using his tog rams, p-p plots, and Kolmo go rov Smir nov test. Sin ce the va ri ab les we re not nor mally dis tri bu ted, the con ti nu o us va ri ab les we - re com pa red bet we en two gro ups using Mann Whit ney U test. Spe ar man s Cor re la ti on (Rho) Test was used for eva lu a ting the cor re la ti on of con ti nu - o us va ri ab les. All com pa ri sons we re ma de for a two-ta i led sig ni fi can ce le vel of 0.05. This study comp li es with Dec la ra ti on of Hel - sin ki-et hi cal Prin cip les for Me di cal Re se arch Invol ving Hu man Sub jects. RE SULTS Üroloji AGE The me di an age was 68 (46-90) ye ars. Of the pa ti - ents, 89.3% (n=86) cu mu la ted bet we en 55-84 ye - ars of age, and 65-74 age gro up was the most crow ded (39.3%, n=37) gro up. Age dis tri bu ti on is shown in Fi gu re 1. Aging was ne ga ti vely cor re la ted with II EF-5 sco re (r=-0.638, p=0.001). Aging al so had a po si ti ve cor re la ti on with pre o pe ra ti ve cre a ti ni ne le vel (r=0.22, p=0.030). The re was no cor re la ti on bet we - en aging and to tal IPSS sco re, pros ta te vo lu me (Vp), pre o pe ra ti ve pros ta te spe ci fic an ti gen (PSA) va lu e, post vo i ding re si du al uri ne vo lu me (PVR), pre o pe - ra ti ve ma xi mum flow ra te (Qmax) and acu te urinary re ten ti on (AUR). LUTS Me di an ti mes pan bet we en be gin ning of LUTS and pros ta tec tomy was 2 (0.1-15) ye ars. Among all, 49% (n=50) of the ca ses we re ope ra ted in the first 4 ye ars, and 90.2% (n=92) we re ope ra ted in the 7 ye ars af ter be gin ning of LUTS. LUTS du ra ti on was not fo und to be re la ted with IPSS sco re, PVR, PSA, Vp or II EF-5 sco re (p>0.05). In ad di ti on, the re was no sta tis ti cally sig ni fi cant re la ti on bet we en LUTS du ra ti on and AUR (p>0.05). The most dis tres sing symptom was noc tu ri a. Noc tu ri a fre qu ency of pa ti ents is shown in Fi gu re 54 Turkiye Klinikleri J Med Sci 2014;34(1)

Urology 2. Noc tu ri a was se lec ted as the most dis tres sing symptom by 34.3% (n=35) of the ca ses, and it was fol lo wed by fre qu ency (29.4%, n=30), ur gency (7.8%, n=8), dysu ri a (5.9%, n=6), and a sen se of incomp le te emp tying (4.9%, n=5). Noc tu ri a had a cor re la ti on with pre o pe ra ti ve PVR (r=0.27 p=0.034), but with no ot her cli ni cal or la bo ra tory pa ra me ters. Ac cor ding to IPSS, most of the ca ses we re eit her mo de ra tely (36.8%, n=35) or se ve rely (57.9%, n=55) sympto ma tic (Fi gu re 3). PRE VI O US LUTS-RE LA TED DRUG TRE AT MENTS Pres crip ti on his tory of α-bloc kers, 5α-re duc ta se inhi bi tors (5ARI) and com bi na ti on of them pre vi o - usly, be fo re sur gery we re 74.6% (n=52), 12.8% (n=9), and 4.9% (n=5), res pec ti vely (Fi gu re 4). Tam su lo sin, do xa zo sin, al fu zo sin and te ra zo sin we - re used by 31.3% (n=32), 9.8% (n=10), 8.8% (n=9), and 0.9% (n=1) of the ca ses, res pec ti vely. Ot her α- bloc kers we re on mar ket in Tur key du ring the study pe ri od. The only drug com bi na ti on used by the pa ti ents was tam su lo sin and du tas te ri de com bina ti on. An tic ho li ner gics and phytot hra pe u tic drugs we re not used by any of the pa ti ents. Alkibay et al. LA BO RA TORY AND CLI NI CAL FIN DINGS Most of the pa ti ents (88.2%, n=90) had nor mal se - rum cre a ti ni ne le vels (0.6-1.2 mg/dl). Se rum cre a ti - ni ne le vels we re 1.2-2.0 mg/dl in 8.8% (n=9) of them, and the re ma i ning 2.9% (n=3) had hig her le v- els. As sta ted abo ve, pre o pe ra ti ve cre a ti ni ne le vel had a po si ti ve cor re la ti on with aging (r=0.22, p=0.030). Me di an pre o pe ra ti ve PSA va lu e was 3.6 (0,13-24) ng/ml. Among all, 58.8% (n=60) of the ca ses had PSA va lu es over 2.5 ng/ml, 45.1% (n=46) had va lu es over 4 ng/ml, and 18.6% (n=19) had va lu es over 10 ng/ml. Pre o pe ra ti ve PSA va lu e was highly cor re la ted with Vp (r=0.74, p=0.001). Me di an Vp ba sed on tran srec tal ul tra so nog - raphy was 56 (15-290) ml. In 72.4% (n=71) of the ca ses, Vp was abo ve 40 ml. Pre o pe ra ti vely, 69.2%(n=45) of the pa ti ents had Qmax va lu es lo wer than 10 ml/sec. Qmax was not cor re la ted with age, pre o pe ra ti ve PVR, PSA, Vp or IPSS. Me di an pre o pe ra ti ve PVR was 167.5 (0-1400) ml. Pre o pe ra ti ve tran srec tal ul tra so und-gu i ded pros ta te ne ed le bi opsy ra te was 27.3% (n=27). Bi op- 39.8% 24.5% 23.5% 26.9% 22.6% 14.7% 16.7% 7.5% 3.2% 4.9% 2% 2% 4.9% 1 2 3 4 5 6 7 8 9 10 45-54 years 55-64 years 65-74 years 75-84 years 85-90 years FIGURE 1: The age distribution of the patients. FIGURE 2: Frequency of nocturia. Nocturia Frequency 57.9% 74.6% 36.8% 5.3% 12.8% 4.9% Mild Moderate Severe FIGURE 3: International Prostate Symptom Scores of the patients (1-7 mild, 8-19 moderate, 20-35 severe). α-blocker 5ARI Combination FIGURE 4: Previous lower urinary tract symptom-related medical therapies. 5ARI: 5α-reductase inhibitors. Turkiye Klinikleri J Med Sci 2014;34(1) 55

Alkibay ve ark. si es re ve a led BPH in 92.5% (n=25), BPH with inf - lam ma ti on in 3.7% (n=1), and aty pi cal small aci nar pro li fe ra ti on in 3.7%(n=1) of the ca ses. Only 15.6% (n=12) of the ca ses had II EF-5 sco - res bet we en 22-25 [no erec ti le dysfunc ti on (ED)]. As sta ted be fo re, age had a strong ne ga ti ve cor re la - ti on with II EF-5 sco re (r= -0.638, p=0.001). Pros ta tec tomy in di ca ti on was re cur rent AUR in 34.3% (n=35) of the pa ti ents. The rest of the ca - ses we re ope ra ted for high IPSS. No ne of the pa ti - ents we re re cor ded to ha ve ot her ab so lu te in di ca ti ons of pros ta tec tomy (blad der sto nes, re current uri nary tract in fec ti ons, re cur rent he ma tu ri a and di la ta ti on of up per uri nary tract du e to BPH). Mo no po lar tran su ret hral pros ta tec tomy (TURP) was the most fre qu ent ope ra ti on. Whi le 75.5% (n=77) of the ca ses had TURP, 19.6% (n=20) had open pros ta tec tomy and 1% (n=1) had tran su - ret hral pros ta tic in ci si on. Of the ca ses, 3.9% (n=4) we re not ope ra ted and disc har ged be ca u se of comor bi di ti es. Pos to pe ra ti ve pat ho lo gic exa mi na ti ons of the pa ti ents re ve a led BPH in 73.2% (n=71), BPH with inf lam ma ti on in 24.7% (n=24), and BPH with pros ta tic ade no car ci no ma in 2.1% (n=2) of the pati ents. Among pa ti ents who ex pe ri en ced AUR, 25.4% (n=18) had only BPH, and 50% (n=12) had BPH with pros ta tic inf lam ma ti on. The dif fe ren ce was fo und to be sta tis ti cally sig ni fi cant bet we en the se gro ups (p=0.025). It se ems that pros ta tic inf - lam ma ti on may trig ger AUR. PSA le vels we re hig her in the ca ses with AUR. Me di an PSA was 5.8 (0.1-24) ng/ml in the ones with AUR, whi le it was 2.9 (0.2-18) in the ones wit ho ut AUR. Aga in, it was sta tis ti cally sig ni fi cant (p=0.017). In ad di ti on, the ca ses who ex pe ri en ced AUR had lar ger pros ta te vo lu mes. Me di an Vp was 74 (16-280) ml in tho se with AUR whi le it was 52 (15-180) ml in tho se wit ho ut AUR. The dif fe ren - ce was sta tis ti cally sig ni fi cant (p=0.028). DIS CUS SI ON The re sults of this study gi ves us a chan ce to over - vi ew the spec trum of LUTS/BPH tre at ment in our co untry. To our know led ge, it is the first study on Üroloji this con text in our co untry. As pros ta tec tomy is the fi nal tre at ment op ti on in LUTS du e to BPH, we had an op por tu nity to ob ser ve all pre vi o us tre at ment mo da li ti es. One must ke ep in mind that, pa ti ents we re ope ra ted in this sing le cen ter, but pre vi o us tre at ments we re ad mi nis te red by dif fe rent uro lo - gists and even prac ti ti o ners. Da ta col lec ti on is ea si - er, bet ter and mo re re li ab le in hos pi ta li zed pa ti ents. This ga ve us the chan ce to de fi ne the LUTS sympto ma to logy le a ding to pros ta tec tomy, and pa ti ent pro fi le of pros ta tec tomy ca ses in Tur key along with cur rent lo cal tre at ment prac ti ces. When pa ti ent de mog rap hics are con si de red, the me di an age (68 ye ars) of pros ta tec tomy in this gro up of pa ti ents was not dif fe rent from tho se repor ted el sew he re. In a re cent da ta ba se se arch of con tem po rary TURP se ri es, the me an pa ti ent age was 67 ye ars. 11 Ol der stu di es by Bor bo rog lu et al. and Me bust et al. re por ted si mi lar fin dings for the me an pa ti ent age. 12,13 This fin ding imp li es the fact that age dis tri bu ti on of pa ti ents who un der go pros - ta tec tomy for LUTS is mo re or less the sa me in diffe rent co un tri es. In con trast to cur rent li te ra tu re, aging did not cor re la te with PSA le vels in our study. It may be spe cu la ted that, yo ung pa ti ents with big pros ta tes (in 72.4% of the ca ses Vp was abo ve 40 ml) is the re a son for this fin ding. Most bot he ring symptom was noc tu ri a fol lo - wed by day ti me fre qu ency in this gro up of pa ti ents who we re hos pi ta li zed for pros ta tec tomy. This was not sur pri sing as a pre vi o us com mu nity-ba sed study abo ut pre va len ce of LUTS in Tur key had alre ady fo und noc tu ri a as the most pre va lent symptom, fol lo wed by fre qu ency. 8 It se ems that, from the be gin ning of LUTS, noc tu ri a is the most bot he - ring symptom in Tur kish pa ti ents. Ac tu ally, this fin ding is not dif fe rent from ot her re gi ons of the world. Stu di es from Ja pan, In di a, Eng land and Austri a, po int to noc tu ri a and fre qu ency as the most com mon and most bot he ring symptoms of LUTS. 6,7,14,15 Noc tu ri a, as a syste mic di sor der, is not a pros ta tec tomy in di ca ti on and has a dif fe rent wor - kup. Des pi te this, it se ems that whi le ope ra ting for high IPSS sco re and fa i led me di cal tre at ment, pros - ta tec tomy may be co me an unin ten ded tre at ment for noc tu ri a in so me pa ti ents. 56 Turkiye Klinikleri J Med Sci 2014;34(1)

Urology Lar ger Vp may be the ma in dif fe ren ce of Tur k- ish pros ta tec tomy pa ti ents as the me di an Vp (56 ml) of the pa ti ents in this study was de fi ni tely lar ger than tho se re por ted in ot her se ri es. In a re cent analysis of 67 ran do mi zed con trol led tri als on TURP, the me an Vp was 47.6 ml and Bor bo rog lu et al. re por - ted me an Vp as 37.1 ml. 11,12 In TURP study of Mebust et al., 85% pa ti ents had pros ta tes smal ler than 45 ml. 13 In te res tingly, In di an, Chi ne se, Ja pa ne se and Ame ri can men we re re por ted to ha ve smal ler pros - ta tes than the pa ti ents of this study. 6,16,17 The re may be eth nic, ge ne tic, be ha vi o ral and en vi ron men tal re - a sons for Tur kish men to ha ve big ger ade no mas than the ot hers in the world. If this fin ding is con fir med by ot her stu di es with big ger sca les, it may ef fect the tre at ment po li ci es of LUTS in Tur key. Most of our study gro up had so me deg re e of ED. Not sur pri singly, ED se ve rity was in cre a sing with aging. This fin ding cor re la tes well with a pre vi o us Tur kish ED pre va len ce study. Ak kuş et al. re por ted the age-ad jus ted ove rall pre va len ce of ED in Tur key was 69.2%, and conc lu ded that the fre qu ency was in cre a sing with age. 18 The un derl - ying comp lex pat ho ge ne tic mec ha nisms lin king BPH/LUTS to ED ha ve be en ele gantly re vi e wed by Gac ci et al., and the ef fect of age is stres sed in ar tic le this as well. 19 The re was a rat her low pre o pe ra ti ve tran srec - tal ul tra so und-gu i ded pros ta te ne ed le bi opsy ra te in our pa ti ents. Cur rently, the re is no uni ver sally ac cep ted thres hold to trig ger a bi opsy, but the re is ten dency to lo wer PSA thres hold from clas si cal 4 ng/ml to 2.5 ng/ml, es pe ci ally in pa ti ents yo un ger than 60 ye ars of age. 20 When we lo ok at the trend of our col le a gu es from this po int of vi ew, the re was lo wer than ex pec ted bi opsy ra te, as 58.83% of the ca ses had PSA va lu es over 2.5 ng/ml. The re may be two exp la na ti ons for this at ti tu de. First is the lar ger Vp in the se pa ti ents as sta ted abo ve, and the se cond may be the per cen ta ge of pa ti ents over 65 ye ars of age. Slightly mo re than 65% of the pa ti - ents we re 65 ye ars old or ol der. It is known that the re is a ge ne ral ten dency to ward al lo wing ol der men (70 ye ars or ol der) to ha ve slightly hig her nor ma l PSAs, in the ran ge of 5.5 to 6.5 ng/ml, alt ho ugh this is not uni ver sally ac cep ted. 20 Alkibay et al. Pre vi o us LUTS re la ted tre at ments we re anot - her po int of in te rest in this study. As sta ted be fo re, the se me di cal the ra pi es we re not ne ces sa rily gi ven in the study cli nic (i.e. Ga zi Uni ver sity Hos pi tal), the re fo re they rep re sent a rat her ge ne ral opi ni on of our col le a gu es. Pres crip ti on his tory of α-bloc - kers, 5ARI and com bi na ti on of them at any ti me pre vi o usly, be fo re sur gery we re 74.6%, 12.8% and 4.9%, res pec ti vely. In a pros pec ti ve, cross-sec ti o - nal, ob ser va ti o nal sur vey in six Eu ro pe an co un tri - es, α-bloc kers we re pres cri bed in 57%, and fi nas te ri de was pres cri bed in 11% of the pa ti ents at any mo ment du ring the fol low-up (inc lu ding switc hes and com bi na ti on of tre at ment). 4 Pres crip - ti on ra tes are not si mi lar, but clo se to each ot her, and es pe ci ally 5ARI pres crip ti on trends re semb le to each ot her. When our study gro up with lar ger Vps was con si de red, mo re 5ARI pres crip ti on was ex pec ted, but this was not se en in prac ti ce. MTOPS and Com bat stu di es ha ve cle arly shown the su pe ri o rity of com bi na ti on tre at ment, but in prac ti ce, the re com men da ti ons de ri ved from the - se stu di es we re not ta ken in to con si de ra ti on, as ex pec ted. 21,22 This was the ca se in ot her co un tri es as well. Stro pe et al. sta ted that wi de va ri a ti ons in eva lu a ti on and tre at ment we re ob ser ved in practi ce in US Me di ca re po pu la ti on, and gu i de li ne comp li an ce was not as ex pec ted. 23 This ar tic le discus sed fac tors as awa re ness of the gu i de li ne, fa mi - li a rity with the gu i de li ne re com men da ti ons, lack of ag re e ment with the re com men da ti ons, po or self-ef fi cacy for imp le men ting gu i de li ne re com - men da ti ons, iner ti a of pre vi o us prac ti ce, and a beli ef that the gu i de li ne wo uld not im pro ve pa ti ent out co mes; but in our ca se with drug use, mo re must be ta ken in to con si de ra ti on. 24 The si de ef fects of 5ARI, li ke ED and eja cu la ti on di sor ders, which are not ea sily ac cep ted by yo un ger pa ti ents may be im por tant re a sons. 25 Pros ta tec tomy in di ca ti on was re cur rent AUR in 34.3% (n=35) of the pa ti ents. The rest of the ca - ses we re ope ra ted for high IPSS. Ac cor ding to EA - U gu i de li nes on LUTS/BPH, se ve re symptoms is a re la ti ve in di ca ti on for sur gery, but EA U and AU A gu i de li nes ac cept sur gery as an op ti on even in pa ti - ents with mo de ra te symptoms. 1,2 AU A gu i de li nes Turkiye Klinikleri J Med Sci 2014;34(1) 57

Alkibay ve ark. do not con si der me di cal the rapy as a re qu i re ment in all pa ti ents, and sta te that so me pa ti ents may wish to pur su e the most ef fec ti ve the rapy as a primary tre at ment if the ir symptoms are par ti cu larly bot her so me. Any how, it may be spe cu la ted that sur gery is used mo re li be rally used by our col le a - gu es as re la ti ve in di ca ti ons do mi na ted in pros ta - tec tomy de ci si on of our ca ses. Anot her po int that must be stres sed in this study is the re la ti on of AUR with pros ta tic inf lam - ma ti on in pros ta tec tomy spe ci mens. It se ems that pros ta tic inf lam ma ti on trig gers AUR, and pa ti ents with pros ta tic inf lam ma ti on carry a hig her risk for pros ta tec tomy. This fin ding can be sup por ted by se ve ral stu di es. A su ba naly sis of the MTOPS study sug ges ted that inf lam ma ti on de tec ted in ba se li ne pros ta tic bi op si es was highly pre dic ti ve of prog res - si on of BPH to AUR, and the ne ed for mo re in va - si ve the rapy. 26 In ad di ti on, Mis hra et al. and As ga ri and Mo ham ma di po in ted to the highly pos sib le rela ti on of pros ta tic inf lam ma ti on with AUR. 27,28 The aut hors of this study aim to con duct a de ta i led pat - ho lo gi cal study of pros ta tec tomy spe ci mens for qu - an ti fi ca ti on of inf lam ma ti on and its re la ti on with se ve rity of LUTS. CONC LU SI ONS Üroloji This study has gi ven us a chan ce to over vi ew the LUTS sympto ma to logy and pa ti ent pro fi le of pros - ta tec tomy ca ses in a Tur kish Uni ver sity hos pi - tal,along with cur rent lo cal tre at ment prac ti ces. The le a ding in di ca ti on for pros ta tec tomy was high IPSS. The most bot her so me symptom was noc tu ri - a. The ra te s of pre o pe ra ti ve bi opsy, pres crip ti on of 5ARI, and com bi na ti on tre at ments we re lo wer than ex pec ted. ED was com mon in the se ca ses and it was in cre a sing with age. Lar ge Vp, high PSA, and pros ta tic inf lam ma ti on we re re la ted with AUR. 1. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011; 185(5):1793-803. 2. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al.; Members of the European Association of Urology (EAU) Guidelines Office. Guidelines on Management of Non-neurogenic Male LUTS. EAU Guidelines, edition presented at the 25th EAU Annual Congress, Barcelona: EAU; 2010. ISBN 978-90-79754-70-0. 3. Homma Y, Gotoh M, Yokoyama O, Masumori N, Kawauchi A, Yamanishi T, et al. Outline of JUA clinical guidelines for benign prostatic hyperplasia. 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