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Platinum Priority – Editorial
Referring to the article published on pp. 570–581 of this issue
Medical Treatment of Male Lower Urinary Tract Symptoms:
Does One Fit All?
Malte Rieken
a , b , * ,Christian Gratzke
ca
Department of Urology, Medical University Vienna, Vienna, Austria;
b
University of Basel, Basel, Switzerland;
c
Department of Urology, Ludwig-Maximilians-
University of Munich, Munich, Germany
Medical treatment is considered first-line therapy for male
lower urinary tract symptoms (LUTS) in the majority of
patients
[1] .a
1
-Adrenoreceptor antagonists (
a
1
-blockers)
and 5
a
-reductase inhibitors (5-ARIs) are established
treatment options with well-documented efficacy
[1]. In
addition, newer medical treatment options such as novel
a
1
-blockers
[2], antimuscarinergic drugs
[3] ,phosphodies-
terase type 5 (PDE5) inhibitors
[4], and a combination of
these drug classes
[5]have been approved by regulatory
agencies in recent years. However, whether these drugs
offer significant advantages over
a
1
-blockers and 5-ARIs
remains controversial.
In this issue of
European Urology
, Dahm and colleagues
analyzed the comparative effectiveness of newer medica-
tions for LUTS attributed to BPH
[6]. For their excellent
systematic review and meta-analysis, they applied a
rigorous statistical approach. The authors found no signifi-
cant advantage in terms of improvement in International
Prostate Symptom Score and/or quality of life for all the
newer drugs, specifically silodosin, and combinations of
antimuscarinergic drugs with
a
1
-blockers, mirabegron, and
PDE5 inhibitors when compared to older
a
1
-blockers. Does
this mean that newer drugs have no place in the treatment
of male LUTS and that, based on the best evidence available,
urologists are left with nothing else than
a
1
-blockers and
5-ARIs? Although
a
1
-blockers and 5-ARIs are apparently not
the silver bullet for medical treatment of male LUTS, several
important conclusions can be drawn from the present
systematic review.
First, the quality of trials assessing new medical
treatment options for male LUTS is generally low. Trials
are often characterized by considerable risk of bias. Given
the tremendous costs associated with drug development,
this is rather frustrating. The urologic community should be
encouraged to perform clinical trials based on the highest
quality and methodological standards. We should openly
engage with pharmaceutical companies to help in shaping
the design of future trials in a way that assures that trial
results are not only statistically significant but also
clinically relevant. In this context, it is also important to
keep in mind that there are currently no drugs other than
5-ARIs available for men with larger prostate volume to
reduce the risk of symptom progression and surgery for
benign prostatic enlargement. Although a considerable
number of patients belong to this group, current research
efforts do not seem focus on these men.
Second, it must be acknowledged that LUTS are a chronic
condition. Given the chronic character of LUTS, long-term
medication is often necessary. Thus, primary endpoints set
at short time points such as 12 wk will not help us in finding
better medical treatment for male LUTS. Short-term follow-
up seems sufficient for regulatory approval, but it is
insufficient as evidence-based guidance for long-term LUTS
treatment.
Third, individualized patient-tailored treatment for LUTS
seems to be the key for success. There are certain subgroups
of patients, such as men with LUTS and concomitant erectile
dysfunction, who benefit from treatment with newer drugs,
specifically PDE5 inhibitors. For these patients, improve-
ment in not only LUTS but also erectile dysfunction should
be taken into account when assessing the clinical efficacy of
new drugs. It should be emphasized that even though new
drugs may have comparable efficacy to
a
1
-blockers, any
improvement in symptoms beyond those investigated in
E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 5 8 2 – 5 8 3available at
www.scienced irect.comjournal homepage:
www.europeanurology.comDOI of original article:
http://dx.doi.org/10.1016/j.eururo.2016.09.032.
* Corresponding author. Department of Urology, Medical University Vienna, Wa¨hringer Gu¨ rtel 18–20, 1090 Vienna, Austria.
E-mail address:
m.rieken@outlook.com(M. Rieken).
http://dx.doi.org/10.1016/j.eururo.2016.11.0190302-2838/
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2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.