Prostate Update
August 2000 Vol. 5 No. 1


PATTERNS OF PRACTICE OF

CANADIAN UROLOGISTS IN PROSTATE DISEASE

Objectives:

To assess the 1998 practice patterns of Canadian urologists in prostate disease including benign prostatic hyperplasia (BPH) and cancer and to compare them with those documented in 1995 and with those of U.S. urologists.

Materials and Methods:

A questionnaire was mailed to all active members of the Canadian Urological Association who practice in Canada and who perform adult urology (n=378).  The questionnaire contained some questions identical to those in the 1995 questionnaire. In addition, a series of questions on BPH were taken from an AUA questionnaire sent to a random sample of 586 urologists practicing in the U.S. in 1995.

Results:

Responses were received from 206 (54.5%) which was higher than the 1995 survey (42.5%).  Fifty-nine percent of respondents practice in a community hospital and 41% in a university teaching hospital.

Demographics: Age   (%) Years in Practice (%)
<40  25% <10  35%
40-49  36%  10-19  30%
50-59  24%  20-29  28%
>60  15% >30  7%

A 55 YEAR OLD MAN IN GOOD HEALTH IS REFERRED WITH MODERATELY SEVERE VOIDING SYMPTOMS.  HE IS BOTHERED BY HIS SYMPTOMS AND WISHES TREATMENT.  ON RECTAL EXAMINATION HE HAS A 25 CC BENIGN FEELING PROSTATE.  URINALYSIS AND CREATININE ARE NORMAL.  

YES (%)
1998 1995
Would you use the AUA/IPSS symptom score for this patient? 61  70
Do you think the AUA/IPSS symptom score is of value? 76 N/A
Do you think the AUA\IPSS symptom score needs to be improved? 56 N/A
Would you do uroflowmetry?  58 60
Do you routinely do uroflowmetry in symptomatic BPH patients? 42 37
Would you do cystoscopy? 51  73
Do you routinely do cystoscopy in symptomatic BPH patients? 39 53
Would you do TRUS? 5 6
Do you routinely do TRUS in symptomatic BPH patients? 1 2
Do you have TRUS in your private office or clinic? 27 25
Do you do your own TRUS and biopsies? 34 31
Would you do an IVP? 6 9
Would you do a renal ultrasound? 23 37
Would you do a post void residual urine:
- by catheterization? 11 20
- by ultrasound? (bladder scan) 56 58

THIS SAME 55 YEAR OLD MAN ASKS FOR YOUR RECOMMENDATION. IRRITATIVE (STORAGE) SYMPTOM SCORE 6/15, OBSTRUCTIVE (VOIDING) SYMPTOM SCORE 12/20. PEAK URINE FLOW RATE 9 ML/SEC.  WHAT WOULD YOU RECOMMEND?

1998 (%) 1995 (%)
Watchful waiting 6 10
Finasteride - 27
Alpha blocker 91 51
Transurethral resection/vaporization (TURP/TUEVP) 2 7
Transurethral incision of prostate (TUIP) 0.5 2
Transurethral needle ablation (TUNA) - -
Transurethral microwave thermotherapy (TUMT) - -
Laser prostatectomy - 1

A HEALTHY PATIENT WITH MODERATELY SEVERE SYMPTOMS (AUA/IPSS SCORE 17), PEAK FLOW RATE 9.8 ML/SEC AND A BENIGN PROSTATE • 50 cc IN VOLUME FAILS MEDICAL THERAPY AND WISHES TREATMENT.  WHAT IS YOUR PREFERENCE?

(%)
Standard TURP 69
TURP using wedge loop 8
Transurethral vaporization (TUVP) 9
Transurethral needle ablation (TUNA) 2
Transurethral microwave thermotherapy (TUMT) 1
Holmium laser resection 5
Visual laser assisted prostatectomy (VLAP) 3
Open enucleation -
Other (please indicate) 3

GENERAL QUESTIONS ON BPH YES (%)
  Do you use the TUNA procedure? 8
  Do you believe it has a place in treating BPH? 63
  Do you plan to use the TUNA procedure? 22
  Do you use TUMT? 9
  Do you believe it has a place in treating BPH? 44
  Do you plan to use TUMT? 11
  Do you use a laser for prostatectomy? 26
  Do you believe the laser has a place in treating BPH? 78
  Do you plan to use a laser for prostatectomy? 46
  When doing a TURP, do you use: 
    Standard loop 94
    Thick/Wedge loop 32
    Rollerball 55
    Holmium laser 10
  Do you use TUIP for small prostates (<30 cc)? 67
  Should the term prostatism be replaced by lower urinary tract
  symptoms (LUTS)?		 49
  Should irritative and obstructive symptoms be replaced by
  storage and voiding symptoms?		 26
  In men with symptomatic BPH, what are your indications for
  urodynamic evaluation with pressure/flow studies?
    - I do in all men with symptomatic BPH? 6
    If no, please answer the following: (b-g)
      Prior to invasive treatment? 14
      Prior to revision TURP? 45
      Men with diabetes mellitus? 59
      Men with neurological disease? 93
      Men under 50 years? 49
      Men with normal sized prostates? 34
      Qmax > 15 ml/s sec 47
      
      
      

 

A 73 YEAR OLD MAN PRESENTS WITH MODERATE VOIDING SYMPTOMS (AUA/IPSS SCORE 18), PEAK FLOW RATE 12 ML/SEC AND A BENIGN FEELING PROSTATE • 30 cc ON DRE.  PSA = 3.2 NG/ML.   HE WISHES TO TRY MEDICAL TREATMENT.  WHAT DO YOU RECOMMEND?

(%)
alpha blocker 84
finasteride 1
either 11
both 3

 

His symptoms improve but he stops treatment because of side effects.
YES (%)
Would you try the alternative drug? 69

A 73 YEAR OLD MAN PRESENTS WITH MODERATE VOIDING SYMPTOMS (AUA/IPSS SCORE 18), PEAK FLOW RATE 12 ML/SEC AND A LARGE, BENIGN FEELING PROSTATE.  PSA = 8.0 NG/ML, TRUS VOLUME = 80 CC. SYSTEMATIC BIOPSIES x 8 WERE BENIGN AND HE WISHES TO TRY MEDICAL TREATMENT..  WHAT WOULD YOU RECOMMEND?

 

(%)
alpha blocker 41
finasteride 32
either 13
both 14
His symptoms fail to improve.
YES (%)
Would you try the other drug? 65

YES (%)
When you prescribe medical therapy for symptomatic BPH do you try to reinforce the positive aspect, ie. It should help you? 80
Do you think this positive approach could influence the effect of drugs? 89

 

A 64 YEAR OLD WITH ACUTE URINARY RETENTION, FAILING MULTIPLE TRIALS OF VOIDING AND HAS A VERY LARGE BENIGN FEELING PROSTATE.  HE IS OTHERWISE WELL.  URINALYSIS AND CREATININE ARE NORMAL.  PSA IS 9.  TRUS SHOWS NO SUSPICIOUS AREAS, VOLUME 105 cc.  SIX SEXTANT BIOPSIES SHOW ONLY BPH. 

Your recommended treatment would be: (%)
  TURP (or variations) 46
  Retropubic prostatectomy 44
  Suprapubic (transvesical) prostatectomy 6
  TUNA 0.5
  TUMT -
  Alpha blocker 2
  Finasteride -
  Other 1

 

A 70 YEAR OLD PRESENTS WITH OVERFLOW INCONTINENCE AND RENAL FAILURE, CREATININE 700.  HE IS CATHETERIZED FOR 1800 ML.  ULTRASOUND SHOWS MODERATE HYDRONEPHROSIS.  OVER THE NEXT WEEK HIS CREATININE STABILIZES AT 180.  PROSTATE • 50 cc  AND FEELS BENIGN.  PSA 3.8.  CYSTOMETROGRAM (CMG) SHOWED NO BLADDER CONTRACTION.  PATIENT WAS UNCOMFORTABLE AT 1100 ML.  WHAT TREATMENT WOULD YOU RECOMMEND?

 

1998 (%) 1995 (%)
Intermittent self catheterization 23 16
Leave with Foley and repeat CMG in one month 34 30
TURP 43 53
Open prostatectomy 0.5 1
Finasteride 0.5 -
Alpha blocker - -
Bethanecol (Urecholine) - -

 

A 60 YEAR OLD SYMPTOMATIC, HEALTHY MAN HAS A PSA OF 6.2.  REPEAT PSA IS 5.9..  PROSTATE FEELS MINIMALLY ENLARGED AND BENIGN.  YOU WOULD RECOMMEND:

 

1998 (%) 1995 (%)
Repeat PSA and DRE in 6-12 months 22 23
TRUS and systematic biopsies 63 49
TRUS and biopsy if PSA density is > 0.15 10 19
TRUS and biopsy only if suspicious lesions see 4 10
TRUS and biopsy if free/total PSA <20% 2 N/A

 

GENERAL QUESTIONS ON PROSTATE CANCER YES (%)
Do you use free/total PSA estimations? 14
Do you routinely use age specific PSA ranges? 80
Do you believe that asymptomatic men aged 50 to 70 years should have an annual DRE and PSA? 87
Do you support the current CUA position on early detection of prostate cancer? 94

The digital rectal examination (DRE) and prostate specific antigen (PSA) measurements increase the early detection of clinically significant prostate cancer.  Men should be made aware of the potential benefits and risks of early detection so that they can make an informed decision as to whether to have this tests performed.

YES (%)
Have you had a DRE and PSA? (Answer only if you are > 50 years old) 70
Do you routinely use the TNM system for staging of prostate cancer? 68
Do you perform radical prostatectomy? 77
  If yes, how many do you do each year? (Optional)
    <5 6%
    5-10 21%
    11-20 42%
    >20 30%
Do you do bone scans in men prior to radical prostatectomy if the PSA <10 ng/ml and no skeletal symptoms? 28
Do you generally perform cystoscopy prior to radical prostatectomy? 29
Do you generally request an x-ray chest prior to radical prostatectomy? 57
If you perform radical prostatectomy, do you ever use the perineal approach? 7

 

Do you use neoadjuvant hormonal therapy prior to:
Never
(0)
Occasionally (1)
Frequently (2)
Always (3)
  radical prostatectomy(%) 20 45 27 8
  radiation therapy (%) 10 35 40 15

 

 

YES (%)
1998 1995
Do you believe that maximal androgen blockade (MAB) is the most effective hormonal therapy for advanced disease?
 		 62 90
Do you usually add an antiandrogen to:
  Surgical castration? 47 N/A
  Medical castration (excluding flare prevention)
 		 60 N/A
Does the cost of these therapies influence your choice? 69 80
Should LHRH agonists be funded by provincial pharmacy plans?
 		 78 63

 

 

YES (%)
1998 1995
Do you use intermittent hormonal therapy? 60 90N/A
If yes,
  Occasionally? 74 N/A
  Frequently? 24 N/A

 

Was this questionnaire 1998 1995
  too long? 19% N/A
  too short? 0.5% N/A
  just right? 80% N/A

 

REFERENCES:

1.  Barry MJ, Fowler Jr. FJ, Bin L and Oesterling JE.  A nationwide survey of practicing urologists: Current management of benign prostatic hyperplasia and clinically localized prostate cancer.  J Urol 158: 488, 1997.

Canadian Prostate Health Council