Urinary retention (UR) is the inability of a patient to fully or partially empty the bladder through voluntary urination. RU can be acute or chronic. Acute UR (AUR) is defined as painful, palpable or percussive bladder, when the patient cannot urinate. Chronic UR (CUR) is defined as a non-painful bladder that remains palpable or percussable after the patient has urinated.
The term implies a significant postvoid residual urine (PMRO) volume (minimum figure of 300 ml).
However, the exact definitions of RUA and RUC remain controversial. The exact incidence of UR in the general population remains unclear, with various estimates between 2.2 and 6.8 events/1000 patient years. Benign prostatic obstruction (BPE) is considered to be the most common cause of UR in men.
Several α1-adrenergic receptor antagonists (α1-blockers) have been tested in patients with AUR to increase rates of successful tubeless micturition (PMSS), including alfuzosin, tamsulosin, and silodosin, most commonly of which have been shown to be more effective than placebo.
The ALFAUR study, the largest clinical trial to date, evaluated the role of alfuzosin 10 mg once/day 2–3 days before PMSS and showed that alfuzosin almost doubled the successful rate of PMSS. .
Since most patients with successful PMSS have not had a short-term relapse of AUR, administration of an α1 blocker before tube removal is considered a valuable treatment. It has been reported that >80% of patients who did not receive any treatment after an episode of AUR underwent surgery within 5 years.
As a result, pharmacological intervention should be considered not only as an aid to increase the chance of success of PMSS, but also as a means to reduce the risk of recurrence of RUA. In the long term, recurrence of RUA could lead to future interventions.
Data from 5 studies evaluating long-term use of α1 blockers revealed that patients had a lower risk of recurrent AUR. The use of 5α reductase inhibitors (5-ARI) as combination therapy with α1 blockers in the treatment of AUR remains controversial.
Another therapeutic option for AUR is emergency prostate surgery , but it has a higher risk of intraoperative and/or postoperative complications and mortality than elective surgery. Therefore, elective surgery is the treatment of choice for most men in whom PMSS has failed.
Increased perioperative morbidity is also associated with the presence of an indwelling urinary catheter in cases operated after PMSS failure.
The treatment of UR secondary to OPB varies greatly. Relevant systematic reviews are scarce. The Non neurogenic Male Lower Urinary Tract Symptoms guideline, from the European Association of Urology (EAU), recognizes that there is currently no important evidence and a growing scientific base, which shows the need to learn more about therapeutic options.
| Aim |
Address the following questions:
1. What are the benefits of treatments for UR (acute or chronic) in adults with OPB?
2. What are the harms of treatments for UR (acute or chronic) in adults with OPB?
The evidence considered in this study comes from randomized controlled trials (RCTs), quasi-RCTs (QRCTs), and prospective comparative studies. Other studies (such as non-comparative ones) and case series were excluded. Intervention versus comparator comparisons were investigated.
> Intervention:
Any pharmacological or non-pharmacological treatment included in the EAU guidelines in men with non-neurogenic lower urinary tract symptoms (LUTS) (2018), as defined below:
1. Pharmacological treatment (monotherapy or combined therapy): α1, 5-ARI blockers, phosphodiesterase 5 inhibitors (PDE5-I), plant extracts (phytotherapy).
2. Non-pharmacological treatment: any type of instrumental intervention (surgical treatment, such as urethral resection of the prostate, including suprapubic or urethral catheterization, regardless of the duration before PMSS.
3. Any combination of the above pharmacological and non-pharmacological treatments.
> Comparator
1. There is no treatment.
2. Placebo or sham treatment.
3. Any pharmacological or non-pharmacological treatment.
The main benefit results were the following:
1. Successful PMSS rate.
2. Recurrence rate of UR (acute or chronic) after successful PMSS.
The results of the primary damage were as follows:
1. Harms of treatment for UR (acute or chronic) including any adverse effects (death, complications of pharmacological or non-pharmacological treatment). Surgical complications occurred up to 1 month postoperatively, which were specifically graded according to the modified Clavien classification system.
Secondary outcomes included the following:
1. Peak flow (Qmax), International Prostate Symptom Score (IPSS) including quality of life [QoL] score, ORPM; absolute values and changes from baseline at each follow-up time point.
2. Specific measures for the evaluation of non-pharmacological treatment (duration of operation, duration of bladder irrigation, postoperative catheterization, and duration of hospitalization).
| Discussion |
The evidence for the management of patients with UR caused by OPB, with pharmacological or non-pharmacological treatments, is limited. The certainty of evidence (CaE) for most results was low or very low.
All selective α1 blockers (alfuzosin, tamsulosin and silodosin) appear to be superior to placebo in terms of rates of successful PMSS after a short period of catheterization.
In contrast, no benefit was found with the use of the non-selective α1 blocker doxazosin, while the addition of sildenafil to tamsulosin provided no additional benefit compared with tamsulosin monotherapy. However, these studies are underpowered; CaE is very low and therefore no definitive conclusions can be drawn for these comparisons.
The pooled results indicate that monotherapy with alfuzosin and tamsulosin provides significantly higher rates of PMSS than placebo, with few adverse effects. Similar rates of successful PMSS were achieved with alfuzosin or tamsulosin. Non-pharmacological treatments have been evaluated through randomized, controlled studies and prospective comparative studies, only sporadically.
According to the authors of these studies, bipolar transmural resection of the prostate and transurethral microwave thermotherapy have been tested in comparison with monopolar transmural resection of the prostate, proving that they have comparable efficacy and safety for the management of patients with UR. , but the authors warn that this conclusion should be interpreted with caution.
Suprapubic catheterization appears to safeguard against some of the possible complications of urethral catheterization, such as urinary tract infection and urethral stricture, allowing spontaneous emptying to be evaluated and avoiding catheterization after a failed attempt.
Although it has been suggested that suprapubic catheterization may be associated with lower rates of urinary tract infection and urethral stricture formation, less patient discomfort, and easier management, a Cochrane systematic review failed to demonstrate a lower risk of symptomatic urinary tract infections. .
After a first episode of AUR, treatment with a catheterization period of 3 days and not 7 days, in addition to the α1 blocker, is preferably recommended, since the longer duration of the catheter stay increases complication rates, without a significant increase in the success of PMSS.
In the case of a delay in surgery, before transurethral resection of the prostate, a short period of intermittent self-catheterization is preferable instead of indwelling catheterization as it could be beneficial to maximize recovery of bladder function, since It is associated with fewer infectious complications.
A systematic review on the management of AUR, including pharmacological and non-pharmacological therapeutic options, is recommended. the use of α 1 blockers before PMSS, discouraging the management of the operative emergency.
Suprapubic puncture instead of indwelling catheterization was debatable and the duration of catheterization was controversial, but <3 days appeared to be a safe option to avoid catheterization-related complications.
Although transurethral resection of the prostate remained the gold standard, a new surgical management using laser techniques emerged. However, conclusions were limited due to low CaE.
In another systematic review, the effectiveness and comparative effectiveness of pharmacological and non-pharmacological treatments for RUC were evaluated. A total of 11 studies were included (randomized and controlled and prospective cohort studies) with patients with RUC whose results were analyzed by etiology: populations with obstructive, non-obstructive and mixed conditions/unknown causes.
Low-quality evidence suggested that transurethral prostate resection and transurethral microwave thermotherapy achieved similar improvements in rates of successful PMSS after 6 months of treatment. The evidence was insufficient to draw conclusions about other outcomes. There is also not enough evidence to decide whether one treatment for RUC due to obstructive causes is better than another.
The evidence on harms was inconsistent across interventions, and no differences were detected between treatment groups; However, the studies were not powered enough to detect differences in harms between groups. More studies of patients with RUC are needed.
A Cochrane systematic review evaluated the effectiveness of α1 blockers on successful resumption of micturition after urethral catheter removal following an episode of AUR in men. We included 9 randomized controlled studies with moderate CaE to suggest that PMSS success rates favored α1 blockers over placebo.
The incidence of recurrent AUR was lower in the groups treated with α1 blockers. CaE was moderate, favoring alfuzosin, tamsulosin and silodosin, but not doxazosin. Of the studies that mentioned adverse effects, there was not enough information to detect statistically significant differences between groups and CaE was low. Overall, rates of adverse effects were low for placebo and α1-blockers.
| Recommendations for future research. |
Future studies should consider the following recommendations:
1. In this systematic review, and based on the inclusion criteria, several contemporary non-pharmacological therapeutic options included in the EAU guidelines on the management of non-neurogenic male LUTS were not evaluated. For example, no non-comparative studies evaluating holmium, Greenlight or thulium lasers were detected. This represents a significant gap in the literature. Such lack of evidence should be addressed by future studies from the subpopulation of patients with UR, which is unique.
2. Do additional studies on AUR, as well as on 5-ARIs administered after successful PMSS, since these and not α1 blockers have been shown to reduce AUR rates.
3. Previous UR is a well-established risk factor for repeat episodes of AUR. The earliest data indicated that only 16% of patients presenting with UR had been catheter-free for 5 years.
According to the EAU guidelines for the management of non-neurogenic male LUTS, surgical treatment is usually necessary when patients have experienced, among others, recurrent or refractory UR or overflow incontinence (absolute indication for operation, need for surgery). .
However, future studies are considered necessary to reliably identify patients who might respond to prolonged medical treatment and who should be scheduled for immediate or elective surgery.
4. Optimal treatment management for frail patients with significant long-term comorbidities.
5. The observed heterogeneity of definitions of successful PMSS between studies not only has an important impact on the evaluation of therapeutic outcomes but also allows the adoption of a universally accepted definition of successful PMSS, necessary for future studies.
6. CaE for the RU must be developed by OPB, following the COMET Initiative (Core Outcome Measures in Effectiveness Trials). Future studies should be adequately powered or follow principles and recommendations established by CONSORT (Consolidated Standards of Reporting Trials).
| Conclusions |
- The evidence for the management of patients with RU/OPB with pharmacological or non-pharmacological treatments is limited. CaE is generally low.
- There is some evidence that the use of α1 blockers (alfuzosin and tamsulosin) may improve the resolution of RU/OPB.
- As most non-pharmacological treatments have not been evaluated in patients with RU/OPB, the evidence is inconclusive about their benefits and harms.
