I. Basic knowledge of benign prostatic hyperplasia
Benign prostatic hyperplasia (BPH) is one of the most common benign diseases causing urinary disorders in middle-aged and elderly men [1]. The main manifestations are histological enlargement of the interstitial and glandular components of the prostate, anatomical enlargement of the prostate (BPE), lower urinary tract symptoms (LUTS) as well as urodynamic obstruction of the bladder outlet (BOO). bladder outlet obstruction (BOO).
(ii) Epidemiology
Histologically the incidence of BPH increases with age, usually initially occurring after the age of 40 years [2], to >50% by the age of 60 years and up to 83% by the age of 80 years [3]. Similar to the histologic presentation, symptoms such as dyspareunia increase with age. Approximately 50% of men with histologically diagnosed BPH have moderate to severe lower urinary tract symptoms [1]. Some studies have shown that it seems that Asians are more prone to moderate-to-severe BPH-related symptoms than Americans [4].
(iii) Etiology
Two important conditions must be present for the development of BPH, ageing and a functioning testis. Domestic scholars investigated 26 elderly eunuchs of the Qing Dynasty and found that the prostate had become completely inaccessible or significantly atrophied in 21 of them [5]. However, the specific mechanism by which BPH occurs is unclear and may be caused by a balanced disruption of epithelial and mesenchymal cell proliferation and apoptosis. Associated factors are: androgens and their interaction with estrogens, interaction of prostatic mesenchymal a glandular epithelial cells, growth factors, inflammatory cells, neurotransmitters and genetic factors [1].
(iv) Pathology
McNeal divided the prostate into peripheral zone, central zone, migratory zone and periurethral glandular area. All BPH nodules occur in the migratory zone and periurethral glandular region [1]. Early nodules in the periurethral glandular region are exclusively mesenchymal in composition; whereas early nodules in the migratory zone show mainly hyperplasia of glandular tissue with a relative decrease in the amount of mesenchyme. Smooth muscle in the interstitial tissue is also an important component of the prostate. These smooth muscles and the periurethral tissue of the prostate are innervated by adrenergic nerves, cholinergic nerves, or other enzymatic transmitters, with the adrenergic nerves playing a major role. There are abundant G receptors, especially αl receptors, in the prostate and bladder neck [6-7], and activation of this adrenergic receptor can significantly increase prostatic urethral resistance.
The anatomical envelope of the prostate and lower urinary tract symptoms are closely related. Due to the presence of this envelope, the hyperplastic gland is compressed and bulges out into the urethra and bladder thereby increasing urinary tract obstruction. After prostate enlargement, the enlarged nodules compress the rest of the gland to form a “surgical envelope” with a clear demarcation between the two. After surgical removal of the hyperplastic part, the compressed gland remains, so the prostate gland can still be detected by postoperative rectal examination and imaging.
(E) Pathophysiological changes
Prostatic hyperplasia leads to lengthening of the posterior urethra, deformation of pressure, narrowing and increased urethral resistance, causing bladder hypertension and symptoms related to the voiding period. With the increase of bladder pressure, compensatory hypertrophy of the bladder forced urinary muscle occurs, and the forced urinary muscle becomes unstable and causes the related symptoms of the urinary storage phase. If the obstruction is not relieved for a long time, the forceps muscle loses its compensatory capacity. The main causes of upper urinary tract changes secondary to BPH, such as hydronephrosis and renal impairment, are urinary retention due to bladder hypertension and ureteral reflux.
(VI) Clinical manifestations, diagnosis and treatment
The main clinical manifestations of BPH include bladder irritation, obstructive symptoms and related comorbidities. Various symptoms may appear sequentially or develop progressively throughout the course of the disease. The diagnosis of BPH is based on symptoms, physical examination, especially rectal examination, imaging, urodynamic examination and endoscopy, etc. The treatment of BPH mainly includes observation and waiting, pharmacological treatment, minimally invasive treatment and surgical treatment. The aim of treatment is to improve the quality of life of patients while protecting renal function. The choice of specific treatment should be based on the severity of the patient’s symptoms, combined with various auxiliary tests, local medical conditions and the patient’s compliance.
The development of guidelines for the treatment of benign prostatic hyperplasia
BPH has become one of the most common diseases in urological clinical practice around the world, and its large patient population and high medical costs have become a social problem. With the continuous development of our national economy and the advent of the aging society, the clinical treatment of BPH will probably become an important issue in the development of urological clinical work and health care in China in the coming decades.
(I) Progress of BPH treatment guidelines
In 1994, the American Health Council and the Society of Urology jointly proposed the first edition of the BPH guideline, which mainly regulated the steps of BPH diagnosis and treatment [1]. 1996, the American Urological Association further proposed a new edition of the BPH guideline focusing on the symptom scoring system. The European Urological Society and the Japanese Urological Society also proposed their own guidelines for the management of BPH in 1998 and 1999, respectively. Subsequently, the American Urological Association and the European Urological Association updated their respective BPH guidelines in 2003 and 2004, respectively [2,3]. The focus of BPH guidelines by national urological societies varies due to different sociocultural developments. The BPH guidelines developed by the American and European urological societies emphasize the outcome of subjective factors, such as the International Prostate Symptom Score (I-PSS) and the Quality of Life (QOL) score, to determine the severity of the patient’s disturbance. The B-value of the patient’s symptoms is determined by the International Prostate Symptom Score (I-PSS) and the Quality of Life Index (QOL). The BPH treatment guidelines proposed by the Japanese Society of Urology combine the results of subjective symptoms and objective factors, such as I-PSS and QOL scores, prostate volume, maximum urinary flow rate, and residual urine volume, to make a comprehensive judgment of the severity of the patient’s condition [4].
(II) The need and purpose of developing BPH treatment guidelines
The clinical manifestations of BPH are mainly different forms of lower urinary tract symptoms, and there are various treatment methods for BPH, including waiting for observation, pharmacological treatment, minimally invasive treatment, and surgical treatment. The purpose of the BPH treatment guidelines is to provide clinical guidance to urologists in different medical conditions in selecting reasonable diagnostic and treatment methods for BPH. The purpose of the BPH diagnosis and treatment guidelines is to provide clinical guidance for urologists in different medical conditions to choose the appropriate diagnosis and treatment of BPH.
(3) The significance of BPH diagnosis and treatment guidelines
The development of BPH diagnosis and treatment guidelines is part of clinical practice guideline in medical field, and the completion of BPH diagnosis and treatment guidelines has positive significance to promote the standardization of clinical medical work. The Chinese Medical Association Urology Society is the most authoritative academic organization in the field of urology in China and has the responsibility to provide standardized medical service model to the society. The development and promotion of various clinical guidelines is of representative significance. The significance of formulating BPH diagnosis and treatment guidelines is mainly: (i) conducive to the selection and unification of BPH diagnosis and treatment methods; (ii) conducive to the continuous observation of the clinical progress of BPHI; (iii) conducive to the determination of the effects of different treatment modalities of BPH; (iv) conducive to the comparison of BPH diagnosis and treatment results in various regions; (v) conducive to the improvement of BPH diagnosis and treatment and further protection of patients’ interests.
(D) Methodology of BPH diagnosis and treatment guidelines
The development of evidence-based guideline development requires the following processes under the premise of clarifying the significance of this topic: ① selection of target diseases; ② establishment of organizational composition; ③ evaluation of clinical research papers; ④ specific development of treatment guidelines; ⑤ promotion and continuous improvement of treatment guidelines [5].
1. Establishment of organizational composition
The Chinese Society of Urology was responsible for the development of BPH guidelines in China, and nine experts and professors, including major hospitals in major regions of China, were hired to develop the guidelines for clinical diagnosis and treatment of BPH in China. The nine expert professors were from Peking University Institute of Urology (2), Beijing Hospital of Ministry of Health (1), Peking Union Medical College Hospital (1), Shanghai Renji Hospital (1), Shanghai Changhai Hospital (1), Guangdong Provincial People’s Hospital (1), West China Hospital of Sichuan University (1), and Wuhan General Hospital of Guangzhou Military Region (1).
2. Judgment of clinical research papers
In the development of BPH treatment guidelines in China, the BPH treatment guidelines developed by the American Urological Association, the European Urological Association and the Japanese Urological Association were discussed repeatedly, and the parts with commonality were considered to be able to be utilized in our BPH treatment guidelines. Of course, we discussed the following issues: (i) there are very few ethnic differences in the treatment of BPH; (ii) all treatments should be in accordance with national health insurance policies; and our BPH treatment guidelines should be internationally applicable. In the specific literature review process, the credibility of specific literature was judged according to the following criteria.