Çetin Volkan ÖZTEKİN, Mesut ÇETİNKAYA, Nasır YILMAZ, Özgür UĞURLU, Ömer Gökhan DOLUOĞLU, Mustafa SUNGUR, Özer GÜZEL

Benign Prostat Hiperplazisinde Tolterodin ve Tamsulosin Kombinasyonunun Semptomlar ve Mesane Çıkım Obstrüksiyonu Üzerine Etkisi

Amaç: Çalışmanın amacı tamsulosin, tolterodin monoterapisi ile kombinasyon tedavisinin benign prostat hiperplazisinde semptomatik ve ürodinamik açıdan kaşılaştırılmasıdır. Gereç ve Yöntemler: Benign prostat hiperplazisine bağlı alt üriner sistem semptomları olan 66 erkek hasta tamsulosin, tolterodin ve tolterodin+tamsulosin olarak üç gruba ayrıldı. Tedavi öncesi ve sonrası yaş, prostat spesifik antijen, prostat hacimleri, "international prostate symptom scor" değerleri belirlendi. Basınç akım çalışması ile Qmax, PdetQmax, sistometrik mesane kapasiteleri ve detrüsör aşırı aktivitesi, rezidüel idrar miktarı, Abrams-Griffith obstrüksiyon skorları (ObstInd) saptandı. Altı ay süre ile birinci gruptaki hastalara tolterodin günde iki kez 2 mg, ikinci gruptaki hastalara tamsulosin günde bir kez 0.4 mg ve üçüncü gruptakilere her iki preparat aynı dozlarda kombinasyon olarak verildi. Tedavi sonrası "international prostate symptom score", ve basınç-akım çalışması tekrarlandı. Elde edilen değişimler her grup kendi içinde ve gruplar arasında karşılaştırıldı. Bulgular: Tolterodin grubunda rezidüel idrar miktarında istatistiksel anlamlı değişiklik saptanmadı ancak tamsulosin ve kombinasyon gruplarında rezidüel idrar miktarı anlamlı olarak azaldı. Qmax, PdetQmax, sistometrik kapasite, Abrams-Griffith obstrüksiyon skorları tolterodin ve tamsulosin gruplarında anlamlı olarak değişmez iken kombinasyon grubunda anlamlı düzeyde iyileşme saptandı. Tamsulosin grubu, "international prostate symptom score -total", "international prostate symptom score -obstrüktif", Vr, PdetQmax ve ObstInd de kombinasyon grubu ile benzer etkinlik gösterirken, kombine tedavi international prostate symptom score irritatif alt skorunda ve noktüri sayısında her iki gruptan daha etkindi. Sonuç: Benign prostat hiperplazisine bağlı alt üriner sistem semptomlarından aşırı aktif mesane semptomu olan ve alfa blokör tedaviden fayda görmeyen hastaların kombine tedaviden fayda göreceğini düşünmekteyiz.

Effects of Tolterodine and Tamsulosin Combination on Sypmtoms and Bladder Outlet Obstruction in Patients with Benign Prostate Hyperplasia

Aim:To compare the symptomatic and urodynamic aspects of mono-therapies and combination therapies of tolterodine and tamsulosin. Meterial and Methods: Sixty-six patients with lower urinary tract symptoms due to benign prostatic hyperplasia were separated into three treatment groups as tolterodine only group, tamsulosin mono-therapy group, and tolterodine+tamsulosin combination therapy group. Demographics of the patients were noted and prostate specific antigen, prostate volumes, and international prostate symptom scores were determined before and after the treatment. Qmax, PdetQmax, cystometric bladder capacities and detrusor hyperactivities, residual urine portions, Abrams-Griffith obstruction scores (ObstInd) were established. Patients took 2 mg of tolterodine twice a day in first group, 0.4 mg of tamsulosine once a day in second group, and equal doses of these medicines were given as combination in third group. All three groups took the medications for six months. International prostate symptom score and pressure-flow studies were repeated after the treatment, and the differences were analyzed both in, and between the groups. Results: There was no statistically significant difference in tolterodine group for residual urine portions, but these values were significantly lowered in tamsulosin group and combination-therapy groups. Qmax, PdetQmax, cystometric capacity, and AbramsGriffith obstruction scores were similar in tolterodine and tamsulosin monotherapy groups, whereas significant improvements were achieved in combination therapy group. Tamsulosin group had similar international prostate symptom score -total, international prostate symptom score -obstructive, Vr, PdetQmax and ObstInd values with combination therapy group. Moreover, combination therapy group was significantly more efficient in international prostate symptom score irritative sub-score and nocturia frequency. Conclusions: We concleded that patients who have overactive bladder symptoms and lower urinary tract symptoms due to benign prostatic hyperplasia, and who do not benefit from alpha-blockers will benefit from combined treatment.

PDF

___

Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia With Age. J Urol 1984;132:474-9.
Tanagho EA, McAninch JW, Joseph C, Presti JR. Neoplasm of the Prostate Gland. In: Tanagho EA, McAninch JW, eds. Smith's General Urology. 16th ed. New York, NY: McGraw-Hill; 2004. p. 367-85.
Girman CJ, Jacobsen SJ, Tsukamato T, Richard F, Garraway WM, Sagnier PP, et al. Health-related quality of life associated with lower urinary tract symptoms in four countries. Urology 1998;51:428-36.
Abrams P, Cardozo L, Fall M, Griffths D, Rosier P, Ulmsten U, et al. The standardization of terminology in lower urinary tract function: Report from the standardization sub-committee of the international continence society. Urology 2003;61:37-49.
Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: Results of the EPIC study. Eur Urol 2006;50:1306-14.
Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. [Internet]. Guidelines on the Management ofMale Lower UrinaryTract Symptoms (LUTS). Arnhem (The Netherlands): European Association of Urology (EAU) 2012; Avaiable from http://www.uroweb.org/gls/pdf/12_Male_LUTS_LR.pdf.
Kirby R, Lepor H. Evaluation and Non-Surgical Management of Benign Prostatic Hypeplasia. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, eds. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders Elsevier; 2007, p. .2766-802.
Tarcan T, Yazıcı C. Benign Prostat Hiperplazisi Tanı ve ve Karşılaştırılması. Türk Üroloji Dergisi 2006;32:110-7.
Kaplan S, Walmsley K, Te A. Tolterodine Extended Release Attenuates lower urinary tract symptoms in men with 2008;179(Suppl):82-5. hyperplasia. J Urol.
Abrams P, Kaplan S, De Koning Gans HJ, Millard R. Safety and tolerability of tolterodine for the treatment of overactive bladder in men with bladder outlet obstruction. J Urol 2006;175:999-04.
Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol 2004;46:547-54.
Thomas AW, Cannon A, Bartlett E, Ellis-Jones J, Abrams P. The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic followup of transurethral resection of prostate for bladder outlet obstruction. J Urol 2005;174:1887-91.
Kirby R, Roehrborn C, Boyle P, Bartsch G, Jardin A, Cary MM, et al. For the prospective European doxazosin and combination therapy study investigators. Efficacy and tolerability of doxazosin and finasteride, alone or in combination, in treatment of symptomatic benign prostatic hyperplasia: the prospective European doxazosin and combination therapy (PREDICT) trial. Urology 2003;61:119-26.
Price DA, Ramsden PD, Stobbart D. The unstable bladder and prostatectomy. Br J Urol 1980;52:529-31.
Lee JY, Kim HW, Lee SJ, Koh JS, Suh HJ, Chancellor MB. Comparison of doxazosin with or without tolterodine in men with symptomatic bladder outlet obstruction and overactive bladder. BJU Int 2004;94:817-20.
Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: A randomized controlled trial. JAMA 2006;296:2319-30.
Kaplan SA, Walmsley K, Te AE. Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2005;174:2273-6.
Rovner ES, Kreder K, Sussman DO, Kaplan SA, Carlsson M, et al. Effect of tolterodine extended release with or without tamsulosin on measures of urgency and patient reported outcomes in men with lower urinary tract symptoms. J Urol 2008;180:1034-41.
Chapple C, Herschorn S, Abrams P, Sun F, Brodsky M, Guan Z. Tolterodine treatment improves storage symptoms suggestive of overactive bladder in men treated with alpha-blockers. Eur Urol 2009;56:534-41.
Kaplan SA, Roehrborn CG, Chancellor M, Carlsson M, Bavendam T, Guan Z. Extended-release tolterodine with or without tamsulosin in men with lower urinary tract symptoms and overactive bladder: Effects on urinary symptoms assessed by the international prostate symptom score. BJU Int 2008;102:1133-9.
Roehrborn CG, Abrams P, Rovner ES, Kaplan SA, Herschorn S, Guan Z. Efficacy and tolerability of tolterodine extended-release in men with overactive bladder and urgency urinary incontinence. BJU Int 2006;97:1003-6.
Roehrborn CG, Kaplan SA, Jones JS, Wang JT, Bavendam T, Guan Z. Tolterodine extended release with or without tamsulosin in men with lower urinary tract symptoms including overactive bladdersymptoms: Effects of prostate size. Eur Urol 2008;55:472-81.
Athanasopoulos A, Gyftopoulos K, Giannitsas K, Fisfis J, Perimenis P, Barbalias G. Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: A prospective, randomized, controlled study. J Urol 2003;169:2253-6.
Yang Y, Zhao XF, Li HZ, Wang W, Zhang Y, Xiao H, et al. Efficacy and safety of combined therapy with terazosin and tolteradine for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia: A prospective study. Chin Med J (Engl). 2007;120:370-4.
Kaplan SA, Roehrborn CG, Dmochowski R, Rovner ES, Wang JT, Guan Z. Tolterodine extended release improves overactive bladder symptoms in men with overactive bladder and nocturia. Urology 2006;68:328-32.
Chung DE, Kaplan SA. Current role for combination therapy in male LUTS. Arch Esp Urol 2010;63:323-32.