Management depends on the etiology of the episode of UR. If likely related to BPH rather than prostate cancer, then manage as per BPH above. If the patient is known to have prostate cancer, or the diagnosis is clinically very likely, then the management should be as follows. Initially, the important step is to establish bladder drainage, as before, including any appropriate investigations that should be performed.
Once bladder drainage has been established, TWOC is unlikely to be successful if AUR has been caused by local disease progression. Similarly, the addition of a-adrenoceptor antagonists is unlikely to be beneficial, as the tissue causing the obstruction is not predominantly smooth muscle. In some cases, TURP (often referred to as channel TURP to differentiate between operations for benign and malignant disease) can be performed, either acutely (within 2-3 days) or electively (after 4-6 weeks). This will provide symptomatic relief of voiding LUTS, but clearly is not intended as curative surgery for the prostate cancer. Alternative treatments have included prostatic stents (Anson et al. 1993), although these have largely gone out of favor. In select patients unsuitable for TURP, however, they may still have a role (Parikh and Milroy 1995; Wilson et al. 2002).
If the diagnosis of prostate cancer is not yet confirmed, then prostate biopsies should be obtained, usually via transrectal ultrasound. Once the diagnosis has been confirmed, then an alternative first-line treatment would be to instigate androgen deprivation treatment. This will shrink the prostate gland and potentially allow the patient to void normally again. Many centers would advocate the use of androgen deprivation therapy synchronously with TURP or stenting. Some patients, however, will have androgen-resistant disease, and in these cases any palliative treatment to improve LUTS is the most appropriate course of action, as outcome in this group tends to be very poor (Weiss et al. 2001; Gnanapragasam et al. 2006).
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