OAB and BPO: The link, non-invasive approaches, surgical strategies, and shared decision-making

The session kicked off with the Confederación Americana de Urología (CAU) presentation, “Non-invasive work-up of male OAB,” by Prof. Márcio Augusto Averbeck (BR). He presented a case of a 64-year-old patient with mixed lower urinary tract symptoms (LUTS), who had been diagnosed with benign prostatic enlargement (BPE) 10 years earlier. With a comorbidity of systemic arterial hypertension, the patient’s most bothersome symptom was urinary urgency. The key question was: what is the non-invasive work-up for a patient with both BPE and OAB symptoms?

Prof. Averbeck cited the EAU Guidelines on non-neurogenic male LUTS and focused on the recommendations regarding medical history, questionnaires (e.g. validated symptom score questionnaire), bladder diaries, physical examination, urinalysis, PSA testing, post-void residual (PVR) measurement, uroflowmetry, and urethrocystoscopy. He also covered urodynamics and other non-invasive assessments.

Link between BPO and OAB
In his state-of-the-art lecture “What is the relationship between BPO and OAB? Separating truth from tradition”, Prof. Marcus Drake (GB) stated, “Does a voiding phase problem affect the storage phase? The jury is still out. We should be careful not to assume that male LUTS is a dustbin of uniform problems that can be solved with the same interventions.” He added that induction is difficult to support epidemiologically or pathophysiologically. Regarding maintenance, individual post-op outcomes might suggest a connection, but not in cases where baseline parameters are moderate to severe.

In addition, Prof. Drake said that “secondary” OAB is not a justified reason for performing surgery to relieve BPO; it can only be surmised post-operatively. He stressed the importance of proper assessment and appropriate counselling regarding uncertainty.

Suitable surgery
During the state-of-the-art lecture, “Which surgery is best for BPO/OAB patients?” Assoc. Prof. Malte Rieken (CH) concluded that different surgical techniques are associated with varying degrees of deobstruction. He stated, “In the majority of patients, deobstruction improves OAB symptoms and detrusor overactivity (DO). If you look at the various technologies, we have established that endoscopic enucleation is the only size-independent surgical technique that offers both obstruction and DO relief. However, there is no one-size-fits-all surgery for BPO/OAB patients, as various factors influence treatment decisions, and we must take patients’ preferences and expectations into account.” Prof. Rieken added that high-level evidence specific to the BPO/OAB population is still lacking.

Brave patients
To conclude the Plenary Session, Prof. Kari Tikkinen (FI) presented his state-of-the-art lecture, “Patients’ values and preferences,” in which he underscored the importance of practising proper shared decision-making with accurate information. “Talk to your patients. You need to ask what’s important to them. That’s personalised LUTS management,” stated Prof. Tikkinen.

In addition, he stressed, “Patients need to receive accurate information. Studies should report honest results in a manner that is easy to understand. We need to know our results better.”

Regarding key information about prognosis and management, Prof. Tikkinen emphasised, “You need to discuss with your patients the risks of not being able to void post-surgery or the potential need for catheterisation. You must inform your patients about which symptoms are more or less likely to resolve. Understanding their prognosis is crucial for decision-making. Talk to them not only about pain but also about erection, ejaculation, continence, and perioperative risks.

“There are no brave urologists, only brave patients. At the end of the day, the patient decides whether the urologist did a good job or not,” Prof. Tikkinen concluded.

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