LAUSR

available at http://www.ncbi.nlm.nih.gov/pubmed/30971393 Editorial Comment: For the last 25 years medical therapy has been the mainstay of treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Virtually every guideline and regulatory body accepts this as gospel. We now have more than a quarter century of data on the short and long-term consequences of medical therapy for BPH, including landmark studies such as MTOPS (Medical Therapy of Prostatic Symptoms), which focused on urological pros and cons. However, data during the last few years have suggested that all may not be well in the medical therapy world. Reports of dementia, depression and suicide risk have populated the literature with particular worry when using the 5a-reductase inhibitors finasteride and dutasteride. This report suggests that use of either finasteride or dutasteride significantly increases the risk of type 2 diabetes compared to tamsulosin. Tamsulosin has been under investigation as well for potential increased risks of dementia, although the data are hardly conclusive. Several patients have contacted me about this report, given that it was shouted out by the venerable Dr. Google. While the jury remains out on the potential long-term sequelae, we need to keep an open mind regarding the unintended consequences of medical therapy for LUTS. Nonetheless, such population based cohort studies tend to use propensity score analyses, and to paraphrase Benjamin Disraeli, there are lies, damned lies and propensity scores. Briefly the most important limitation of all methods of confounder control, including multivariable logistic regression and propensity scoring, is that although they can balance observed baseline covariates between groups, they do nothing to balance unmeasured characteristics and confounders. Thus, we know what we know but don’t recognize what we don’t know, and therefore may unintentionally bias our analysis. The bottom line is that there are emerging reports that are important, should not be overdramatized and should be part of our continued examination of long-term therapeutic interventions. Should these trends become increasingly apparent, the therapeutic algorithm for LUTS secondary to BPH will change dramatically. Buckle up! Steven A. Kaplan, MD Suggested Reading Bechis SK, Otsetov AG, Ge R et al: Personalized medicine for the management of benign prostatic hyperplasia. J Urol 2014; 192: 16. 0022-5347/19/2024-0634/0 THE JOURNAL OF UROLOGY 2019 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. https://doi.org/10.1097/JU.0000000000000447 Vol. 202, 634-668, October 2019 Printed in U.S.A. 634 j www.auajournals.org/jurology Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.