What is the best management plan for an 81-year-old male with recurrent superficial bladder TCC, BPH, and nocturia, on Uroxatral (alfuzosin) and Avodart (dutasteride)?

Management Plan for an 81-Year-Old Male with Recurrent Superficial Bladder TCC, BPH, and Nocturia

The optimal management plan for this patient includes continued combination pharmacotherapy with Uroxatral (alfuzosin) and Avodart (dutasteride) for BPH, prophylactic antibiotics following cystoscopy, and close surveillance for bladder cancer recurrence with regular cystoscopy every 3 months initially.

Bladder Cancer Management

• The recent cystoscopy revealed a small superficial bladder TCC lesion adjacent to the left ureteral orifice, which was appropriately fulgurated with Bugbee electrode 1
• For non-muscle invasive bladder cancer (Ta lesion), close follow-up is essential with cystoscopy at 3-month intervals for the first 1-2 years, then at increasing intervals over the next 2 years, and annually thereafter 1
• Urinary cytology should be performed along with cystoscopy during follow-up visits to monitor for recurrence 1
• Upper tract imaging (CT urogram or IVP) should be considered every 1-2 years due to the high-grade nature of the tumor 1
• The prophylactic antibiotic therapy with Augmentin 875 mg BID for 3 days post-procedure is appropriate to prevent infection 1

BPH Management

Current Treatment Assessment

• The patient is currently on appropriate combination therapy with alfuzosin (Uroxatral, an alpha-blocker) and dutasteride (Avodart, a 5α-reductase inhibitor) for BPH 1, 2
• This combination is particularly appropriate for patients with enlarged prostates and persistent symptoms, as it provides both immediate symptom relief (alpha-blocker) and long-term prostate size reduction (5α-reductase inhibitor) 1
• Despite this therapy, the patient continues to experience significant nocturia (3-5 times per night) and has obstructing prostate on cystoscopy with bladder trabeculation 1

Nocturia Management

• For persistent nocturia despite combination therapy, a frequency-volume chart should be completed to determine if nocturnal polyuria (>33% of 24-hour urine output occurring at night) is present 1, 3
• Lifestyle modifications should be implemented, including:
  • Limiting fluid intake in the evening (aim for 200 ml or less) 3, 4
  • Avoiding caffeine and alcohol, especially in the evening 3, 4
  • Reviewing medication timing (particularly diuretics) 3, 5
• If nocturnal polyuria is confirmed, consider adding desmopressin as adjunctive therapy to the current BPH medications 5, 4
• If reduced functional bladder capacity is the primary cause, the current alpha-blocker and 5α-reductase inhibitor combination should be continued as these can help reduce nocturia episodes 5, 6

Surgical Options

• The patient was appropriately counseled about surgical options including TURP and REZUM water vapor therapy, but elected to continue with combination pharmacotherapy 1
• Surgical intervention should be reconsidered if the patient develops:
  • Refractory urinary retention 1, 7
  • Recurrent UTIs 1
  • Progressive renal insufficiency due to BPH 1
  • Bladder stones 1
• The presence of bladder trabeculation observed during cystoscopy indicates bladder outlet obstruction, which may eventually require surgical intervention if symptoms worsen 1, 7

Follow-up Plan

• Schedule cystoscopy with cytology every 3 months for the first year to monitor for bladder cancer recurrence 1
• Assess BPH symptoms, including nocturia, at each follow-up visit using a validated symptom score 1, 8
• Monitor renal function with serum creatinine (currently 1.32) and PSA (currently 1.5) annually 1
• Consider upper tract imaging annually due to the history of bladder cancer 1
• If nocturia persists despite optimization of current therapy, consider urodynamic studies to better characterize the underlying cause 1, 8

Important Considerations

• Alpha-blockers like alfuzosin may cause orthostatic hypotension, dizziness, and asthenia, which are particularly concerning in an elderly patient 9
• Dutasteride reduces serum PSA by approximately 50%, which must be considered when interpreting PSA results for prostate cancer screening 2
• The atypical urothelial cells in the recent urine cytology warrant close surveillance as they may indicate recurrent disease 1
• The patient should be advised to inform his ophthalmologist about alfuzosin use before any cataract surgery due to the risk of intraoperative floppy iris syndrome 9