Acute relief or future prevention: is urology ready for preventive health care?

The approach to clinical medicine has evolved over the last 20 years to incorporate therapeutic strategies to prevent long-term negative outcomes rather than simply treat acute events. As a result, new treatment paradigms have been developed in various disease areas. These paradigms arise from clinical trials that show a correlation between risk reduction and decreases in painful, traumatic, or fatal events. The field of urology has been relatively slow to adopt the concept of disease prevention. Several areas of clinical urology do employ prophylactic or metaphylactic therapies, although these are generally for secondary prevention after a primary event (e.g., secondary prevention of recurrent bladder cancer or recurrent kidney stones). There is, however, growing interest in the primary prevention of prostate cancer with a variety of interventions, ranging from dietary modifications to selenium and finasteride. Traditionally, clinical trials of agents for the treatment of symptomatic benign prostatic hyperplasia (BPH) have studied improvements in lower urinary tract symptoms, urinary flow rate, and reduction in prostate volume over relatively short periods of 6 weeks to 1 year. More recently, with the availability of long-term data from community-based studies of the natural history of BPH and placebo-controlled clinical trials, interest is shifting beyond short-term effects on symptoms to reducing the risk of long-term negative outcomes and disease progression. This signals an important reorientation of clinical investigation in BPH.