Finasteride as a Neo-Adjuvant Treatment for TURP-Literature Review

Hagerty, et al. [10] conducted the 1st prospective cohort study about the role of preoperative finasteride for 25 patients given finasteride for about 2-4 months and 50 controls without treatment. They followed both groups for 4 months and found that only 8.3% of patients underwent preoperative treatment experienced perioperative bleeding while 37% of the control group got bleeding during the operation. So, they concluded that preoperative finasteride decreases the bleeding rate, postoperative complication such as clot retention especially in Abstract

Finasteride is a selective 5 Alpha Reductase Inhibitor (ARI) which prevents the conversion of testosterone to Dihydrotestosterone (DHT) which leads to decrease the symptoms of urethral obstruction and hematuria [1,2,4].
Hematuria resolves within1-2 weeks after the treatment with finasteride in 80% of the patients [1,4,5].Bladder out flow obstruction symptoms decrease subsequently after decreasing DHT levels leading to decease glandular and fibro muscular tissue of the prostate and overall decrease of the prostate tissue by 25-30% after 6-12 months treatment by finasteride [1,4] .
Preoperative treatment with finasteride is essential to decrease perioperative bleeding and consequently to decrease patients with larger prostate size > 30 gm.Finasteride decreases the bleeding through decreasing the expression of vascular endothelial growth factor (VEGF) which in turn decrease the angiogenesis and bleeding [1,6].
Foley, et al. [11] conducted a prospective observational control study of 57 patients with chronic intermittent hematuria and then randomly divided in 2groups, one given finasteride and others are control group .The rate of recurrent hematuria was significantly less among group treated with finasteride.
Ozdal, et al. [5] demonstrated the effect of short term pretreatment with finasteride in BPH patients.They collected 40 patients with BPH who will perform TURP and randomized them into 2 groups, 20 of them received 5 mg of finasteride for 4 weeks while other 20 patients act as a control.They found that there is a significant decrease in blood loss perioperatively among the patients who received finasteride and there is subsequent decrease in the post-operative complication such as transfusion and clot retention.Although the size of respected prostate in finasteride group was larger than the control group (23.25 gm Vs 18.73 g ), the amount of perioperative bleeding in the finasteride group was less (173.47 ml Vs 235.46ml in the control group).Bleeding per gm respected prostate was less in the finasteride group 7.6ml/g Vs 13.99ml/g in control with p <0.0001.Donohue, et al. [7] reported that 5 mg of finasteride taken daily for 2 weeks Pre-TURP decreases the blood loss during operation in 70 patients randomized into finasteride and placebo group with mean age 70 years old.
Hochberg, et al. [12] reported the effect of finasteride on decreasing MVD in a study of 22 patients with clinical BPH and hematuria.
Pareek, et al. [13] also showed a significant decrease in the expression of VEGF and MVD in patients treated with finasteride in a study of 24 patients receiving finasteride for 6 weeks prior to the surgery.
Carlin, et al. [14] confirmed the efficacy of 5 mg finasteride for 2 weeks in the treatment of BPH related hematuria ina prospective study of 12 patients.
McConnell, et al. [15] observed that oral administration of finasteride for only 1 week decreases the levels of DHT in the prostate by 85% in a randomized, double blinded, placebo controlled study.Kearney, et al. [16] reported that the effective duration for finasteride to stop hematuria is dependent on the prostatic volume as one week may be sufficient for prostatic volume of 40 cc, while 45 treatment days may be needed for prostate more than 150 cc.
In our practice, we did not routinely use Finasteride as a neoadjuvant treatment before TURP, however; it was evident that less bleeding was encountered with patients that underwent TURP while they were taking Finasteride as a medical treatment for their enlarged prostate.We currently started to believe that, the routine short term use of Finasteride before TURP for large prostates may allow a safer surgery and a smoother postoperative period.

Conclusion
Finasteride is an effective drug that may be considered pre-TURP for patients with prostatic volume more than 30 cc.The duration of treatment ranges from 1-6 weeks depending on the prostatic volume.