Prostate International xxx (2018) 1e6

Contents lists available at ScienceDirect

Prostate International
journal homepage: https://www.journals.elsevier.com/prostate-international

Original Article

Adherence of Indonesian urologists to practice guidelines for the

management of benign prostatic hyperplasia
Fakhri Rahman, Ida Bagus Putra, Chaidir Arif Mochtar, Nur Rasyid*
Department of Urology, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Clinical guideline is built to provide consistent, efficient, and high quality of medical care
Received 5 December 2017 based on recent evidence. This study aimed to investigate the adherence of Indonesian urologists to
Received in revised form clinical guidelines for the management of benign prostatic hyperplasia (BPH).
10 January 2018
Materials and methods: This was a cross-sectional study using questionnaire conducted between
Accepted 31 January 2018
Available online xxx
January and June 2017. Respondents were Indonesian urologists registered as members of Indonesia
Urological Association and had already practice in urology for at least 6 months. Questionnaires were
sent via e-mail and Google Form. The level of adherence was measured using scoring system decided by
Keywords:
Benign prostatic hyperplasia
authors' agreement. All data were processed using SPSS, version 23, and presented in descriptive fashion.
Guideline adherence Results: Of 352 urologists who fulfilled inclusion and exclusion criteria, 209 (59.4%) respondents
Urologists returned the questionnaire. Most of respondents (95.2%) used Indonesia Urological Association BPH
guidelines as their clinical practice guidance. Routinely performed recommended examination, such as
symptom scoring system, digital rectal examination, urinalysis, uroflowmetry, postvoid residual urine,
and prostate imaging were used by 89.9%, 92.5%, 70.4%, 50.8%, 53.3%, and 98.6% respondents, respec-
tively. After patient is diagnosed with BPH, most of respondents considered medical therapy (99%),
surgical therapy (93%), and watchful waiting (78.4), with alpha-blocker as the drugs most preferred by
respondents. For indication to perform surgery for BPH, only bladder stones, decreased renal function,
and trial without catheter failure were considered by more than 85% of respondents. Open prostate
surgery was performed by 54.8% respondents for the following reasons: large prostate volume, presence
of bladder stone, unavailability of endourology equipments, abnormality of bladder, and residency
training program. At last, this study found median (minimumemaximum) of Indonesian urologists
adherence level toward BPH guidelines is 78.5% (28.6%e100%).
Conclusions: In general, Indonesian urologists have a good adherence toward guidelines. However,
there is still wide variation of their adherence to it.
© 2018 Asian Pacific Prostate Society, Published by Elsevier Korea LLC. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction tract infection, hematuria, urinary stone disease, and urinary

retention, and sometimes causing loss of sleep and depression.6
Benign prostatic hyperplasia (BPH) is a progressive disease, and However, the impact of the disease is not only due to problems
its increase in prevalence is parallel to age with an increased risk of mentioned above which lead to a decline in patient's quality of
4% each year.1e3 It is a pathological diagnosis, and an autopsy study life but also due to its significant cost. In the United States, it has
showed that its prevalence is 8% in the 4th decade of life, 50% in the been estimated that this disease cost $4 billion annually.7
6th decade of life, and 80% in 9th decade of life.4,5 This disease leads To solve those problems, guidance is required to provide
to bladder outlet obstruction resulting in lower urinary tract consistent and efficient clinical practice. Clinical guidelines could
symptoms (LUTSs) and other clinical complications, such as urinary be the key to solve the problem.8 Currently, numerous practice
guidelines on BPH exist. However, implementing these guidelines
in clinical practice is not always successful, and variations occur in
clinical practice.9,10 The difference are related to urologist prefer-
* Corresponding author. Cipto Mangunkusumo Hospital, Jl. Dipenogoro No. 71, ence or beliefs, cost, and available medical resources.10 A study by
Jakarta Pusat, Indonesia.
Strope et al showed that variation existed for BPH evaluation. This
E-mail address: nur.rasyid@gmail.com (N. Rasyid).

https://doi.org/10.1016/j.prnil.2018.01.003
p2287-8882 e2287-903X/© 2018 Asian Pacific Prostate Society, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003
2 Prostate International xxx (2018) 1e6

variation was influenced by location, urologist's experience, and considered as routinely performed examination are scoring system,
resources.11 digital rectal examination (DRE), urinalysis, uroflowmetry, postvoid
To provide a quality health care that is based on the latest evi- residual urine (PVR), and prostate imaging that was further divided
dence and recommendation, the Indonesian Urological Association into transrectal ultrasound (TRUS) and transabdominal ultrasound
(IUA) has updated its 2003 clinical guidelines on BPH in 2015.12 The (TAUS). Meanwhile, examinations that are considered as optional
updated guidelines have included level of evidence and grade of examination are kidney function test, prostate-specific antigen
recommendation for the management of BPH. It is hoped that with (PSA) test, urinary tract imaging, urethrocystoscopy, and urody-
updated guidelines, Indonesian urologists will provide the best namic test. Furthermore, these guidelines also divided the indica-
possible care for patients, attuned to the available resources. tion to perform surgery for BPH patient into absolute indication,
To date, it is not known about how Indonesian urologists use such as acute urinary retention, trial without catheter (TWOC)
and comply with the IUA BPH clinical guidelines. In this study, we failure, recurrent urinary tract infection, retractable macroscopic
will investigate the adherence of Indonesian urologists to clinical hematuria, bladder stone, decreased renal function due to
guidelines for the management of BPH. obstruction caused by BPH, and pathological change of bladder and
upper urinary tract, and relative indication, such as moderatee
2. Methods severe International Prostate Symptom Score (IPSS), no improve-
ment after nonsurgical treatment, and patient preference.
2.1. Study's design and population Before the questionnaire was distributed, it underwent reli-
ability test using testeretest reliability, and it had reliability coef-
This was a cross-sectional study conducted between January ficient more than 0.9 in all questions.
and June 2017. Respondents had to be registered as urologist under
the IUA database and had already practiced urology for at least for 6 2.4. Data measurement and presentation
months when the data were collected. Urologists who no longer
practice were excluded from this study. To measure adherence, a scoring system was developed ac-
cording to authors' agreement. Every examination which is rec-
2.2. Data collection ommended to be routinely performed by IUA BPH guidelines was
given a score þ1 if it was offered by urologist. However, for other
Data were collected using questionnaires which were distrib- examination which is considered optional by IUA BPH guidelines,
uted in a national urology symposium (8th Uro Oncology update the given score was 0. Score 0 will be given to all optional medical
held between 9e11 February 2017) and electronically via e-mail therapies chosen by urologists based on IUA BPH guidelines, except
and Google Form. Google Form link was sent as a part of e-mail and for phytopharmaca which is not recommended by IUA BPH
through short message service (SMS)/chat message (Whatsapp guidelines and score -1 will be given to every urologist who offered
messenger application) to every individual who fulfills inclusion this therapy to patient. Moreover, urologists were given a score þ1
and exclusion criteria between April and June 2017. Urologists' e- for offering surgical therapy to absolute indications. To the urologist
mail and phone number were obtained from IUA database. Advance who performed open surgery, score þ1 was given if the indication
notifications were sent through an e-mail and SMS/Whatsapp to do open surgery was large prostate volume, but score e1 was
messages, 1 week before the first e-mail. Follow-up and reminder given for other indications. Therefore, the maximal score which can
were done every 2 weeks for four times using e-mails and SMS/ be achieved by each urologist is 14, and level of adherence will be
Whatsapp messenger. Respondents had to fill out their name in the determined by percentage of total score obtained by the urologist
questionnaire or had to be identifiable to further be included in this divided by maximal score.
study and to prevent data duplication. Respondent's confidentiality Data were presented in descriptive fashion. Categorical data
was guaranteed, and privacy policy statements were stated in the were presented as absolute value and its percentage. Several cat-
introduction of the questionnaire. egorical data were presented as charts. Numerical data were pre-
sented as mean and standard deviation if the data had normal
2.3. Study's questionnaire and its investigation distribution or as median and range if the data did not have normal
distribution. All of the data were processed using Statistical Package
The questionnaire was constructed using Indonesian language for the Social Science (SPSS), version 23.
and was divided into two sections which are questions regarding The data were divided based on the first question in BPH
respondents' demographic characteristics and BPH management. management session which is respondent's guidance for BPH
BPH management questionnaire consists of eight questions as management. Only respondents who claimed to use IUA BPH
follow: respondent's guidance for BPH management; diagnostic guidelines as their BPH management guidance were taken into
tools used; type of therapy given; selection of medical therapy account for other questions.
given for the first time; indication of BPH surgery; whether the
respondents are performing open surgery and their reasons; first
time evaluation after therapy given; and examination performed 2.5. Study's ethical committee approval
when evaluation. All the questions were multiple choice questions
and respondents could choose more than one answer except for This study was approved by the Faculty of Medicine, Universitas
question: first time evaluation after therapy given. Respondents may Indonesia Ethical Committee: 976/UN2.F1/ETIK/2016.
also provide their own answer apart from the given option for the
following questions: diagnostic tools used; type of therapy given; 3. Results
reasons to do open surgery; first time evaluation after therapy
given; and examination performed when evaluation. All of the Of 352 respondents who fulfilled inclusion and exclusion
choices given in the questionnaire were based on IUA BPH guide- criteria, 209 (59.4%) respondents returned the questionnaire. De-
line's key recommendations. mographic characteristics of respondents returning the question-
IUA BPH guidelines divided examination into routinely per- naire were presented in Table 1. Indonesian urologists could
formed examination and optional examination. Examinations practice in three different hospitals, and this explained why the

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003
 F. Rahman et al. / Adherence to BPH Guidelines 3

Table 1 As for medical therapy, alpha-blocker alone was chosen by most

Demographic characteristics of respondents respondents (83.4%) followed by combination of alpha-blocker and
Parameter All respondents who Respondents 5a-reductase inhibitor (40.7%) and 5a-reductase inhibitor alone
filled out questionnaire using IUA guidelines (16.6%). Other medical therapies, such as phosphodiesterase-5 in-
N 209 199 hibitor and combination of alpha-blocker and antimuscarinic were
Respondent's agea) 42 (30e75) 42 (30e75) used by 0.5% and 10.1% respondents. Phytotherapy, which is not
Length of work as urologista) 7 (0.5e37) 7 (0.5e37) recommended by IUA BPH guidelines, was offered by 1% re-
Place of urology educationb)
spondents. When medical therapies were given, patients were
Bandung 17 (8.1%) 15 (7.5%)
Jakarta 120 (57.4%) 115 (57.8%)
asked to return by respondents after 1 month (67.8%), 2 weeks
Surabaya 65 (31.1%) 62 (31.2%) (26.1%), 3 months (3%) or 1 week (2.5%).
Yogyakarta 6 (2.9%) 6 (3.0%) Indications to perform surgery for BPH among respondents
Others 1 (0.5%) 1 (0.5%) were presented in Fig. 2. There were only 54.8% of respondents who
Location of Serviceb)
performed open surgery for BPH and mostly under the indication of
Sumatra 38 (18.2%) 36 (18.1%)
Java 143 (68.4%) 136 (68.3%) large prostate volume (81.7%). Other reasons to performed open
Bali and Nusa 12 (5.7%) 12 (6.0%) surgery were presence of bladder stones (22.9%), unavailability of
Tenggara/Lesser Sunda endoscopy (13.8%), abnormality of bladder, such as diverticle (7.3%)
Borneo 10 (4.8%) 9 (4.5%) and residency training program (7.3%).
Celebes 5 (2.4%) 5 (2.5%)
Moluccas and Papua 1 (0.5%) 1 (0.5%)
Center of Serviceb) 3.3. Evaluation
Public hospital
Yes 159 (76.1%) 153 (76.9%) In evaluating treatments, the following examinations were
No 50 (23.9%) 46 (23.1%)
used: symptom scoring system (93.5%), medical therapy side effect
Private hospital
Yes 117 (56.0%) 110 (55.3%) (72.4%), uroflowmetry (46.7%), PVR (43.7%), urinalysis (25.6%), PSA
No 92 (44.0%) 89 (44.7%) (13.1%), DRE (8%) and TAUS (2%).
Clinic In the end, this study found median (minimumemaximum) of
Yes 4 (1.9%) 4 (2.0%) Indonesian urologist's adherence level toward BPH guidelines is
No 205 (98.1%) 195 (98%)
BPH cases per monthb)
78.5% (28.6%e100%).
1e25 cases 69 (33.0%) 61 (30.7%)
26e50 cases 84 (40.2%) 83 (41.7%) 4. Discussion
51e100 cases 30 (14.4%) 30 (15.1%)
>100 cases 26 (12.4%) 25 (12.6%)
BPH is a complex disease which commonly presented with
BPH, benign prostatic hyperplasia; IUA, Indonesia Urological Association LUTSs. Even though not fatal, this disease has a high burden effect
a)
Median (minimumemaximum). due to high cost and bothersome symptoms which can
b)
n (%).
decrease patient's quality of life.6,7 Owing to advancement in
medical equipment, there are many options of diagnostic tools and
total number of respondent's center of services is more than the treatments. Therefore, to provide consistent, efficient, and high-
total number of respondents. quality of medical care based on current evidence, IUA created BPH
In managing BPH, 95.2% respondents used IUA guidelines as practice guidelines for urologists and general practitioners. How-
their practice guidance. Other guidance such as other guidelines ever, even though nearly all Indonesian urologists claimed to have
(EAU, AUA, etc), textbook, or journal article were used by 63.2%, used IUA BPH practice guidelines, this study found that there was
23%, and 17.7% respondents, respectively. There were small pro- still variation in their compliance to the clinical guideline. It might
portions of respondents who used personal experiences (1.4%) and due to unavailability of facilities or difference in hospital manage-
hospital practice guidelines (0.5%) as their practice guidance. ment. However, this study did not further explore the reason
behind the variation of guidelines compliance. Strope et al showed
that geographic location, patient's comorbidity, and patient's age
3.1. BPH diagnosis
were associated with guidelines compliance.10
For diagnostic tools, variations were seen in both of routinely
Among respondents who used the IUA guidelines, the routinely
performed and optional examinations. Regarding routinely per-
performed and optional examinations were presented in Fig. 1.
formed recommended examinations, nearly all respondents used
There were very small proportions of respondents who use renal
DRE and TAUS for BPH workup and followed by symptom scoring
ultrasonography (USG) (0.5%), Computed tomography scan (1%),
system which used by most respondents. High performance of DRE
and magnetic resonance imaging (0.5%) as their workup for BPH.
was similar with previous study which showed that all Indonesian
Among respondents who offered prostate imaging to patients,
urologists considered LUTS as an indication to perform DRE exami-
76.2% only offered TAUS, 4.4% only offered TRUS and 19.4% offered
nation.13 Other routinely performed recommended examinations,
both examinations.
such as urinalysis, uroflowmetry, PVR, and TRUS were only used by
less than three-quarter of the respondents. However, not many
3.2. BPH management routinely performed TRUS of the prostate. This might be due to un-
availability of transrectal probe compared to transabdominal probe.
After BPH was diagnosed, almost all respondents (99%) offered Either TAUS or TRUS was recommended by IUA BPH guidelines to
medical treatment to patients. Furthermore, surgery and conser- guide the selection of medical treatment or surgery.12 For examina-
vative therapy (watchful waiting or lifestyle education) were also tions considered as optional, less than half of respondents used it,
offered by most respondents (93% and 78.4%, respectively). How- except for kidney function test and PSA test. Based on IUA BPH
ever, only small proportion of respondents (27.1%) chose clean guidelines, kidney function test was only performed when there is
intermittent catheterization (CIC), cystostomy or indwelling cath- suspicion of renal impairment and PSA test was only performed
eter as their BPH management option. when there is a possibility of prostate malignancy or helping to make

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003
4 Prostate International xxx (2018) 1e6

Fig. 1. Percentage of IUA's routine/optional examination used by respondents for BPH workup.
BPH, benign prostatic hyperplasia; DRE, digital rectal examination; IUA, Indonesia Urological Association; IVP, intravenous pyelogram; PSA, prostate-specific antigen; PVR, postvoid
residual urine.

decision on progressive risk BPH.12 However, if the facility to perform choose alpha-blocker as their first choice of medical treatment,
PSA examination is available, DRE should be completed with PSA followed by combination of alpha-blocker and 5-alpha reductase
examination because combination of both examinations is more inhibitor (5-ARI). This is similar to study conducted in Croatia,
superior to detect prostate cancer compared to DRE alone.12 There- China, and Korea where alpha-blocker is a vanguard of medical
fore, it can be considered that the high number of DRE and PSA ex- treatment choice.14e16 However, interestingly, study in Croatia
aminations which were done by Indonesian urologists was for showed that more than two-thirds of urologist would choose a
prostate cancer screening. Variation in performance of BPH guide- combination of alpha-blocker and 5-phosphodiesterase inhibitor,
line's recommended examination was also reported by Tomaskovic half of them chose antimuscarinic, and more than 50% of them
et al which showed variation between 8 and 100%.14 Tomaskovic recommended phytotherapy.14 This is contradictive to the results of
et al's study refers to European Association of Urology and showed this study which showed only small proportion of urologists
that DRE, ultrasound, PSA, urinalysis, and IPSS were performed by preferred those treatments. IUA BPH guidelines recommend the
100%, 100%, 100%, 81%, and 31% of respondents for their initial usage of 5-phosphodiesterase inhibitor for those who have mod-
assessment, respectively.13 Another study conducted in China erateesevere LUTS with or without erectile dysfunction and anti-
showed that recommended diagnostic test, such as IPSS, DRE, uri- muscarinic for those with storage symptom dominance. The use of
nalysis, PSA, ultrasonography, and uroflowmetry were used by 58.8%, 5-ARI in combination with alpha-blocker is increasing in line with
67.5%, 92.5%, 88.8%, 92.7%, and 31.2%, respectively; meanwhile in severity of LUTS. However, this study did not explore the choice of
Korea, IPSS, DRE, urinalysis, PSA, uroflowmetry and TRUS were highly medical treatment based on severity of symptom.
preferred for BPH initial assessment; 89e98% of urologists used it in This study showed low compliance in performing surgery based
general hospital.15,16 These variations were thought to be caused by on indication stated by IUA BPH guideline. Only bladder stones and
human resources, difference in availability of medical technology, TWOC failure were considered by more than 85% of respondents as
cultural differences among urologists, and socioeconomic factors.15,16 an indication of surgery even though IUA BPH guidelines stated that
Nearly all respondents considered medical therapy and surgical there were seven absolute indications of surgery in BPH patients.
treatment as their treatment options. Small proportion of re- However, the reason behind the low compliance in performing
spondents considered CIC, indwelling catheter, or cystostomy for surgery based on IUA BPH guidelines indication were not explored
BPH treatment. This is parallel with IUA BPH guideline stating that in this study, and this should be explored in further study.
CIC, indwelling catheter, and cystostomy were used only for specific With the advancement of minimally invasive technique in BPH
situation.12 For medical therapy options, most of the respondents surgery, open surgery is not considered as gold standard and only

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003
 F. Rahman et al. / Adherence to BPH Guidelines 5

Fig. 2. Indication to perform BPH surgery among respondents using IUA guidelines
BPH, benign prostatic hyperplasia; IUA, Indonesia Urological Association; LUTS, lower urinary tract symptom; TWOC, trial without catheter; UTI, urinary tract infection; UUT, upper
urinary tract.

recommended in patients with prostate volume larger than 80 ml Regarding level of adherence among Indonesian urologists to-
and moderateesevere LUTS.12 This recommendation is in line with ward BPH guidelines, there was no previous study which could
our finding which showed that most of respondents performed become a benchmark regarding classification of adherence level
open surgery due to large prostate volume, even though this study toward practical guideline.
did not further explore the exact number of prostate volume. This was first study to explore Indonesian urologists' compli-
However, more than 40% of respondents did not perform open ance to BPH guidelines and could also show Indonesian urologist's
surgery and this might due to surgeon's skill to do minimally pattern care in treating BPH patients. This study had a good
invasive technique, even in large prostate volume.17 Moreover, response rate of 59.4%, considering this study used e-mail as a
almost quarter of respondents considered bladder stones as an primary tool to collect the data. This study could be the basis of
indication to perform open surgery. However, today, open surgery further studies that essentially aim to improve patient care, espe-
due to bladder stone was also challenged by less-invasive surgery cially in treating BPH effectively and efficiently with high quality of
due to advancement in endoscopic technology even in the presence care.
of large bladder stone.18 This study also found that small proportion This study concludes that Indonesian urologists have a good
of respondents considered residency training program as an indi- adherence toward guidelines in general. However, there is still
cation to perform open surgery. This happened because some re- wide variation of their adherence to it.
spondents worked in teaching hospital which is the place to
practice for urology residents or general surgery residents. After
Conflicts of interest
graduation, both residents will be placed in hospitals which might
have limited facilities. Therefore, they should be given the oppor-
The authors declare that there is no conflict of interest regarding
tunity to master the technique of open surgery so that later they can
the publication of this paper.
provide optimal service in hospitals with limited facilities.
For patient's follow-up, IUA BPH guidelines recommend to
evaluate patient using IPSS, uroflometry, and PVR. Most of the re- Appendix A. Supplementary data
spondents have already complied with the symptom scoring sys-
tem as the evaluation tool. However less than half of respondents Supplementary data related to this article can be found at
used uroflowmetry and PVR for evaluation. https://doi.org/10.1016/j.prnil.2018.01.003.

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003
6 Prostate International xxx (2018) 1e6

References 10. Gravas S, Tzortzis V, Melekos MD. Translation of benign prostatic hyperplasia
guidelines into clinical practice. Curr Opin Urol 2008;18(1):56e60.
11. Strope SA, Elliott SP, Smith A, Wei JT, Wilt TJ, Saigal CS. Urologist practice
1. Safarinejad MR. Prevalence of benign prostatic hyperplasia in a population-
styles in the initial evaluation of elderly men with BPH. Urol J 2011;77(3):
based study in Iranian men 40 years old or older. Int Urol Nephrol
535e40.
2008;40(4):921e31.
12. Mochtar CA, Umbas R, Soebadi D, Rasyid N, Noegroho B, Poernomo B. Panduan
2. Kristal AR, Arnold KB, Schenk JM, Neuhouser ML, Weiss N, Goodman P, et al.
penatalaksanaan klinis pembesaran prostat jinak. Jakarta 2015.
Race/ethnicity, obesity, health related behaviors and the risk of symptomatic
13. Monoarfa R, Hamid A, Mochtar C, Umbas R. Diagnosis kanker prostat dalam
benign prostatic hyperplasia: results from the prostate cancer prevention trial.
perspektif spesialis urologi di Indonesia: sebuah studi kuesioner. Indones J
J Urol 2007;177(4):1395e400.
Cancer 2012;6(3).
3. Lu S-H, Chen C-S. Natural history and epidemiology of benign prostatic hy-
14. Tomaskovi c I, Tomi
c M, Nikles S, Neretljak I, Mili
ci
c V. Croatian urologists'
perplasia. Formos J Surg 2014;47(6):207e10.
clinical practice and compliance with guidelines in the management of non-
4. Patel ND, Parsons JK. Epidemiology and etiology of benign prostatic hyperplasia
neurogenic male lower urinary tract symptoms. Acta Clin Croat 2015;54(4):
and bladder outlet obstruction. Indian J Urol 2014;30(2):170e6.
453e7.
5. Egan KB. The epidemiology of benign prostatic hyperplasia associated with
15. Wu N, Sun J, Yu P, Sun Z. Chinese urologists' views of practice patterns in the
lower urinary tract symptoms: prevalence and incident rates. Urol Clin N Am
diagnosis and treatment of benign prostatic hyperplasia: a nationwide survey.
2016;43(3):289e97.
Int Neurourol J 2012;16(4):191e5.
6. Clarke T and adapted for publica. Optimizing population health and economic
16. Oh CY, Lee SH, Yoo SJ, Chung BH. Korean urologist's view of practice patterns in
outcomes: innovative treatment for BPH. Popul Heal Manag 2013;16(S2). S-1-S-13.
diagnosis and management of benign prostatic hyperplasia: a nationwide
7. Vuichoud C, Loughlin KR. Benign prostatic hyperplasia: epidemiology, eco-
survey. Yonsei Med J 2010;51(2):248e52.
nomics and evaluation. Can J Urol 2015;22(October):1e6.
17. Persu C, Georgescu D, Arabagiu I, Cauni V, Moldoveanu C, Geavlete P. TURP for
8. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits,
BPH. How large is too large? J Med Life 2010;3(4):376e80.
limitations, and harms of clinical guidelines. BMJ 1999;318:527e30.
18. Zhao J, Shi L, Gao Z, Liu Q, Wang K, Zhang P. Minimally invasive surgery for
9. Strope SA, Elliott SP, Saigal CS, Smith A, Wilt TJ, Wei JT. Urologist compliance
patients with bulky bladder stones and large benign prostatic hyperplasia
with AUA best practice guidelines for benign prostatic hyperplasia in medicare
simultaneously: a novel design. Urol Int 2013;91(1):31e7.
population. Urology 2011;78(1):3e9.

Please cite this article in press as: Rahman F, et al., Adherence of Indonesian urologists to practice guidelines for the management of benign
prostatic hyperplasia, Prostate International (2018), https://doi.org/10.1016/j.prnil.2018.01.003