Head-to-head comparison of prostatic urethral lift and water vapor thermal therapy for the treatment of symptomatic benign prostatic hyperplasia: a real-life study

Comparison of Durability Between Rezum Water Vapor Therapy and UroLift in Treating Benign Prostatic Hyperplasia: A Multicenter Propensity Score-Matched Analysis

Background Rezum water vapor therapy and UroLift are among the minimally invasive surgical therapies (MISTs) gaining popularity in the treatment of benign prostatic hyperplasia (BPH). This study aims to evaluate and compare the reintervention rates, a measure of durability, for Rezum water vapor therapy and UroLift as MISTs for BPH. Methods We conducted a retrospective cohort study using data from the TriNetX Global Collaborative Network, a large database of electronic health records from January 2014 to June 2024. Current Procedural Terminology (CPT) and International Classification of Diseases 10th Revision codes (ICD-10) were used to build the cohorts of men aged over 18 years who underwent either Rezum water vapor therapy or UroLift. Reintervention rates and complication profiles were evaluated over a follow-up period of up to five years. Results Cumulative reintervention rates were collected for both Rezum water vapor therapy and UroLift at the 1st, 3rd, and 5th years (2.83% vs. 3.59%, 5.99% vs. 8.76%, 6.81% vs. 10.85%). The average annual increase rate was 1% for Rezum water vapor therapy compared with 1.82% for UroLift, respectively. Most complications were more prominent in the Rezum water vapor therapy group, with urinary retention accounting for 23.42%. Discussion Rezum water vapor therapy demonstrates a more durable effect with lower reintervention rates compared to UroLift, based on this large multicenter cohort study. The higher reintervention rate observed with UroLift may reflect differences in the mechanisms of action between the two procedures. Conclusions These findings elucidate the superiority of Rezum water vapor therapy in sustaining the therapeutic effect over the long term compared to UroLift. However, more complications were noted in the Rezum water vapor therapy group. Thus, clinicians should take into account the durability and complication profiles in shared decision-making when considering MISTs for BPH.

Clinical experience and video description of minimally invasive surgery for benign prostatic obstruction using the Schelin Catheter®

Although designed for in-office use, water vapor thermal therapy (Rezum™) remains a painful procedure, and oral±intravenous sedation is often required. Schelin Catheter® (ProstaLund AB, Lund, Sweden) is an innovative bladder catheter that delivers local anesthesia to the prostate in a sterile transurethral way. We aimed to evaluate the safety and feasibility of Rezum™ for male lower urinary tract symptoms due to benign prostatic obstruction (LUTS/BPO) with local anesthesia delivered with Schelin® catheter, and to report its first step-by-step video description. A total of 15 patients were enrolled, and 14 analyzed. Median pain numeric rating scale at catheter insertion, anesthetic injection, Rezum™ insertion, Rezum™ treatment, and at 2-h postoperatively were 3 (2-5), 3 (2-5), 1 (0-3), 3.5 (2-6), and 0 (0), respectively. In 1 patient local anesthesia protocol failed and intravenous sedation was used. All Rezum™ therapies were performed successfully. Local anesthesia with Schelin® catheter opens up new possibilities for ultra-minimally invasive surgery for LUTS/BPO.

Expert consensus on Rezūm™: Indications, surgical technique and postoperative care

Background

Lower urinary tract symptoms associated to benign prostatic hyperplasia (LUTS/BPH) is a growing condition in males associated to a high clinical, economic and humanistic burden. Currently, there is a wide range of therapeutic options, both pharmacological and surgical. In recent years, several minimally invasive therapies have emerged, but they still have limitations. In this context, water vapour thermal therapy (WVTT), Rezüm™, is a new minimally invasive surgical technique with a low retreatment rate and the ability to preserve sexual function. The objective of this study is to establish recommendations for the correct execution of WVTT, as well as to define the ideal patient profile for the intervention.

Methods

A literature search was conducted in PubMed, without date limitations, using the terms 'benign prostatic hyperplasia', 'benign prostatic enlargement', 'prostatic hyperplasia', 'bph', 'Rezūm', 'water vapour thermal therapy', 'quality of life' and 'HRQOL'. A systematic review of the evidence was conducted and subsequently discussed in a face-to-face meeting with a panel of five experts in the field of urology. The aspects addressed were classified into patient profile, pre-intervention, intervention and post-intervention.

Results

The search returned 172 results, ultimately leading to the analysis of 49 articles. Evidence and expert opinion showed that WVTT could be a good option for patients with moderate to severe symptomatology, no age restriction, Qmax <15 mL/s and prostate volume greater than 30 cm3, but not necessarily less than 80 cm3. Low retreatment rate and low impact on erectile capacity and ejaculatory function were also demonstrated.

Conclusions

WVTT is considered a safe treatment option, even as a first-line approach for certain patient profiles. However, further research is needed in areas where evidence and clinical experience remain limited, including postoperative catheter management, anaesthesia, antibiotic prophylaxis and follow-up care for patients after the procedure.

Water vapor thermal therapy for treatment of lower urinary tract symptoms due to large benign prostatic hyperplasia (≥ 80 g)

INTRODUCTION

Water vapor thermal therapy (WVTT; REZUM™; Boston, USA) offers symptom relief with reduced risks of complications in patients with lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). WVTT therapy has been validated in the pivotal study in men with smaller prostates (< 80 cc). Yet, its feasibility for larger prostates (≥ 80 cc) remains underexplored.

METHODS

This retrospective study assessed WVTT efficacy and safety in 131 patients with symptomatic BPH treated between January 2022 and March 2024. Patients were categorized based on prostate size: smaller prostates (SP) (< 80 cc) and larger prostates (LP) (≥ 80 cc). Baseline characteristics, treatment specifics, and post-procedure outcomes-including retreatment rates, symptom scores, and adverse events (AEs)-were recorded. All patients who required surgical retreatment underwent Holmium laser enucleation of the prostate (HoLEP). Statistical analyses compared results between groups over 6- and 12-month follow-up periods.

RESULTS

Among the 131 patients, 48 (37%) had LP, with a median volume of 93 cc (Interquartile range (IQR) 88-110). Patients with LP experienced more non-serious AEs, primarily hematuria (p = 0.001), although serious AEs were similar across groups and limited to urinary retention (p = 0.35). At 6 months postoperatively, LP patients had a higher PVR (42 mL(IQR 21-75) vs. 21 mL (IQR2-40); p = 0.032), though this resolved by 12 months. No significant differences were observed between the groups in IPSS, maximum flow rate (Qmax), or erectile function (IIEF-5) scores at either follow-up point. Medical retreatment rates at 12 months were similar (LP: 4% vs. SP: 7%; p = 0.39), as were surgical retreatment rates (LP: 2% vs. SP: 2%; p = 0.51). Ejaculatory function was largely preserved in both groups (LP: 96%, SP: 95%).

CONCLUSION

WVTT therapy in LP is associated with a higher risk of minor post-operative AEs, with similar functional outcomes at one year compared to SP. Longer follow-up studies are needed to compare the durability of treatment in LP.

Convective Water Vapor Energy Ablation (Rezum®) Versus Prostatic Urethral Lift (Urolift®): A 2-Year Prospective Study

Introduction: To compare the clinical outcomes and complication rates of convective water vapor energy ablation (Rezum®) and prostatic urethral lift (Urolift®). To identify predictive factors for treatment failures in both treatments. Materials & Methods: Prospective clinico-epidemiological data of patients who underwent Urolift® or Rezum® in a single institution for benign prostatic hyperplasia (BPH) was collected. The choice of intervention depended on the preference of the patients after patient-centric discussions. Results: From October 2019 to October 2022, 86 patients underwent Rezum®, and 62 patients underwent Urolift®. Rezum® involved a longer indwelling catheter duration (12.38 ± 5.548 vs 1.39 ± 3.010 days, p < 0.001) compared with Urolift®. Rezum® was associated with more complications compared with Urolift® (36 [41.9%] vs 10 [16.1%] cases, p < 0.001). Rezum® had more cases of hematuria (17 [19.8%] vs 4 [6.5%] cases [p = 0.022]) and urinary tract infections (27 [31.4%] vs 3 [4.8%] cases, p < 0.001) compared with Urolift®. There were no significant differences in Clavien-Dindo Grade 3-5 complications between the interventions. Urolift® was associated with higher reoperation rates (5 [8.1%] vs 0 [0%] cases, p = 0.010) compared Rezum®. Rezum® had higher anticholinergic usage rates compared with Urolift® post-operation (22 [25.6%] vs 8 [12.9%] cases, p = 0.024). Both interventions showed improvement in the International Prostate Symptom Score (IPSS), quality of life score, and peak velocity flow over the 2 years with no significant difference between the two. Based on receiver operating characteristic curve, preoperation IPSS ≥16 had 95.7% sensitivity and 38.4% specificity to predict the probability of treatment failures after the interventions. Conclusions: There was no difference in clinical outcomes of patients who underwent Rezum® and Urolift®. However, patients who had undergone Rezum® faced more minor complications and more required anti-cholinergic medications. Lastly, physicians should note that patients with IPSS ≥16 would unlikely benefit from either intervention.

Comparing Patient-Reported Outcomes Following the Minimally Invasive Treatment of Benign Prostatic Hyperplasia (BPH)-Related Lower Urinary Tract Symptoms: Rezum Versus UroLift

Purpose The purpose of this study is to compare patient-reported outcomes of minimally invasive treatments for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), namely, transurethral water vapor therapy (Rezum) and prostatic urethral lift (UroLift), due to the lack of direct comparison in the existing literature. Methods A retrospective single-institution study was conducted comparing Rezum and UroLift procedures performed by three surgeons between January 2019 and June 2022. The difference in American Urological Association Symptom Scores (AUA SS) was the primary outcome measure. Associated quality of life (QOL) scores were additionally assessed. Patient-reported scores were completed prior to their procedure and at least one month after their procedure. Outcomes were compared between 80 Rezum-treated patients and 68 UroLift-treated patients utilizing Mann-Whitney U tests and Fisher's exact tests. Results Rezum-treated patients were younger on average at 67.55 years compared to 71.79 years in UroLift-treated patients (p=0.0049). Prior to treatment, the mean initial AUA SS was 22.46 for Rezum-treated patients and 19.96 for UroLift-treated patients (p=0.0164). Following treatment, the mean AUA SS improved to 9.83 for Rezum-treated patients and 13.37 for UroLift-treated patients (p=0.0026). Overall, Rezum-treated patients reported a 58.29% improvement in the mean AUA SS, while UroLift-treated patients reported a 44.53% improvement in the mean AUA SS (p=0.002). The mean follow-up QOL was 1.89 for Rezum-treated patients and 2.72 for UroLift-treated patients (p=0.0079). Conclusion Both Rezum and UroLift demonstrate efficacy in the treatment of BPH-related LUTS. Patients who underwent Rezum reported worse initial urinary symptoms and better post-procedural urinary symptoms and quality of life compared to those who underwent UroLift.

Minimally invasive connective water vapor energy method for benign prostatic hyperplasia

The Rezūm system has emerged as a promising treatment option for benign prostatic hyperplasia (BPH) by employing endoscopic removal of prostate tissue. This meta-analysis aimed to evaluate the benefits and drawbacks of Rezūm therapy in recent studies. A systematic literature search was conducted in EMBASE, PubMed, and the Cochrane Library databases until December 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search utilized keywords such as water vapor thermal therapy, Rezūm, convective water vapor thermal therapy, and convective radiofrequency water vapor thermal therapy. A total of 21 studies were included in the analysis, comprising 5 prospective randomized studies, 2 case series, 2 randomized controlled trials, 1 crossover study, and 11 retrospective studies. The collective sample involved 2090 patients with a mean follow-up period of 14.42 ± 18.08 (1-72) months and a mean age of 68.12 ± 4.79 years. Significant improvements were reported in the International Prostate Symptom Score (IPSS), quality of life (QoL), maximal flow rate (Qmax), postvoid residual urine volume (PVR), prostate volume (PV), and International Erectile Index Function (IIEF) values. Unlike other BPH treatments that often require general or regional anesthesia, the connective water vapor energy system can be administered with sedo-analgesia and local anesthesia, potentially leading to improved sexual function scores. Considering the relief of symptoms, Rezūm therapy may serve as a viable alternative to transurethral surgery for patients with prostate volumes ranging from <30 to >80 cc.

Modified holmium laser enucleation for benign prostatic obstruction to preserve sexual and ejaculatory function

INTRODUCTION

To report ejaculatory and urinary results in patients who underwent holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe (MLHoLEP).

METHODS

Patients with lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) who underwent MLHoLEP to preserve ejaculatory function in a single center were retrospectively identified. Urinary function was assessed using International Prostate Score Symptom (IPSS), IPSS-Quality of Life index (IPSS-QoL), peak urinary flow (Qmax) and postvoid residual (PVR). Erectile function was assessed using International Index of Erectile Function (IIEF-5). In patients with preoperative antegrade ejaculation, retrograde ejaculation was routinely screened at each follow-up visit. Sexual and urinary functions at 3 and 12 months were compared with baseline values.

RESULTS

A total of 55 patients met our inclusion criteria. A significant improvement in the IPSS, IPSS-QoL, PVR and Qmax was found at 3 and 12 months, compared with baseline (all P<0.05). Eight patients (14.5%) required surgical reintervention due to persistant LUTS/BPO. No significant changes in the erectile function were found at 3 (P=0.3) and 12 months (P>0.9). In patients with preoperative antegrade ejaculation (n=32), only four cases of de novo retrograde ejaculation were recorded postoperatively.

CONCLUSION

MLHoLEP represents a new alternative for men with LUTS/BPO who wish to preserve their ejaculatory function. Patients should be aware that improvement in urinary function may be inferior to the traditional technique, with a higher reintervention rate due to persistent LUTS.

LEVEL OF EVIDENCE

Grade 4.

Complications and device failures associated with urolift: Findings from the MAUDE database

INTRODUCTION

Urolift is an established intervention for symptoms of bladder outflow obstruction caused by benign prostate enlargement. Reported advantages include its minimally invasive profile, short learning curve and feasibility as a day case procedure. Our aim was to use a national registry as a means to evaluate the nature of complications and device failures that have been documented to occur.

METHODS

Retrospective review was performed of the US Manufacturer and User Facility Device Experience (MAUDE) database, a prospective register, which contains voluntarily submitted adverse events associated with surgical devices. Information collected include event timing, underlying cause, procedural completion, complications and mortality status.

RESULTS

Between 2016 and 2023, 103 device failures, 5 intra-operative complications and 165 post-operative complications (early: 151, late: 14) were registered. The commonest device problem (56%, n = 58) was failure of the implant to deploy with subsequent requirement for complete replacement. There were 50 cases of documented urosepsis. 62 patients with post operative haematuria were registered including 12 that underwent emergency embolisation. Other complications included stroke (n = 5), pulmonary embolism (n = 3) and necrotising fasciitis (n = 1). Twelve ITU admissions were registered. In the reports, 22 cases were filed that recorded a hospital stay of 7 days or more. Eleven deaths were captured in the database over the study period.

CONCLUSION

While urolift is recognised as less invasive intervention compared to alternatives such as transurethral resection of the prostate, serious adverse events have been reported to occur including death. Our findings can provide learning points for surgeons and allow for improved patient counselling and treatment planning accordingly.

A scoping review of ejaculatory dysfunction due to surgical treatments for benign prostatic hyperplasia: limitations of available tools for assessment and reporting

INTRODUCTION

Clinicians primarily focus on the presence or absence of anterograde ejaculation following surgery for benign prostatic hyperplasia (BPH). Failing to assess dysfunctional ejaculation and associated bother in a granular fashion can underestimate the prevalence and significance of ejaculatory dysfunction in this population.

OBJECTIVES

This scoping review provides critical appraisal of existing tools assessing ejaculatory function and associated bother, emphasizing the importance of adequate history-taking, preoperative counseling, and supplemental questions that should be used prior to and after treatment.

METHODS

A literature review was conducted using pertinent keywords from 1946 to June 2022. Eligibility criteria included men developing ejaculatory dysfunction following BPH surgery. Measured outcomes included the assessment of patient bother related to ejaculatory function, pre- and postoperative scores from the Male Sexual Health Questionnaire (MSHQ). and Danish Prostate Symptom sexual function domain (DAN-PSSsex).

RESULTS

Results of this study included only 10 documented patients' bother due to ejaculatory dysfunction following treatment. Pre- and postoperative MSHQ were used as the diagnostic tool in 43/49 studies, one study documented "preservation of anterograde ejaculation", and one used DAN-PSSsex. Q1-4 of the MSHQ were used in 33/43 studies, 3/43 used Q1, 3, 5-7, 1/43 used solely Q4, 1/43 used Q1-3 + Q6 and Q7, and 5/43 used the entire MSHQ. No studies used post-ejaculation urinalysis to diagnose retrograde ejaculation. Only four studies explicitly documented bother and found 25-35% of patients were bothered with a "lack of ejaculate" or "other ejaculation difficulties" during sexual activity after BPH surgery.

CONCLUSIONS

There are currently no studies stratifying patient bother by various components of ejaculation (force, volume, consistency, sensation of seminal expulsion, painful ejaculation, etc.) after BPH surgery. Opportunities for improvement exist in reporting ejaculatory dysfunction related to BPH treatment. A comprehensive sexual health history is needed. Further investigation into effects of BPH surgical treatments on specific characteristics of the patient's experience of ejaculation is required.

Pharmacologic and Surgical Retreatment After Office-based Treatments for Benign Prostatic Hyperplasia: A Systematic Review

CONTEXT

Office-based treatments are increasingly offered as an optional step to replace medical treatment or delay surgery for male lower urinary tract symptoms (LUTS). Nevertheless, little is known regarding the risks of retreatment.

OBJECTIVE

To systematically evaluate the current evidence regarding retreatment rates after water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), and temporarily implanted nitinol device (iTIND) procedures.

EVIDENCE ACQUISITION

A literature search was conducted up to June 2022 using the PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to identify eligible studies. The primary outcomes were the rates of pharmacologic and surgical retreatment during follow-up.

EVIDENCE SYNTHESIS

A total of 36 studies including 6380 patients met our inclusion criteria. Surgical and minimally invasive retreatment rates were generally well reported in the studies included and reached up to 5% after 3 yr of follow-up for iTIND, and up to 4% for WVTT and 13% for PUL after 5 yr of follow-up. The types and rates of pharmacologic retreatment are poorly reported in the literature, with the latter reaching up to 7% after 3 yr of follow-up for iTIND, and up to 11% after 5 yr of follow-up for WVTT and PUL. The main limitations of our review are the unclear to high risk of bias in most of the studies included and the lack of long-term (>5 yr) data on retreatment risks.

CONCLUSIONS

Our results highlight the low retreatment rates at mid-term follow-up after office-based treatments for LUTS, supporting the development of these strategies as an intermediate step between BPH medication and conventional surgery. Pending more robust data with longer follow-up, these results should be used to improve patient information and facilitate shared decision-making.

PATIENT SUMMARY

Our review highlights the low risk of mid-term retreatment after office-based treatments for benign enlargement of the prostate that is affecting urinary function. For well-selected patients, these results support the increasing use of office-based treatment as an intermediate option before conventional surgery.

Medium-Term Real-World Outcomes of Minimally Invasive Surgical Therapies for Benign Prostatic Hyperplasia: Water Vapor Thermal Therapy (Rezum) vs Prostatic Urethral Lift (UroLift) in a High-Volume Urban Academic Center

Purpose: Water vapor thermal therapy (WVTT, i.e., Rezum^®) and prostatic urethral lift (PUL, i.e., Urolift^®) are minimally invasive surgical therapy (MIST) options for benign prostatic hyperplasia (BPH). Few studies have directly compared the two procedures. We examined the clinical characteristics and postoperative outcomes of patients undergoing WVTT and PUL at our high-volume urban academic center. Methods: We reviewed our institutional MIST database to identify patients with prostate sizes ≥30 and ≤80 cc who underwent WVTT or PUL for treatment of BPH between January 2017 and September 2021. Pre- and postoperative outcomes, including retreatment rates, American Urological Association symptom score (AUA-SS), maximum flow (Qmax), postvoid residual (PVR), medication usage, trial of void success rates, catheterization requirements, and postoperative complications within 90 days were extracted and compared between procedures. Results: Three hundred seven patients received WVTT and 110 patients received PUL with average follow-up times of 11.3 and 12.8 months, respectively. WVTT patients showed significant improvements in AUA-SS, Qmax, and PVR, whereas PUL patients showed improvements in only AUA-SS and Qmax. Both WVTT and PUL patients with longitudinal follow-up demonstrated improvements in AUA-SS, Qmax, and PVR. Postoperatively, alpha-blocker utilization was significantly decreased following both WVTT and PUL (WVTT: 73.9%-46.6%, PUL: 76.4%-38.2%, both p < 0.001). Compared to patients receiving PUL, WVTT patients more frequently reported postoperative dysuria (22.8% vs 8.3%, p = 0.001) and nonclot-related retention (18.9% vs 7.3%, p = 0.005); PUL patients more frequently experienced postoperative clot retention (7.3% vs 2.6%, p = 0.027). There were no differences in rates of postoperative bladder spasm, trial of void success, urinary tract infections, or emergency department visits. Postoperative erectile dysfunction and retrograde ejaculation were rare and occurred at similar rates. Conclusion: In the real-world setting, WVTT and PUL have similar medium-term efficacy in improving symptoms and decreasing medication utilization for patients with BPH. Differences in postoperative complication profiles should inform patient counseling.

Emerging outcomes of water vapor thermal therapy (Rezum) in a broad range of patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia: A systematic review

Water vapor thermal therapy (Rezum) is a novel, minimally invasive surgical technology used to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The objective of this systematic review is to evaluate the latest efficacy and safety profile of Rezum in patients with LUTS secondary to BPH. PubMed/MEDLINE and the Cochrane Library databases were systematically searched, in accordance with the PRISMA statement, for relevant articles in the English language till 1 August 2021. Randomized and nonrandomized studies that evaluated urinary outcomes and/or adverse events were deemed eligible. Nineteen studies (N = 1942), published in 25 articles, were included. International Prostate Symptom Score (IPSS), quality of life (QoL), and maximum urinary flow rate (Qmax) significantly improved as early as 1 month postoperatively and remained durable for up to 5 years. Significant median percent improvements in IPSS, QoL, and Qmax at 3 months were 51%, 51%, and 66%, respectively. Patients with obstructive median lobes, large prostates (>80 g), small prostates (<30 g), and urinary retention also experienced significant relief in LUTS, with 83% of urinary retention patients becoming catheter independent at a median of 14 days. Most adverse events were transient and nonserious and occurred in 0% to 76% of patients (median 29%), with de novo erectile dysfunction rates ranging between 0% and 3.1%. Surgical retreatment rate ranged between 4.4% and 7.5% at 5 years postoperatively. Rezum provides durable improvements in symptoms, irrespective of prostate volume and urinary retention status, and has low rates of sexual dysfunction.