The Prostatic Urethral Lift for the Treatment of Lower Urinary Tract Symptoms Associated with Prostate Enlargement Due to Benign Prostatic Hyperplasia: The L.I.F.T. Study

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

Two-year long-term follow-up of treatment with the Optilume BPH catheter system in a randomized controlled trial for benign prostatic hyperplasia (The PINNACLE Study)

BACKGROUND

Patient outcomes were assessed 2 years after treatment with the Optilume BPH Catheter System, a minimally invasive surgical therapy for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

METHODS

One-hundred forty-eight adult males with symptomatic BPH were enrolled and randomized in a 2:1 fashion to Optilume BPH or Sham (100 Optilume BPH; 48 Sham). Long-term measures include International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), Post-Void Residual Urine (PVR), quality of life measures and sexual function. Follow-up beyond one year was limited to those treated with Optilume BPH.

RESULTS

At 2 years, 67.5% (56/83 CI 56.3%, 77.4%) of participants in the Optilume BPH arm were symptomatic responders as defined by ≥30% improvement in IPSS without medical or surgical retreatment. IPSS significantly improved from 23.4 ± 5.5 (n = 100) to 11.0 ± 7.0 (n = 74). Qmax improved by 116.8.% (8.9 ± 2.2 (n = 97) to 19.0 ± 16.3 (n = 65)), while PVR showed a slight reduction (83.7 ± 70.3 (n = 99) to 65.9 ± 74.5 (n = 65)). Improvement in uroflowmetry measures was consistent across all prostate volumes. BPH-II improved from 7.0 ± 2.9 (n = 98) to 2.3 ± 2.5 at 1 year (n = 89) and remained consistent at 2.3 ± 2.9 at the 2-years (n = 74), representing a 53.9% improvement. IPSS QoL also improved from 4.6 ± 1.3 (n = 100) at baseline to 2.2 ± 1.5 (n = 74). The most common adverse events reported in the Optilume BPH arm were hematuria and urinary tract infection (UTI). No device and/or treatment related serious adverse events were reported occurring beyond 12 months post-procedure. There was no impact to sexual function.

CONCLUSIONS

In the PINNACLE study, participants treated with the Optilume BPH Catheter System demonstrated continued and durable results at 2 years, affirming tolerability, safety, and the enduring effectiveness. The Optilume BPH Catheter System provides lasting results that are comparable to the more invasive therapies, while preserving the advantages with being a minimally invasive therapy.

REGISTRATION

ClinicalTrials.gov NCT04131907.

Real-world short-term outcomes of prostate urethral lift in Japan: A prospective cohort study

OBJECTIVES

We report the first prospective trial of prostatic urethral lift for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia in Japan.

METHODS

This prospective study was conducted at a single institution and included patients with benign prostatic hyperplasia who underwent prostatic urethral lift based on the Japanese surgical indication. The primary efficacy endpoint was reduced international prostatic symptoms score in the early postoperative period after prostatic urethral lift. To assess efficacy, international prostatic symptoms score, quality of life, sexual health inventory for men, and uroflowmetry were evaluated 2 weeks before, 2 weeks after, and 6 weeks after surgery.

RESULTS

We enrolled 120 elderly men. The patients experienced significantly reduced international prostatic symptoms scores from 15 at the baseline to 13 at 2 weeks, and to 10 at 6 weeks, respectively. The peak flow rates did not change significantly at any time point. Three patients had serious adverse events of grade 3a in the Clavien-Dindo classification. Four patients were evaluated for sexual function, and none had ejaculatory dysfunction.

CONCLUSION

In the Japanese population, prostatic urethral lift is reliably performed under local anesthesia and rapidly improves symptoms.

Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia

OBJECTIVE

To assess the re-intervention rates of new surgical benign prostatic hyperplasia (BPH) interventions, as the clinical durability of new surgical interventions for BPH is not widely known.

METHODS

A critical review of new surgical BPH therapies namely 'UroLift®', 'Aquablation', 'Rezum', 'prostatic artery embolisation (PAE)' and 'temporary implantable nitinol device (iTIND)' was performed on PubMed, the Cochrane Library, and Embase databases between May 2010 and December 2022 according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. All relevant articles were reviewed, and the risk of bias was evaluated using the Cochrane risk assessment tool and Newcastle-Ottawa Scale.

RESULTS

Of the 32 studies included, there were 10 randomised controlled trials and 22 prospective observational cohorts. A total of 2400 participants were studied with a median patient age of 66 years, a median prostate volume of 51.9 mL, and a median International Prostate Symptom Score of 22. The lowest re-intervention rate at 12 months was for Aquablation at 0.01%, followed by Rezum at 0.02%, iTIND at 0.03%, and PAE at 0.05%. Network meta-analysis (NMA) showed that the best-ranked treatment at 12 months was transurethral resection of the prostate (TURP), followed by Aquablation, iTIND, Rezum, and UroLift. Re-intervention rates with these new BPH interventions are comparable, although some interventions reported better outcomes than TURP in the shorter term.

CONCLUSIONS

While this systematic review and NMA showed that the re-intervention rate with these new surgical BPH interventions appears to be comparable to TURP in the short term, further studies are required to directly compare these various BPH procedures.

The efficacy and safety of prostatic urethral lift as a minimally invasive therapeutic modality to treat lower urinary tract symptoms while maintaining sexual function in patients with benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Benign prostatic hyperplasia (BPH) is prevalent among elderly men, necessitating focused attention. The Prostatic Urethral Lift (PUL) procedure, a minimally invasive intervention, has emerged as a promising option for BPH management. It has shown remarkable results in ameliorating lower urinary tract symptoms (LUTS), enhancing quality of life, and preserving sexual function. This study aims to evaluate the effectiveness and safety of PUL in BPH patients.

METHODS

Key databases (MEDLINE, Cochrane CENTRAL, ScienceDirect, EBSCO, Google Scholar) were systematically searched using pertinent terms related to PUL and BPH. Following the PRISMA checklist, we considered only randomized controlled trials (RCTs) from 2013 to 2023. The assessment focused on LUTS, quality of life, sexual function, and adverse events within three months. Follow-up post-treatment mean values compared with controls (Sham) and the improvement from baseline to post-treatment follow-up duration were considered. Statistical analysis and risk of bias evaluation were conducted using Review Manager 5.4.1, presenting results as difference of mean values (MD) and risk ratios (RR).

RESULTS

A meta-analysis with a Random Effects Model of 7 RCTs involving 378 confirmed BPH patients demonstrated significant improvements in the PUL arm including International Prostate Symptom Score (IPSS) (MD 5.51, p<0.0001), maximum urinary flow rate (Qmax) (MD 2.13, p=0.0001), BPH Impact Index (BPHII) (MD 2.14, p=0.0001), and IPSS-QoL (MD 1.50, p<0.0001), without significant increase of adverse events (RR 1.51; p=0.50). Positive outcomes were observed in sexual function variables and post-void residual measurements when post-treatment values were compared to baseline.

CONCLUSIONS

PUL holds advantages over control interventions, providing encouraging prospects for BPH management. This study underscores the need for further exploration of PUL's efficacy and safety in BPH patients.

Investigating trends in interest for benign prostatic hyperplasia surgery options using Google Trends

Understanding patient interest among surgical options is challenging. We used Google Trends to analyze interest in benign prostatic hyperplasia (BPH) surgeries recommended for prostate volumes <80 cc. Google Trends was queried with five BPH surgeries. Final rank of search terms was TURP, UroLift, Rezum, Aquablation, and Greenlight. Google Trends can be an effective tool for evaluating public interest trends in BPH surgery.

Impact of minimally invasive surgical procedures for Male Lower Urinary Tract Symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review

BACKGROUND

Surgical treatments for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are affected by potentially bothersome side effects on sexual, and, above all, ejaculatory function. Several minimally invasive techniques have been proposed in the last years in order to overcome these consequences. Our aim is to summarize and evaluate the efficacy on LUTS relieve and the impact on sexual/ejaculatory function of Rezum, prostate artery embolization (PAE), implantation of a prostatic urethral lift (PUL) and the temporary implantable nitinol device (TIND).

METHODS

A systematic review of the English-language literature was conducted using the MEDLINE, Embase, and Web of Science databases from January 2000 to October 2022, according to the PRISMA guidelines (PROSPERO ID: CRD42023466515). Randomized controlled trials (RCTs), prospective studies and non-comparative or comparative studies assessing the impact on functional and ejaculatory function after minimally invasive surgical therapies for Male LUTS were evaluated. Risk of bias assessment was performed according to the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for comparative studies, and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for RCTs.

RESULTS

Overall, 47 studies were included (n = 4 for TIND; n = 9 for Rezum; n = 13 for PUL; n = 21 for PAE). Most studies relied on prospective patient cohorts and were rated as low risk of bias. Across studies assessing the efficacy of Rezum, a significant improvement in terms of IPSS (ranging from -47% to -56%) and Qmax (ranging from +39% to +87%) was reported. On the other hand, according to IIEF-5 score, Rezum had a minimal impact on sexual function (ranging from -1% to -3%). PUL showed a positive impact on IPSS (ranging from -35% to -58.2%) and Qmax (ranging from +49.9% to +114.7%) and sexual function. Finally, PAE showed encouraging functional results with IPSS score reducing from -12.8% to 63.3% and Qmax improving from +8% to 114.9% but the available evidence regarding the potential impact of PAE on sexual outcomes were limited.

CONCLUSION

Rezum, PAE, PUL and TIND are safe and feasible techniques associated with a significant functional improvement. While available data suggest a minimal impact of Rezum and PUL on ejaculatory function, the evidence after PAE and TIND are still limited. Therefore, our review lays the foundation for further research aiming to identify the criteria to select best candidates for uMIST to tailor the management in light of specific patient- and disease- factors.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

Two cases of pelvic hematoma after prostatic urethral lift surgery

Introduction

There are few reports of pelvic hematoma after prostatic urethral lift. Here, we report two cases of pelvic hematoma in Japan.

Case presentation

The first case was a 71-year-old man with benign prostatic hyperplasia who underwent prostatic urethral lift. Although the procedure was uneventful, he experienced lower abdominal pain the day after the operation. CT revealed a hematoma in the right pelvis; however, it was manageable with conservative treatment. The second case was a 68-year-old man. The procedure was uneventful; however, 6 days after the operation, a subcutaneous hematoma appeared in the lower abdomen. CT revealed a hematoma in the left pelvis. We then performed pelvic hematoma removal surgery.

Conclusions

Pelvic hematomas after PUL may requires attention, particularly in men with the narrow pelvises. Appropriate compression of the prostate and a high lithotomy position procedure could effectively avoid the occurrence of pelvic hematomas.

[Minimally invasive treatment of benign prostatic hyperplasia : The German S2e guideline 2023-part 4]

BACKGROUND

Lower urinary tract symptoms suggestive for benign prostatic obstruction (LUTS/BPO) are one of the most frequent diseases in men and can have a significant impact on quality of life. Instrumental therapies are common, and many patients seek minimally invasive treatment options.

OBJECTIVE

Presentation and evidence-based evaluation of the minimally invasive therapy for benign prostatic syndrome.

MATERIALS AND METHODS

Summary and overview of chapters 11-13 on minimally invasive therapies for LUTS/BPO of the current long version of the German S2e guideline.

RESULTS

In case of absolute indication for surgery or after unsatisfactory or undesired medical therapy, minimally invasive treatments such as UroLift® (Neotract Inc., Pleasanton, CA, USA), Rezῡm™ (Boston Scientific, Malborough, MA, USA), iTIND™ (Olympus America Inc., Westborough, MA, USA), and prostatic artery embolization (PAE) can be considered. These indirect/delayed ablative therapies offer lower morbidity and the possibility of performing them under local anesthesia, but they are inferior to direct ablative/resective techniques in terms of effectiveness and sustainability.

CONCLUSIONS

The updated German S2e guideline summarizes evidence-based recommendations for new minimally invasive therapies for LUTS/BPO, which present alternative treatment options for selected patients.

Cost-effectiveness analysis of minimally invasive surgical treatments for benign prostatic hyperplasia: implications for Japan's public healthcare system

AIMS

Benign prostatic hyperplasia (BPH) represents a significant public health issue in Japan. This study evaluated the lifetime cost-effectiveness of water vapor energy therapy (WAVE) versus prostatic urethral lift (PUL) for men with moderate-to-severe BPH from a public healthcare payer's perspective in Japan.

MATERIALS AND METHODS

A decision analytic model compared WAVE to PUL among males in Japan. Clinical effectiveness and adverse event (AE) inputs were obtained from a systematic literature review. Resource utilization and cost inputs were derived from the Medical Data Vision database and medical service fee national data in Japan. Experts reviewed and validated model input parameters. One-way and probabilistic sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affect the model results.

RESULTS

Throughout patients' lifetimes, WAVE was associated with higher quality-adjusted life years (0.920 vs. 0.911 year 1; 15.564 vs. 15.388 lifetime) and lower total costs (¥734,134 vs. ¥888,110 year 1; ¥961,595 vs. ¥1,429,458 lifetime) compared to PUL, indicating that WAVE is a more effective and less costly (i.e. dominant) treatment strategy across all time horizons. Lifetime cost-savings for the Japanese healthcare system per patient treated with WAVE instead of PUL were ¥467,863. The 32.7% cost difference between WAVE and PUL was predominantly driven by lower WAVE surgical retreatment rates (4.9% vs. 19.2% for WAVE vs PUL, respectively, at 5 years) and AE rates (hematuria 11.8% vs. 25.7%, dysuria 16.9% vs. 34.3%, pelvic pain 2.9% vs. 17.9%, and urinary incontinence 0.4% vs. 1.3% for WAVE vs PUL, respectively, at 3 months). Model findings were robust to changes in parameter input values.

LIMITATIONS

The model represents a simplification of complex factors involved in resource allocation decision-making.

CONCLUSIONS

Driven by lower retreatment and AE rates, WAVE was a cost-effective and cost-saving treatment for moderate-to-severe BPH in Japan compared to PUL, providing better outcomes at lower costs to the healthcare system.

New minimally invasive solutions for Benign Prostatic Obstruction (BPO) management: A position paper from the UrOP (Urologi Ospedalità Gestione Privata)

To the Editor, In recent years, alternative solutions have been proposed to obtain effective results comparable to TURP, which is currently considered the gold standard, and laser vapo-enucleation techniques (1, 2), but with the possibility of maintaining sexual functions. In recent years there has been a growing trend towards ejaculation preservation. Although the results of TURP (3), and most laser enucleation techniques are undoubted in the Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) management, they often lack in the preservation of ejaculation. All the alternative recently proposed interventions (Rezum, AquaBeam, Urolift, TPLA, i-TIND, LEST) are procedures considered by some authors to be promising in both managing BPO and preserving sexual functions. However, all these methods are limited by a lack of long-term follow-up that would evaluate the efficacy over time, possible complications related to the method and the correct patient selection for a specific method. The aim of this letter is to summarize the available evidence and provide clinicians with practical recommendations on the use of the brand new minimally invasive techniques for the management of BPO. [...].

Initial experience with prostatic urethral lift versus enucleation of the prostate: a retrospective comparative study

BACKGROUND

This study aimed to assess initial results and patient characteristics of prostatic urethral lift (PUL) compared with those of bipolar transurethral enucleation of the prostate (TUEB) in the treatment of benign prostatic hyperplasia (BPH) in older patients.

METHODS

This retrospective study was conducted at a single institution and involved 25 consecutive patients with BPH who underwent PUL between April 2022 and May 2023. Patient characteristics, operative details, and pre- and postoperative symptom scores were evaluated. The results were compared with those of a previously reported TUEB group (n = 55).

RESULTS

The mean age of the patients in the PUL group was 74.6 years, and the mean prostate volume was 47.5 ml. The PUL procedure significantly improved urinary symptoms, particularly incomplete emptying (p = 0.041), intermittency (p = 0.005), and weak stream (p = 0.001). The PUL group had higher comorbidity scores (p = 0.048) and included older patients (p = 0.002) than the TUEB group. TUEB showed better improvements in some symptoms and maximum flow rate (p = 0.01) than PUL; however, PUL had a shorter operative time and fewer complications than TUEB (p < 0.001).

CONCLUSION

The initial results demonstrate the efficacy and safety of PUL in older patients with BPH. Despite TUEB showing better outcomes in certain aspects than PUL, PUL offers advantages such as shorter operative time and fewer complications. Therefore, PUL can be considered a viable option for high-risk older patients with BPH.

Effects of resection volume on postoperative micturition symptoms and retreatment after transurethral resection of the prostate

PURPOSE

Despite advances in technology, such as advent of laser enucleation and minimally invasive surgical therapies, transurethral resection of the prostate (TURP) remains the most widely performed surgical technique for benign prostatic hyperplasia (BPH). We evaluated resection volume (RV)-derived parameters and analyzed the effect of RV on post-TURP outcomes.

METHODS

This observational study used data from patients who underwent TURP at two institutions between January 2011 and December 2021 Data from patients with previous BPH surgical treatment, incomplete data, and underlying disease affecting voiding function were excluded. The collected data included age, prostate-specific antigen, transrectal ultrasound (TRUS)- and uroflowmetry-derived parameters, RV, perioperative laboratory values, perioperative International Prostatic Symptom Score (IPSS), follow-up period, retreatment requirements and interval between the first TURP and retreatment.

RESULTS

In 268 patients without prior BPH medication, there were no differences in prostate volume (PV), transitional zone volume (TZV), or RV according to IPSS. A total of 60 patients started retreatment, including medical or surgical treatment, within the follow-up period. There was a significant difference in RV/PV between the groups without and with retreatment respectively (0.56 and 0.37; p = 0.008). However, preoperative TRUS- and uroflowmetry-derived parameters did not differ between the two groups. Multiple linear regression analysis showed that RV (p = 0.003) and RV/TZV (p = 0.006) were significantly associated with differences in perioperative IPSS. In the multivariate logistic regression analysis, only RV/PV was correlated with retreatment (p = 0.010).

CONCLUSION

Maximal TURP leads to improved postoperative outcomes and reduced retreatment rate, it may gradually become a requirement rather than an option.

Retreatment rates and postprocedural complications are higher than expected after BPH surgeries: a US healthcare claims and utilization study

BACKGROUND

Up to 50% of men over 50 and 80% over 80 are affected by BPH. Shared decision-making regarding BPH treatment options can benefit from an improved understanding of relative risks and benefits for various treatments.

METHODS

Data for this longitudinal retrospective population-based cohort study were obtained from a random sample of US Medicare and commercial claims (IBM Watson MarketScan) and restricted to men undergoing BPH surgery (TURP, PVP, PUL, WVTT) from 2015 to 2021 across all sites of service. Retreatments included Holmium laser enucleation and index procedures. Main outcomes were rates of retreatment and procedural complications over 1 year, identified via CPT and ICD-9/10CM codes. Procedural complications that occurred at least 1 day post-index treatment were assessed, as were surgical retreatments with patients who had at least 1 and 5 year's-worth of data. Baseline phenotype characterization did not control for symptomatology and was limited to age, comorbidities, and BMI. Univariate cumulative incidence estimates, cumulative proportion and log-rank tests justified inclusion for covariate (e.g., age, comorbidities) adjustment in Cox proportional hazard models.

RESULTS

43,147 men diagnosed with BPH underwent 22,629 TURP, 11,392 PVP, 7,529 PUL, and 1,597 WVTT. At 1-year post-index: PUL was associated with the lowest rate of complication (PUL 15%, TURP 17%; PVP 19%, ; WVTT 26%); retreatment rates were not different (TURP 5.3%, PVP 5.3%, PUL 5.9%, WVTT 6.2%). At 5 years post-index: retreatment was lowest for TURP (7.0%) and was not significantly different between PVP and PUL (8.9% and 11.6%, respectively).

CONCLUSIONS

Real-world patients diagnosed with BPH may be selected to undergo one of the various available therapies based on patient preference or baseline phenotype. These therapies, however, are associated with different risks for complications. The results of this study suggest that within one year of BPH surgery, one-in-twenty patients may require retreatment regardless of treatment choice, and for some technologies as many as one-in-four may require treatment for a complication.

Bladder stone due to late clip migration after prostatic urethral lift procedure: A case report

BACKGROUND

Prostatic urethral lift (PUL) therapy is an alternative to minimally invasive and other surgeries in younger patients who want to preserve their sexual and ejaculatory functions, and in elderly male patients with benign prostatic hyperplasia who cannot be anesthetized because of the risk of anesthesia. The procedure can be performed as an outpatient and without anesthesia, and complications are few and temporary. In long-term follow-up, encrustations that require retreatment are rarely seen.

CASE SUMMARY

In our case, a 62-year-old prostate patient who had a PUL operation 8 years ago and had a stone on the PUL material near the bladder neck was treated. The patient's stone was removed by endoscopic cystolithotripsy using pneumatic fragmentation. Bipolar transurethral resection of the prostate was applied to the patient in the same session. After the patient's 7-year follow-up, the patient's complaints relapsed, and cystoscopy was performed again. In cystoscopy, stone formation adjacent to the wall was observed at the junction of the bladder neck to the left lateral wall. The stone was fragmented with a pneumatic lithotripter.

CONCLUSION

Placing clips too close to bladder neck in the PUL procedure may result in clip migration.

Trans - Perineal laser ablation of the prostate in high surgical risk patients affected by severe lower urinary tract symptoms related to benign prostatic obstruction

BACKGROUND

In our study, we aimed to test the efficacy and safety of Trans-Perineal Laser Ablation of the prostate (TPLA®) in the surgical treatment of high-risk Benign Prostatic Obstruction (BPO) patients.

METHODS

We defined a high-risk BPO patient as an elderly man affected by severe comorbidities, among which coagulation issues due to pre-existent medications or diseases. From October 2020 to June 2022, we prospectively enrolled high-risk patients affected by a moderate to severe and/or complicated BPO condition. The analysis of the efficacy of the Trans-Perineal Laser Ablation was defined as the primary endpoint of the study. Secondary endpoints were post-operative surgical complications and patient-reported quality of life.

RESULTS

Globally, 40 consecutive patients were enrolled. Median (IQR) age was 80 (72.5-84) years. Median Charlson Comorbidity Index was 6 (5-7). Median prostate volume was 38 (30.5-73) cc. In all cases, a TPLA® procedure was performed under local anesthesia, and patients being discharged within the same day of the procedure. A progressive reduction of median prostate volumes was reported at 3 and 6 months post-operatively, compared to baseline [38 (30.5-73) vs 35 (26-49) vs 34 (28-49) cc, p < 0.001]. Median International Prostate Symptom Score (IPSS) improved accordingly [25 (19-30) vs 10.5 (7.5-13) vs 8 (6-11.5), p < 0.001]. A permanent bladder catheter was successfully removed in 13 out of 23 (56.5%) cases. Within 90 days from surgery, 19 (47.5%) patients experienced at least one surgical complication. According to the Clavien-Dindo classification, complications were classified as grade I in 16 (40%) cases, grade II in 9 (22.5%), and grade III in 1 (2.5%). We did not observe any grade IV or V complications.

CONCLUSIONS

The Trans-Perineal Laser Ablation of the Prostate is a feasible, safe, and effective Minimally Invasive Surgical Technique, when offered to elderly, high-risk patients affected by severe Benign Prostatic Obstruction.

mparing Urolift and tandard ransurethral resection of prostate head of adiotherapy in men with urinary symptoms secondary to prostate enlargement in Southwest London and North Cumbria (CO-STAR): a study protocol for a randomised feasibility study

INTRODUCTION

Patients undergoing prostate radiotherapy with an enlarged prostate can have short-term and long-term urinary complications. Currently, transurethral resection of the prostate (TURP) is the mainstay surgical intervention for men with urinary symptoms due to an enlarged prostate prior to radiotherapy. UroLift (NeoTract, Pleasanton, CA, USA) is a recent minimally invasive alternative, widely used in benign disease but is untested in men with prostate cancer.

METHODS AND ANALYSIS

A multicentre, two-arm study designed in collaboration with a Patient Reference Group to assess the feasibility of randomising men with prostate cancer and coexisting urinary symptoms due to prostate enlargement to TURP or UroLift ahead of radiotherapy. 45 patients will be enrolled and randomised (1:1) using a computer-generated programme to TURP or UroLift. Recruitment and retention will be assessed over a 12 month period. Information on clinical outcomes, adverse events and costs will be collected. Clinical outcomes and patient reported outcome measures will be measured at baseline, 6 weeks postintervention and 3 months following radiotherapy. A further 12 in-depth interviews will be conducted with a subset of patients to assess acceptability using the Theoretical Framework of Acceptability. Descriptive analysis on all outcomes will be performed using Stata (StataCorp V.2021).

ETHICS AND DISSEMINATION

The trial has been approved by the Research Ethics Committee (REC) NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW). The results will be published in peer-reviewed journals, presented at national meetings and disseminated to patients via social media, charity and hospital websites.

TRIAL REGISTRATION NUMBER

NCT05840549.

Emerging Technologies for the Surgical Management of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Obstruction. A Systematic Review

CONTEXT

Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or vaporisation. Apart from established ablation modes according to the European Association of Urology guidelines, various technologies have emerged as safe/effective alternatives but remain under investigation.

OBJECTIVE

To explore short-term benefits/harms of emerging technologies for surgical management of LUTS/BPO.

EVIDENCE ACQUISITION

A systematic literature search was conducted using MEDLINE, EMBASE, and CENTRAL via Ovid up to June 18, 2022. We included randomised controlled trials (RCTs) exploring aquablation, prostatic arterial embolisation (PAE), Rezum, prostatic urethral lift (PUL), and temporary implantable nitinol device (iTIND) versus sham/transurethral resection of the prostate (TURP).

EVIDENCE SYNTHESIS

We included ten RCTs (1108 men). Aquablation versus TURP: insignificant change in International Prostate Symptoms Score (IPSS; mean difference [MD] 0.0, 95% confidence interval [CI] -2.44 to 2.44), quality of life (QoL; MD 0.30, 95% CI -0.81 to 0.21), maximum urinary flow rate (Qmax; MD -0.30, 95% CI -3.71 to 3.11), retreatment (risk ratio [RR] 0.18, 95% CI 0.02-1.66), and urinary incontinence (UI; RR 0.71, 95% CI 0.26-1.95). PAE versus monopolar TURP (M-TURP): insignificant change in IPSS (MD 3.33, 95% CI -28.39 to 35.05), QoL (MD 0.12, 95% CI -0.30 to 0.54), International Index of Erectile Function (IIEF-5; MD 3.07, 95% CI -1.78 to 7.92), and UI (RR 0.15, 95% CI 0.01-2.86), and significant change in Qmax (MD -9.52, 95% CI -14.04 to -5.0), favouring M-TURP. PAE versus bipolar TURP: insignificant change in IPSS (MD -2.80, 95% CI -6.61 to 1.01), QoL (MD -0.69, 95% CI -1.46 to 0.08), Qmax (MD -3.51, 95% CI -8.08 to 1.06), UI (RR 0.14, 95% CI 0.01-2.51), and retreatment (RR 1.91, 95% CI 0.19-19.63). PUL versus TURP: insignificant change in QoL (MD 0.40, 95% CI -0.29 to 1.09), UI (RR 0.13, 95% CI 0.02-1.05), and retreatment (RR 0.48, 95% CI 0.12-1.86), and significant change in IPSS (MD 3.40, 95% CI 0.22-6.58), and IIEF-5 (MD 3.00, 95% CI 0.41-5.59) and Qmax (MD -9.60, 95% CI -13.44 to -5.76), favouring PUL and TURP, respectively. Rezum and iTIND have not been evaluated in RCTs against TURP to date.

CONCLUSIONS

Supporting evidence for clinical use of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits/harms should be investigated further in high-quality RCTs.

PATIENT SUMMARY

This review summarises the evidence for the clinical use of aquablation, prostatic arterial embolisation (PAE), prostatic urethral lift (PUL), Rezum, and temporary implantable nitinol device (iTIND) to manage lower urinary tract symptoms secondary to benign prostatic obstruction. The supporting evidence for the clinical usage of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits and harms should be investigated further in high-quality randomised controlled trials.

Ejaculation physiology and dysfunction after BPH surgery: the role of the new MISTs

BACKGROUND

Human ejaculation can be defined as a complex and still largely unknown function. Since decades, Benign Prostatic Hyperplasia (BPH) surgery-associated loss of antegrade ejaculation has been reported as a bother by many patients. New technologies and modified surgical techniques were developed, to reduce the impact of ejaculatory dysfunction on patients' perceived quality of life. Recently, the emerging of the new Minimally Invasive Surgical Techniques (MISTs) empowered the urological surgeons with the technological means to introduce the ejaculation-sparing principles into everyday clinical practice.

METHODS

Our paper was conceived as a state-of-the-art analysis about the anatomical and physiological premises of the human ejaculation and their clinical application in the field of ejaculation-sparing surgery for the treatment of Lower Urinary Tract Symptoms (LUTS). Moreover, we proposed an innovative physiological model for antegrade ejaculation.

RESULTS

We analysed the elements of the "ejaculatory apparatus" from an anatomical point of view. We investigated the physio-pathological models of the human ejaculation, from the classical "combustion chamber" paradigm to the new evidences by which it could be overcome. Finally, we provided a synthetic literature review about the ejaculation-sparing techniques for BPH surgery. Particularly, we distinguished them between classical techniques, modified for ejaculation-preserving purposes, and the new MISTs, characterized by the introduction of new technologies and different treatment modalities.

CONCLUSIONS

Modified surgical techniques and new technologies opened new perspectives about human ejaculation. Previously established functional paradigms were questioned and overcome by recent clinical evidence. The new MISTs gained a prominent role in the process, opening a whole new era for BPH surgery.

Biocompatibility and efficacy of prostatic urethral lift in benign prostate hyperplasia: an in vivo and in vitro study

The study aimed to assess the biocompatibility and efficacy of a prostatic urethral lift (PUL) for benign prostatic hyperplasia (BPH). Human BPH-1 cells were co-cultured with implant anchors and sutures, and cytotoxicity was measured. Scanning electron microscopy (SEM) was used to observe adhesion and growth of cells and to evaluate implant biocompatibility. Fifteen male beagle dogs were randomly assigned to the surgical (n = 9) or sham-operated (n = 6) groups. The surgical group underwent cystotomy, and PUL was used to insert two implants in each lobe of the prostate to compress the enlarged prostate and dilate the urethra; the sham group underwent cystotomy without implant insertion. Compared with the control group, no significant difference in cell viability among the groups with different co-culture times of implant anchors and sutures (P > 0.05) was observed. SEM revealed good adhesion and growth of prostate cells on the implants. Improvements in urine flow rates remained stable at 7, 28, and 180 days after surgery, and the urethral diameter in the prostate region was significantly increased compared with that before surgery. PUL is a biocompatible and effective treatment for BPH, improving the urine flow rate without causing inflammation, tissue damage, or cytotoxic effects. Here, the basis for further PUL application was provided.

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis

PURPOSE

To review and compare the effectivity of novel minimally invasive treatments (MITs) to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) in men.

METHODS

Medline, Embase, and Cochrane databases were searched from January 2010 to December 2022 for randomized controlled trials (RCTs) evaluating MITs, compared to TURP or sham, in men with LUTS. Studies were assessed by risk of bias tool, and evidence by GRADE. Functional outcomes by means of uroflowmetry and IPSS were the primary outcomes, safety and sexual function were secondary outcomes. As part of this review, a network meta-analysis (NMA) was conducted. MITs were ranked based on functional outcome improvement probability.

RESULTS

In total, 10 RCTs were included, evaluating aquablation, prostatic urethral lift, prostatic artery embolization (PAE), convective water vapor thermal treatment or temporary implantable nitinol device. All MITs showed a better safety profile compared to TURP. Functional outcome improvement following aquablation were comparable to TURP. In the NMA, aquablation was ranked highest, PAE followed with the second highest probability to improve functional outcomes. Other novel MITs resulted in worse functional outcomes compared to TURP. Level of evidence was low to very low.

CONCLUSIONS

Five MITs for treatment of LUTS were identified. Aquablation is likely to result in functional outcomes most comparable to TURP. Second in ranking was PAE, a technique that does not require general or spinal anesthesia. MITs have a better safety profile compared to TURP. However, due to high study heterogeneity, results should be interpreted with caution.

Angioembolization for massive pelvic hematoma after prostatic urethral lift

Introduction

Pelvic hematomas are a rare complication of prostatic urethral lift. We would like to report the first case of massive pelvic hematoma after prostatic urethral lift that was successfully managed by selective angioembolization.

Case presentation

An 83-year-old gentleman with benign prostatic hyperplasia underwent prostatic urethral lift. Although the procedure was uneventful, he developed shock while in the recovery room. Urgent contrast computed tomography scan showed a large heterogenous hematoma at the right pelvis extending to the right retroperitoneum with contrast extravasation noted. Urgent angiogram confirmed extravasation from the right prostatic artery. Angioembolization with coils and 33% N-butyl cyanoacrylate glue was successfully performed.

Conclusion

Prostatic urethral lift can be complicated by the rare massive pelvic hematoma, possibly more common in small prostates. With a prompt contrast computed tomography scan, pelvic hematomas can be managed with angioembolization first and hopefully prevent open exploratory surgery.

Pharmacotherapy vs. minimally invasive therapies as initial therapy for moderate-to-severe benign prostatic hyperplasia: a cost-effectiveness study

BACKGROUND

Recently, minimally invasive therapies (MITs), such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH), offering symptom relief with a favorable safety profile. The objective of this study was to evaluate the cost-utility of MITs (WVTT and PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the US public payer perspective) per quality-adjusted life year (QALY), discounted at 3% annually. Various clinical scenarios were evaluated given that most men undergo several lifelong therapies up to surgical intervention and potentially thereafter. As such, in the study model men could receive up to three lines of therapy: (1) initial pharmacotherapy with MIT as second-line, and transurethral resection of the prostate (TURP) or pharmacotherapy as third-line; (2) initial MIT (WVTT or PUL) with MIT again, TURP or pharmacotherapy as second-line, and TURP as third-line. Model was populated using data from the published literature. Probabilistic analyses were performed.

RESULTS

Initial treatment with WVTT led to the highest QALYs (13.05) and the lowest cost ($15,461). The cumulative QALYs and lifetime costs were 12.92 QALYs and $20,280 for pharmacotherapy followed by WVTT, 12.87 QALYs and $22,424 for pharmacotherapy followed by PUL, 12.86 QALYs and $20,930 for initial treatment with PUL. In the cost-utility analysis, WVTT as initial treatment dominated all three strategies, i.e., generated more QALYs at a lower cost.

CONCLUSION

WVTT is an effective and cost-saving procedure, and may be an appropriate first-line alternative to pharmacotherapy for moderate-to-severe BPH patients who seek faster improvement and no lifelong commitment to daily medications.

Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures

Lower urinary tract symptoms due to benign prostatic hyperplasia constitute a substantial burden, affecting the quality of life of those affected by this condition. While watchful waiting and medical management using a wide array of pharmaceuticals can be effective, surgery has been one of the most definite solutions for those highly affected by this condition. Transurethral resection of the prostate (TURP) is the gold standard surgical procedure, but other alternatives using laser (HoLEP and ThuLEP) and robotic water jets (Aquablation) are emerging treatments aimed at reducing postoperative morbidity. Minimally invasive procedures conducted in outpatient settings and under local anesthesia or sedation are increasingly being used, especially in those patients with high surgical risk due to comorbidities. These procedures include prostatic arterial embolization, water vapor thermal therapy (Rezum), prostatic urethral lift (Urolift), temporary implantable nitinol device (TIND/iTIND), and transurethral microwave thermotherapy (TUMT). The evidence supporting these treatments is growing, but some uncertainties remain as to what is the magnitude of their advantages and disadvantages compared to TURP. Innovations in the technologies involved in these new procedures may improve their profile for effectiveness and safety. Moreover, new devices are being investigated for marketing approval. Issues around costs and patients' preferences are also yet to be elucidated, thus their evolving role needs to be weighed against the aforementioned considerations.

Comparative efficacy and safety of prostatic urethral lift vs prostatic artery embolization for benign prostatic hyperplasia: a systematic review and network meta-analysis

OBJECTIVE

To assess and compare the clinical efficacy and safety of prostatic urethral lift (PUL) and prostatic artery embolization (PAE) for the treatment of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) by means of a systematic review and network meta-analysis.

METHODS

A systematic literature search was performed using PubMed and Web of Science from inception to March 2021 to identify randomized controlled trials (RCTs) that compared PUL or PAE with either transurethral resection of the prostate (TURP) or sham procedures as control interventions. Qualitative and quantitative analyses were performed to pool the data on direct and indirect comparisons between interventions using STATA 14.

RESULTS

Eight RCTs with 675 participants were included in our network meta-analysis. Quantitative synthesis revealed that TURP was the most efficacious intervention for clinical (International Prostate Symptoms Score and quality of life) and functional outcomes (maximum urinary flow rate and post-void residual urine volume), and was associated with a lower reintervention rate compared with PAE (risk ratio [RR] 2.08 with 95% confidence interval [CI] 0.96 to 4.51) and PUL (RR 2.33 with 95% CI 0.50 to 10.86), although the difference were not statistically significant. Indirect comparison indicated that PUL and PAE resulted in similar outcomes. PAE was associated with fewer minor adverse events (AEs; RR 0.75 with 95% CI 0.48 to 1.18) and PUL with fewer major AEs (RR 0.72 with 95% CI 0.17 to 3.13) when compared with TURP. Whilst PAE had a better ranking with regard to improvement of most clinical and functional outcomes, PUL was the best ranked procedure regarding erectile function, as measured by the International Index of Erectile Function 5, but no significant difference was observed.

CONCLUSION

Current evidence suggests that PUL and PAE have similar clinical efficacy and safety profiles in the management of LUTS associated with BPH. However, the quality of evidence is relatively low because of the paucity of RCTs available, and results should be interpreted with caution.

Risk Factors and Real-World Short-Term Outcomes of a Failed Trial of Void After Rezum Therapy in a Multiethnic Population

Background: Postoperative urinary retention is a common complication following surgery for benign prostatic hyperplasia. We aimed to identify risk factors for a failed trial of void (TOV) following treatment with the Rezum system and assess the impact of a failed TOV on short-term outcomes. Methods: A single-office retrospective study was conducted on patients treated with Rezum therapy between 2017 and 2019. A urinary catheter was placed in all patients following Rezum therapy. Demographic data and outcome measures, including the International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax), postvoid residual (PVR), and adverse events, were analyzed at baseline and 1, 3, and/or 6 months postoperatively. Risk factors were identified through multivariate logistic regression analysis. Results: A total of 289 patients were included. Thirty-five patients (12.1%) failed a TOV, while 254 (87.9%) had an effective TOV. All patients were given a TOV after a median of 5 days (4-5). Those who failed the TOV spent an additional mean of 13.7 ± 13.3 days with a catheter. Patients who failed the TOV were more likely to get a urinary tract infection compared with those who had an effective TOV (20.0% vs 4.7%, p < 0.001). All patients experienced significant improvements in IPSS, QoL, and Qmax at 1, 3, and/or 6 months. On multivariate analysis, a high baseline PVR was the only independent predictor of a failed TOV (odds ratio: 1.01, 95% confidence interval 1.00-1.01). A greater proportion of patients with a baseline PVR >200 mL failed the TOV (40.0%) compared with patients with a baseline PVR <200 mL (10.9%, p = 0.008). Conclusions: Approximately one in eight patients failed the TOV following Rezum therapy. Baseline PVR was the only independent risk factor for a failed TOV. Nevertheless, all patients experienced significant relief of urinary symptoms. Patients with high baseline PVR, particularly >200 mL, may require a catheter for an extended duration.

Cost-effectiveness of alternative first- and second-line treatments for benign prostatic hyperplasia in Singapore

BACKGROUND

Minimally invasive surgical therapies, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically second-line options for patients in whom medical management (MM) failed but who are unwilling or unsuitable to undergo invasive transurethral resection of the prostate (TURP). However, the incremental cost-effectiveness of WVTT or PUL as first- or second-line therapy is unknown. We evaluated the incremental cost-effectiveness of alternative first- and second-line treatments for patients with moderate-to-severe benign prostatic hyperplasia (BPH) in Singapore to help policymakers make subsidy decisions based on value for money.

METHODS

We considered six stepped-up treatment strategies, beginning with MM, WVTT, PUL or TURP. In each strategy, patients requiring retreatment advance to a more invasive treatment until TURP, which may be undergone twice. A Markov cohort model was used to simulate transitions between BPH severity states and retreatment, accruing costs and quality-adjusted life-years (QALYs) over a lifetime horizon.

RESULTS

In moderate patients, strategies beginning with MM had similar cost and effectiveness, and first-line WVTT was incrementally cost-effective to first-line MM (33,307 SGD/QALY). First-line TURP was not incrementally cost-effective to first-line WVTT (159,361 SGD/QALY). For severe patients, WVTT was incrementally cost-effective to MM as a first-line treatment (30,133 SGD/QALY) and to TURP as a second-line treatment following MM (6877 SGD/QALY). TURP was incrementally cost-effective to WVTT as a first-line treatment (48,209 SGD/QALY) in severe patients only. All pathways involving PUL were dominated (higher costs and lower QALYs).

CONCLUSION

Based on the common willingness-to-pay threshold of SGD 50,000/QALY, this study demonstrates the cost-effectiveness of WVTT over MM as first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL is not cost-effective as a first- nor second-line treatment. For patients with severe BPH, TURP as first-line is also cost-effective.

Prostatic Urethral Lift for Obstructive Median Lobes: Consistent Results Across Controlled Trial and Real-World Settings

Introduction: The evidence for prostatic urethral lift (PUL), in treating lower urinary tract symptoms/benign prostatic hyperplasia (BPH) in men with obstructive median lobes (OMLs), has grown. In this study, we present the first detailed comparison of outcomes between OML patients treated with PUL in controlled and real-world settings to relevant comparators (subjects treated with transurethral resection of the prostate [TURP] and sham in randomized controlled trials [RCTs]) to demonstrate similar symptom, safety, and patient experience outcomes. Materials and Methods: Symptom and safety outcomes and patient satisfaction were compared through 12 months among controlled PUL studies: BPH6 RCT (35 men randomized to TURP); L.I.F.T. pivotal RCT in subjects with lateral lobe obstruction (66 subjects randomized to sham) and MedLift, an U.S. Food and Drug Administration-approved Investigational Device Exemption (IDE) extension of the L.I.F.T. trial (45 men with OML). Symptom improvement, catheterization, and adverse event rates were compared between MedLift subjects and OML patients (n = 187) from the large real-world retrospective (RWR) study of PUL filtered on baseline characteristics to approximate the MedLift population. Results: Posttreatment, International Prostate Symptoms Score (IPSS) improvement for MedLift subjects was 170% greater compared with sham at 3 months with significantly better quality of life (QoL), Qmax, and benign prostatic hyperplasia impact index (BPHII). Compared with TURP, MedLift IPSS and QoL improved significantly better at 1 and 3 months and with superior ejaculatory function scores at all time points after PUL. IPSS, QoL, postvoid residual (PVR), and Qmax outcomes were equivalent between MedLift and RWR OML groups at 3, 6, and 12 months. RWR OML patients did not experience higher rates of overall adverse events compared with MedLift. Conclusion: Controlled and real-world outcomes confirm PUL is a safe and effective treatment for BPH patients with and without OML.

Prostatic artery embolization compared to transurethral resection of the prostate and prostatic urethral lift: a real-world population-based study

BACKGROUND

There are growing interests for minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS). Prostatic artery embolization (PAE) uses selective angioembolization of prostatic arteries, thereby reducing size to improve LUTS/BPH. However, real-world data comparing surgical outcomes between MISTs and tissue resective techniques are lacking. We assessed the differences in surgical outcomes between PAE, transurethral resection of the prostate (TURP), and prostatic urethral lift (PUL) in a real-world population for LUTS/BPH.

METHODS

We present an observational population-based study of 12,902 men with BPH in New York State who received PAE, TURP, and PUL in outpatient and ambulatory surgery settings from 2014 to 2018. For short-term outcomes, we report 30-day and 90-day risks of readmission to inpatient and emergency room (ER) with/without complications and compared them across groups using χ² tests and mixed-effect logistic regressions. For long-term outcomes, we report surgical retreatment and stricture rates using Kaplan-Meier failure curves and compared them using Log rank tests and Cox regression models.

RESULTS

Of 12 902 men, 335 had PAE, 11,205 had TURP, and 1362 had PUL. PAE patients had the highest 30-day (19.9%) and 90-day (35.6%) risks of readmission to inpatient or ER (p < 0.01). Non-specific abdominal pain was the main diagnosis associated with 30-day and 90-day readmissions to inpatient or ER after PAE (14.3% and 26.8%, respectively). After 2 years of follow-up, PAE patients had the highest retreatment rate of 28.5% (95%CI 23.7-34.2%) compared to TURP (3.4% (95%CI 3.1-3.8%)) and PUL (8.5% (95%CI 5.6-12.9%)) (p < 0.001).

CONCLUSION

In a real-world population, PAE was associated with the most frequent 30-day and 90-day readmission to inpatient or ER and the highest retreatment rate among all surgical techniques even when controlled for individual patient comorbidities and surgical volume.

[Minimally Invasive Therapy: What Is The Status In 2021 - What's Coming, What's Going?]

Due to the large number of men affected and a variable clinical presentation, the widespread disease "benign prostatic syndrome" requires individual treatment options tailored to the patient's specific clinical characteristics and wishes. If surgical treatment is indicated, there is a wide range of invasive procedures available. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard, but these procedures are associated with increased morbidity and limitations in sexual function. Therefore, there is now an increasing call for minimally invasive treatment options that will provide effective and safe treatment in the outpatient setting. Over the past years, a variety of technologies and procedures have been developed and tested, but only a few of them have found their way into clinical practice, mostly due to insufficient functional results. For instance, transurethral needle ablation, transurethral microwave thermotherapy, intraprostatic botulinum toxin A or PRX302 injections as well as prostatic stents are no longer recommended. In contrast, the European Association of Urology is currently recommending UroLift, Aquablation and prostatic artery embolisation, which achieve significant long-term improvements in functional parameters while providing a good safety profile and preserved sexual function. Promising data are also available for the temporarily implanted nitinol device (iTIND), Rezūm, intraprostatic injection of fexapotide triflutate and transperineal laser ablation of the prostate, but the efficacy and safety of these procedures need to be confirmed in further studies.

Fexapotide triflutate vs oral pharmacotherapy as initial therapy for moderate-to-severe benign prostate hyperplasia patients: a cost-effectiveness analysis

BACKGROUND

To assess the price range in which fexapotide triflutate (FT), a novel injectable, is cost-effective relative to current oral pharmacotherapy (5 α-reductase inhibitor, α-blocker, 5 α-reductase inhibitor and α-blocker combination therapy) as initial therapy followed by surgery for moderate-to-severe benign prostate hyperplasia patients with lower urinary tract symptoms (BPH-LUTS).

METHODS

We developed a microsimulation decision-analytic model to track the progression of BPH-LUTS and associated costs and quality-adjusted life years in the target population. The cost-effectiveness analysis was performed from Medicare's perspective with a time horizon of 4 years using 2019 US dollars for all costs. The microsimulation model considered treatment patterns associated with nonadherence to oral medication and progression to surgery. Model parameters were estimated from large randomized controlled trials, literature and expert opinion. For each initial treatment option, simulations were performed with 1000 iterations, with 1000 patients per iteration.

RESULTS

Three upfront oral pharmacotherapy options are close in cost-effectiveness, with combination therapy being the most cost-effective option. Relative to upfront oral pharmacotherapy options, FT slightly increases quality-adjusted life years (QALY) per patient (1.870 (95% CI, 1.868 to 1.872) vs. 1.957 (95% CI, 1.955 to 1.959) QALYs). Under the willingness-to-pay (WTP) threshold of $150,000 per QALY, at price per injection of $14,000, FT is about as cost-effective as upfront oral pharmacotherapy options with net monetary benefit (NMB) $279,168.54. Under the WTP threshold of $50,000 per QALY, at price per injection of $5,000, FT is about as cost-effective as upfront oral pharmacotherapy options with NMB $92,135.18. In an alternative 10-year time horizon scenario, FT price per injection at $11,000 and $4,500 makes FT as cost-effective as oral pharmacotherapies. One-way sensitivity analysis showed this result is most sensitive to upfront therapy prices, FT efficacy and initial IPSS. At price per injections of $5,000, $10,000 and $15,000, the probability that FT is either cost-effective or dominant compared to upfront oral pharmacotherapy options using a WTP threshold of $150,000 per QALY is 100%, 93% and 40%, respectively.

CONCLUSIONS

Compared to upfront oral pharmacotherapy options, FT would be cost-effective at a price per injection below $14,000, assuming a WTP threshold of $150,000 per QALY.

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.

A comprehensive analysis of clinical, quality of life, and cost-effectiveness outcomes of key treatment options for benign prostatic hyperplasia

Treatment options for men with moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) have variable efficacy, safety, and retreatment profiles, contributing to variations in patient quality of life and healthcare costs. This study examined the long-term cost-effectiveness of generic combination therapy (CT), prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), photoselective vaporization of the prostate (PVP), and transurethral resection of the prostate (TURP) for the treatment of BPH. A systematic literature review was performed to identify clinical trials of CT, PUL, WVTT, PVP, and TURP that reported change in International Prostate Symptom Score (IPSS) for men with BPH and a prostate volume ≤80 cm³. A random-effects network meta‐analysis was used to account for the differences in patient baseline clinical characteristics between trials. An Excel-based Markov model was developed with a cohort of males with a mean age of 63 and an average IPSS of 22 to assess the cost-effectiveness of these treatment options at 1 and 5 years from a US Medicare perspective. Procedural and adverse event (AE)-related costs were based on 2021 Medicare reimbursement rates. Total Medicare costs at 5 years were highest for PUL ($9,580), followed by generic CT ($8,223), TURP ($6,328), PVP ($6,152), and WVTT ($2,655). The total cost of PUL was driven by procedural ($7,258) and retreatment ($1,168) costs. At 5 years, CT and PUL were associated with fewer quality-adjusted life years (QALYs) than WVTT, PVP, and TURP. Compared to WVTT, the incremental cost-effectiveness ratios (ICERs) for both TURP and PVP were above a willingness-to-pay threshold of $50,000/QALY (TURP: $64,409/QALY; PVP: $87,483/QALY). This study provides long-term cost-effectiveness evidence for several common treatment options for men with BPH. WVTT is an effective and economically viable treatment in resource-constrained environments.

Real-world data comparing minimally invasive surgeries for benign prostatic hyperplasia

OBJECTIVES

To assess the differences in surgical outcomes between the prostatic urethral lift (PUL) and previous thermal energy procedures for the treatment of benign prostatic hyperplasia (BPH).

METHODS

We present an observational population-based study of 2694 men with BPH in New York State and California who received PUL, transurethral needle ablation (TUNA), or transurethral microwave therapy (TUMT) in outpatient and ambulatory surgery settings from 2005 to 2018. For these surgical procedures, short-term outcomes were reported and compared using a Chi-square test and mixed-effect logistic regressions. Long-term outcomes were described using Kaplan-Meier failure curves and compared using a Log-rank test and Cox regressions.

RESULTS

A significant portion of PUL patients had a comorbidity count ≥ 2 (n = 838, 37.0%). PUL exhibited the lowest 30 day and 90-day inpatient or ER readmission rates among all surgical techniques except for 90-day ER readmission (p < 0.05). No differences were observed for 1- and 3-year risks of reoperation between PUL [5.5% (95% CI 4.4-6.8%) and 14.9% (95% CI 10.9-20.1%)], TUNA [7.4% (95% CI 5.0-10.9%) and 11.3% (95% CI 8.3-15.4%)] and TUMT [8.5% (95% CI 4.7-15.2%) and 15.3% (95% CI 9.5-24.0%)]. 1- and 3-year risks of stricture development for PUL were 0.2% (95% CI 0.0-0.7%) and 0.2% (95% CI 0.0-0.07%), respectively.

CONCLUSION

In a patient population with chronic conditions, patients treated with PUL exhibited similar 30- and 90-day inpatient or ER readmission rates when compared to previous reports. However, 1- and 3-year reoperation risks for PUL closely resembled previous thermal energy surgical procedures.

The UroLift implant: mechanism behind rapid and durable relief from prostatic obstruction

BACKGROUND

Benign prostatic hyperplasia (BPH) is an affliction of the aging male population that contributes to bothersome and disruptive lower urinary tract symptoms (LUTS). The UroLift® implant has been developed as a mechanical means of widening the prostatic urethra and providing relief from lower urinary tract symptoms (LUTS) through a minimally invasive procedure.

METHODS

In the current study, we utilize histological results from canine tissue, resected tissue from human subjects treated with the UroLift System and post-market surveillance data collected by the manufacturer in order to elucidate the long-term biological mechanism of action of the UroLift implant.

RESULTS

The delivery of the implant causes tissue compression, likely resulting in focal ischemia that causes observed local atrophy and minimal-mild chronic inflammation that ultimately remodels tissue to produce a widened prostatic urethra.

CONCLUSIONS

These studies reveal the lack of impact the device has on systemic tissue, providing evidence that the UroLift System is benign and biocompatible, and offering histologic explanation for the clinically observed durability.

Surgical treatment options for benign prostatic obstruction: beyond prostate volume

PURPOSE OF REVIEW

Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization.

RECENT FINDINGS

A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP.

SUMMARY

BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

The placebo and nocebo effects in functional urology

A placebo is an inert substance normally used in clinical trials for comparison with an active substance. However, a placebo has been shown to have an effect on its own; commonly known as the placebo effect. A placebo is an essential component in the design of conclusive clinical trials but has itself become the focus of intense research. The placebo effect is partly the result of positive expectations of the recipient on the state of health. Conversely, a nocebo effect is when negative expectations from a substance lead to poor treatment outcomes and/or adverse events. Randomized controlled trials in functional urology have demonstrated the importance of the placebo and nocebo effects across different diseases such as overactive bladder, urinary incontinence, lower urinary tract symptoms and interstitial cystitis/painful bladder syndrome, as well as male and female sexual dysfunction. Understanding the true nature of the placebo-nocebo complex and the scope of its effect in functional urology could help urologists to maximize the positive effects of this phenomenon while minimizing its potentially negative effects.

Minimally invasive treatments for benign prostatic hyperplasia: a Cochrane network meta-analysis

OBJECTIVE

To assess the comparative effectiveness and ranking of minimally invasive treatments (MITs) for lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

We searched multiple databases up to 24 February 2021. We included randomized controlled trials assessing the following treatments: convective radiofrequency water vapour thermal therapy (WVTT; or Rezūm); prostatic arterial embolization (PAE); prostatic urethral lift (PUL; or Urolift); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT) compared to transurethral resection of the prostate (TURP) or sham surgery. We performed a frequentist network meta-analysis.

RESULTS

We included 27 trials involving 3017 men. The overall certainty of the evidence of most outcomes according to GRADE was low to very low. Compared to TURP, we found that PUL and PAE may result in little to no difference in urological symptoms, while WVTT, TUMT and TIND may result in worse urological symptoms. MITs may result in little to no difference in quality of life, compared to TURP. MITs may result in a large reduction in major adverse events compared to TURP. We were uncertain about the effects of PAE and PUL on retreatment compared to TURP, however, TUMT may result in higher retreatment rates. We were very uncertain of the effects of MITs on erectile function and ejaculatory function. Among MITs, PUL and PAE had the highest likelihood of being the most efficacious for urinary symptoms and quality of life, TUMT for major adverse events, WVTT and TIND for erectile function and PUL for ejaculatory function. Excluding WVTT and TIND, for which there were only studies with short-term (3-month) follow-up, PUL had the highest likelihood of being the most efficacious for retreatment.

CONCLUSIONS

Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and quality of life compared to TURP at short-term follow-up.

[Minimally invasive treatment options for the management of benign prostatic hyperplasia]

Benign prostatic hyperplasia is one of the most common diseases of aging men. Hyperplasia of the glandular tissue can cause distressing lower urinary tract symptoms, which can be treated with both drugs and interventions. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard of surgical treatment. In order to be able to offer patients an outpatient treatment with few complications, shorter hospital stays and high efficiency, a variety of minimally invasive treatment options have been developed. While recommendations have already been made for the excision by focused waterjet, prostatic urethral lift, and prostatic artery embolization, there are several other very promising procedures for which, however, long-term data and data from comparative studies with reference procedures must still be awaited.

[Prostatic Urethral Lift under local anesthesia: Single-centre retrospective observational study]

INTRODUCTION

Urolift implant placement may be preferred to conventional endoscopic surgery for patients who wish to preserve their sexuality or for those who prefer a rapid post-operative recovery. The absence of general anaesthesia is an important element that reinforces the minimally invasive aspect of the procedure and improves the speed of recovery. The aim of this work was to report our preliminary experience of Urolift treatment under local anaesthesia.

MATERIALS AND METHODS

A retrospective analysis was conducted including all patients treated with Urolift between 2017 and 2021 in our centre. Local anaesthesia was based on the instillation of 2 Xylocaine gels at 4°C into the urethra 15minutes before the procedure. The primary endpoint was the successful completion of the procedure without interruption due to pain or the need for any other form of anaesthesia or analgesia.

RESULTS

Twenty-seven patients were included with a median age of 65 years and a prostate volume of 46mL. The International Prostate Symptom Score (IPSS) was 23. The first 3 patients were operated on under general anaesthesia. Local anaesthesia was introduced from the fourth patient onwards. There was no recourse to other modalities of analgesia or anaesthesia or interruption of the procedure. The operating time was 10minutes and pain was assessed at 1 on a visual analogue scale. At 3 months, the IPSS score was 9 (P=0.001).

CONCLUSION

This preliminary experience confirms the feasibility of placing the Urolift implant under local anaesthesia without any failure of the proposed management. The improvement in IPSS score was consistent with previously published clinical trials.

LEVEL OF EVIDENCE

3.

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes

Context

Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective

To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence acquisition

A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence synthesis

The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions

Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient summary

We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home  Message

Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

The role of benign prostatic hyperplasia treatments in ejaculatory dysfunction

Ejaculatory dysfunction is not only psychologically distressing but can become a significant obstacle for men who wish to conceive. Dysfunction comes in the form of anejaculation, reduced ejaculation, retrograde ejaculation, painful ejaculation, or premature ejaculation. Most treatments for lower urinary tract symptoms related to benign prostatic hyperplasia, which commonly occurs in aging men, carry significant risks of absent, reduced, or retrograde ejaculation. This review focuses on such risks that accompany both the medical and surgical management of lower urinary tract symptoms/benign prostatic hyperplasia and how these risks impact male fertility.

Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop

BACKGROUND

The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges.

OBJECTIVES

To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials.

DESIGN

To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout.

SETTING

A workshop to discuss and summarise the existing knowledge and to develop the new guidelines.

RESULTS

To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect.

CONCLUSIONS

The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial.

LIMITATIONS

Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS.

FUTURE WORK

Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space.

FUNDING

Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.

Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis

BACKGROUND

A variety of minimally invasive treatments are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). However, it is unclear which treatments provide better results.

OBJECTIVES

Our primary objective was to assess the comparative effectiveness of minimally invasive treatments for lower urinary tract symptoms in men with BPH through a network meta-analysis. Our secondary objective was to obtain an estimate of relative ranking of these minimally invasive treatments, according to their effects.

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science and LILACS), trials registries, other sources of grey literature, and conference proceedings, up to 24 February 2021. We had no restrictions on language of publication or publication status.

SELECTION CRITERIA

We included parallel-group randomized controlled trials assessing the effects of the following minimally invasive treatments, compared to TURP or sham treatment, on men with moderate to severe LUTS due to BPH: convective radiofrequency water vapor therapy (CRFWVT); prostatic arterial embolization (PAE); prostatic urethral lift (PUL); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model for pair-wise comparisons and a frequentist network meta-analysis for combined estimates. We interpreted them according to Cochrane methods. We planned subgroup analyses by age, prostate volume, and severity of baseline symptoms. We used risk ratios (RRs) with 95% confidence intervals (CIs) to express dichotomous data and mean differences (MDs) with 95% CIs to express continuous data. We used the GRADE approach to rate the certainty of evidence.

MAIN RESULTS

We included 27 trials involving 3017 men, mostly over age 50, with severe LUTS due to BPH. The overall certainty of evidence was low to very low due to concerns regarding bias, imprecision, inconsistency (heterogeneity), and incoherence. Based on the network meta-analysis, results for our main outcomes were as follows. Urologic symptoms (19 studies, 1847 participants): PUL and PAE may result in little to no difference in urologic symptoms scores (MD of International Prostate Symptoms Score [IPSS]) compared to TURP (3 to 12 months; MD range 0 to 35; higher scores indicate worse symptoms; PUL: 1.47, 95% CI -4.00 to 6.93; PAE: 1.55, 95% CI -1.23 to 4.33; low-certainty evidence). CRFWVT, TUMT, and TIND may result in worse urologic symptoms scores compared to TURP at short-term follow-up, but the CIs include little to no difference (CRFWVT: 3.6, 95% CI -4.25 to 11.46; TUMT: 3.98, 95% CI 0.85 to 7.10; TIND: 7.5, 95% CI -0.68 to 15.69; low-certainty evidence). Quality of life (QoL) (13 studies, 1459 participants): All interventions may result in little to no difference in the QoL scores, compared to TURP (3 to 12 months; MD of IPSS-QoL score; MD range 0 to 6; higher scores indicate worse symptoms; PUL: 0.06, 95% CI -1.17 to 1.30; PAE: 0.09, 95% CI -0.57 to 0.75; CRFWVT: 0.37, 95% CI -1.45 to 2.20; TUMT: 0.65, 95% CI -0.48 to 1.78; TIND: 0.87, 95% CI -1.04 to 2.79; low-certainty evidence). Major adverse events (15 studies, 1573 participants): TUMT probably results in a large reduction of major adverse events compared to TURP (RR 0.20, 95% CI 0.09 to 0.43; moderate-certainty evidence). PUL, CRFWVT, TIND and PAE may also result in a large reduction in major adverse events, but CIs include substantial benefits and harms at three months to 36 months; PUL: RR 0.30, 95% CI 0.04 to 2.22; CRFWVT: RR 0.37, 95% CI 0.01 to 18.62; TIND: RR 0.52, 95% CI 0.01 to 24.46; PAE: RR 0.65, 95% CI 0.25 to 1.68; low-certainty evidence). Retreatment (10 studies, 799 participants): We are uncertain about the effects of PAE and PUL on retreatment compared to TURP (12 to 60 months; PUL: RR 2.39, 95% CI 0.51 to 11.1; PAE: RR 4.39, 95% CI 1.25 to 15.44; very low-certainty evidence). TUMT may result in higher retreatment rates (RR 9.71, 95% CI 2.35 to 40.13; low-certainty evidence). Erectile function (six studies, 640 participants): We are very uncertain of the effects of minimally invasive treatments on erectile function (MD of International Index of Erectile Function [IIEF-5]; range 5 to 25; higher scores indicates better function; CRFWVT: 6.49, 95% CI -8.13 to 21.12; TIND: 5.19, 95% CI -9.36 to 19.74; PUL: 3.00, 95% CI -5.45 to 11.44; PAE: -0.03, 95% CI -6.38, 6.32; very low-certainty evidence). Ejaculatory dysfunction (eight studies, 461 participants): We are uncertain of the effects of PUL, PAE and TUMT on ejaculatory dysfunction compared to TURP (3 to 12 months; PUL: RR 0.05, 95 % CI 0.00 to 1.06; PAE: RR 0.35, 95% CI 0.13 to 0.92; TUMT: RR 0.34, 95% CI 0.17 to 0.68; low-certainty evidence). TURP is the reference treatment with the highest likelihood of being the most efficacious for urinary symptoms, QoL and retreatment, but the least favorable in terms of major adverse events, erectile function and ejaculatory function. Among minimally invasive procedures, PUL and PAE have the highest likelihood of being the most efficacious for urinary symptoms and QoL, TUMT for major adverse events, PUL for retreatment, CRFWVT and TIND for erectile function and PUL for ejaculatory function.

AUTHORS' CONCLUSIONS

Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and QoL compared to TURP at short-term follow-up. They may result in fewer major adverse events, especially in the case of PUL and PAE; resulting in better rankings for symptoms scores. PUL may result in fewer retreatments compared to other interventions, especially TUMT, which had the highest retreatment rates at long-term follow-up. We are very uncertain about the effects of these interventions on erectile function. There was limited long-term data, especially for CRFWVT and TIND. Future high-quality studies with more extended follow-up, comparing different, active treatment modalities, and adequately reporting critical outcomes relevant to patients, including those related to sexual function, could provide more information on the relative effectiveness of these interventions.

Holmium Laser Enucleation of the Prostate Following Previous Prostatic Urethral Lift

PURPOSE

To determine the feasibility and operative challenges of holmium laser enucleation of the prostate (HoLEP) in patients with a previous prostatic urethral lift (PUL) procedure.

MATERIALS AND METHODS

A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2021. 793 consecutive HoLEP cases were identified. Data collected included demographics, the time elapsed since previous PUL, number of PUL implants, pre-operative prostate size, intra-operative complications/challenges, and post-operative follow-up.

RESULTS

22 men with a mean pre-operative prostate size of 90 grams (range 32-180 g) underwent HoLEP at a median of 14.4 months (range 2.8-48) after PUL. 63.6% (14/22) of cases involved prostates with pre-operative sizes ≥ 80 grams. Three cases involved PUL implant jamming of morcellator blades which required replacing the blades. 15 cases (68.2%) required using a grasper or a basket device to remove free PUL implants or adenoma parts with PUL implants embedded in them. One patient needed a second procedure to remove a relatively large piece of calcified adenoma. non-post-PUL HoLEP was more time efficient than post-PUL HoLEP (0.77 ml/min versus 0.55 ml/min respectively). There was no difference in functional outcome between post-PUL and non-post-PUL HoLEP cases.

CONCLUSIONS

While HoLEP can be performed safely and effectively in the PUL failure population, unique challenges arise. PUL implants may distort prostate anatomy, jam morcellator blades, and may be encountered in aberrant locations. Patients with borderline indications for PUL, should be aware of the possibility of performing HoLEP in case of PUL failure.