Prostatic Urethral Lift (PUL) for obstructive median lobes: 12 month results of the MedLift Study

Selecting Minimally Invasive Surgical Treatments for Benign Prostatic Hyperplasia: A Clinical Consultation Guide

Optimal patient selection on the basis of prostate size, presence of a median lobe, and patient preferences is key to success for various minimally invasive surgical treatments for benign prostatic hyperplasia (BPH), including Rezūm, UroLift, a temporary implantable nitinol device, prostate artery embolization, and Optilume BPH balloon dilatation.

Clinical application of the UroLift® prostatic urethral lift in Spain: consensus on the treatment of lower urinary tract symptoms associated with urinary flow obstruction and secondary to benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) is an increasingly common pathology in the adult male. BPH increases after the age of 40-45 years, and its management consumes an enormous amount of resources. The UroLift® System is an approved technology designed to treat lower urinary tract symptoms (LUTS) secondary to BPH and is used to perform the prostatic urethral lift (PUL) procedure. Various urology specialists in Spain with experience in PUL have prepared this consensus document. Endorsed by the Spanish Urology Association, its information is based on the most recent findings. The main objective of this document is to disseminate the consensus recommendations among all professionals treating patients with LUTS/BPH. Both primary care physicians and urologists can assess and offer PUL as an effective, minimally invasive treatment.

Complication rate across the minimally invasive surgical treatments (MISTs): where do we stand? A systematic review of the literature

BACKGROUND

Over the past decade, the range of surgical options to benign prostatic obstruction (BPO) has expanded significantly with the advent of minimally invasive surgical therapies (MISTs). Nevertheless, the available evidence in the field is heterogeneous. Efficacy and safety thresholds are yet to be determined.

OBJECTIVE

To evaluate perioperative and long-term complications after MISTs - including Aquablation, steam injection (Rezūm), Transperineal laser ablation of the prostate (TPLA), implantation of a prostatic urethral lift (PUL) and temporary implantable nitinol device (iTIND) - in patients with lower urinary tract symptoms due to BPO.

EVIDENCE ACQUISITION

A systematic literature search was conducted in January 2024 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria (Patients, Interventions, Comparisons, Outcomes) [1], focusing specifically on patients with BPH-associated LUTS who underwent MIST or other comparative treatments, aiming to assess both perioperative and long-term safety outcomes. 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.

EVIDENCE SYNTHESIS

The initial electronic search identified 3660 records, of which 24 ultimately met the inclusion criteria and were included in the analysis. Overall, Aquablation was associated with a higher major complications rate of 14% (IQR 6-22), particularly in the case of patients with prostates <70 ml. PUL showed a higher early postoperative acute urinary retention rate (10.9%, IQR 9.2-12.3%), while 1.4% of patients treated with iTIND experienced major perioperative complications. Urinary tract infections were mostly reported in series assessing TPLA and Rezūm.

CONCLUSIONS

The adoption of MISTs for LUTS due to BPH is associated with a varied spectrum of perioperative and long-term complications. Our findings showed an acceptable safety profile with specific complications dependent on the type of MIST performed, highlighting the importance of individualized patient selection and procedure-specific considerations.

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.

Advances in Outpatient Therapies and Treatment of Benign Prostatic Hyperplasia: A Comprehensive Review for Men's Health

Benign prostate hyperplasia (BPH) affects a large number of men and can be treated with behavioral, medical, or surgical treatments. The newest addition to medical therapy is β3-agonists for overactive lower urinary tract symptoms. Multiple new surgical treatments have become available in the past decade, including several clinic-based minimally invasive surgical techniques (eg, UroLift, Rezum, Optilume BPH), OR treatments (eg, Aquablation, single port robotics), and prostate artery embolization. The growth of options allows providers to better tailor BPH treatment to the specific disease factors and patient preferences.

[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.

Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database

INTRODUCTION AND OBJECTIVES

Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management.

METHODS

A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.

RESULTS

Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%).

CONCLUSIONS

The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

Evaluation of Current Surgical BPH Interventions for Young and Elderly Men

PURPOSE OF REVIEW

Benign prostatic hyperplasia affects the quality of life of a significant number of men, especially as they age. There are continuous innovations in the surgical management of benign prostatic hyperplasia, but many of these innovations are studied in the core population of men 50-70 years of age. This review focuses on the outliers of men aged 18-50 and 70 and older.

RECENT FINDINGS

Older populations have more comorbidities, higher rates of antithrombotic medications, and advanced symptoms. Properly selected older men can safely have significant objective and subjective improvement in their symptoms. The literature was scarce when evaluating younger men; however, ejaculatory preserving techniques are promising providing improvement in symptoms and preserving ejaculation. This review demonstrates that in properly selected elderly patients, improvements in quality of life while also providing safe surgical interventions can be achieved. Ejaculatory preservation techniques demonstrate promising results, but further studies are required to elucidate true outcomes.

[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.

Incidence of Surgical Reintervention for Benign Prostatic Hyperplasia Following Prostatic Urethral Lift, Transurethral Resection of the Prostate, and Photoselective Vaporization of the Prostate: A TriNetX Analysis

Background

Prostatic urethral lift, or UroLift, has gained popularity as a treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). Surgical reintervention rates are a reliable indicator for treatment durability.

Objective

The objective of this study was to utilize TriNetX, a third-party database, to investigate the incidence of surgical reintervention following UroLift, transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) procedures for BPH from 2015 to 2018.

Design setting and participants

Male patients aged 18-100 yr diagnosed with BPH were identified in the TriNetX Diamond Network database between January 2015 and December 2018. Cohorts of individuals undergoing their first UroLift procedure were built using Current Procedural Terminology and International Classification of Diseases 10th Revision codes. TURP and PVP cohorts were built as comparison groups. The cohorts were then queried for subsequent BPH-related procedures.

Outcome measurements and statistical analysis

Reprocedure rates were assessed and descriptive statistics were used.

Results and limitations

The mean age at first-time UroLift was 70.1 ± 9.4 yr (n = 14 343). Cumulative reprocedure rates collected after first-time UroLift included 1 yr after UroLift (5.1%, n = 14 343) and 4 yr after UroLift (16.1%, n = 710), with an average annual increase of +3.6% per year following 1 yr after the procedure. Comparatively, TURP (n = 22 071) and PVP (n = 14 110) had 4-yr reprocedure rates of 7.5% and 7.8%, respectively, during the same timeframe. Limitations include a lack of clinical data and loss of follow-up data outside the Diamond Network.

Conclusions

The reprocedure rate of UroLift at 4 yr is double the rate of TURP and PVP. In appropriately selected patients, UroLift might be a suitable option for those who desire symptomatic relief from BPH with minimal erectile and ejaculatory side effects. However, the risk of secondary surgical intervention should be considered when considering BPH treatments.

Patient summary

We compared the reintervention rates of prostatic urethral lift (PUL), transurethral resection of the prostate (TURP), and photoselective vaporization of the prostate (PVP) using the TriNetX database, and have found that the highest reintervention rates were for PUL of 16% at 4 yr of follow-up, compared with about 8% for those who had TURP and PVP. Interestingly, the most common reintervention was the same operation at 1 yr. This has important implications when counseling patients about the durability of these various outlet procedures for BPH.

Water vapor thermal therapy: Technical variations among spanish hospitals and efficacy at 2-year follow-up

AIM

The aim of this work is to evaluate the initial experience with water vapor thermal therapy (WVTT) for benign prostatic hyperplasia (BPH) in Spanish university hospitals, as well as to describe the differences in technique and follow-up between centers.

MATERIALS AND METHODS

This retrospective observational multicenter study collected baseline characteristics, surgical, postoperative and follow-up data at 1, 3, 6, 12 and 24 months, including validated questionnaires, flowmetric variations, complications, and the need for pharmacological or surgical treatment following the procedure. Possible triggers for postoperative acute urinary retention (AUR) were also analyzed.

RESULTS

A total of 105 patients were included. No differences were observed between the groups with and without AUR with respect to catheterization time (5 and 4.3 days respectively, P=.178), or prostate volume (47.9g and 41.4g respectively, P=.147). The mean improvement at 3, 6, 12 and 24 months in terms of peak flow was 5.3, 5.2, 4.2 and 3.8ml/s, respectively. As for ejaculation, an improvement was observed after 3 months of follow-up and was maintained over time.

CONCLUSIONS

Minimally invasive treatment for BPH with WVTT shows good functional outcomes at 24 months follow-up, without significant impairment of sexual function and a low incidence of complications. There are minor inter-hospital variations, mainly in the immediate postoperative period.

The prostatic middle lobe: clinical significance, presentation and management

The role of the prostatic middle lobe in the presentation and management of benign prostatic hyperplasia (BPH) is under-appreciated. Middle lobe enlargement is associated with intravesical prostatic protrusion (IPP), which causes a unique type of bladder outlet obstruction (BOO) via a 'ball-valve' mechanism. IPP is a reliable predictor of BOO and the strongest independent factor for failure of medical therapy necessitating conversion to surgical intervention. Men with middle lobe enlargement tend to exhibit mixed symptoms of both the storage and the voiding types, but symptomatology will vary depending on the degree of IPP present. Initial assessments such as uroflowmetry and post-void residual volumes are inadequate to detect IPP and could confound the clinical picture. Radiological evaluation of prostate morphology is key to assessment as it provides important prognostic information and can help with operative planning. Treatment strategies employed for BPH should consider the shape and morphology of prostate adenomata, specifically the presence of middle lobe enlargement and the degree of associated IPP.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Persistent need for ongoing medical or surgical therapy despite UroLift: Data from an academic center

INTRODUCTION

The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6% at five years. We assessed the proportion of patients who had ongoing medical or surgical BPH management following PUL.

METHODS

With institutional review board approval, cases of PUL performed from 2015-2020 at our academic institution were retrospectively reviewed for management of BPH following PUL.

RESULTS

A total of 209 men were identified, with followup available for 198 (95%). Mean age was 68.9 years and mean followup was 18.5 months. Mean prostate size was 43 g. Patients were discharged from recovery in 97% of cases, with 29% discharged with indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I-II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life subscore (QoL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits within 30 days of the procedure occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. In followup, α-blockers and/or 5α-reductase inhibitors were continued or initiated postoperatively for 44% of men; 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4-56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05).

CONCLUSIONS

Most men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term.

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.

Complications associated with minimally invasive surgical therapies (MIST) for surgical management of benign prostatic hyperplasia: a Manufacturer and User Facility Device Experience (MAUDE) database review

PURPOSE

MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures.

METHODS

The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures.

RESULTS

We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment.

CONCLUSION

MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process.

Six novel minimally invasive therapies for benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in men. When drug treatment is ineffective or conventional surgery is not suitable, novel minimally invasive therapies can be considered. These include prostatic urethral lift, prostatic artery embolisation, water vapor thermal therapy, Aquablation-image guided robotic waterjet ablation, temporary implantable nitinol device and prostatic stents. These novel therapies can be performed in outpatient setting under local anesthesia, with shorter operative and recovery times, and better protection of ejaculatory function and erectile function. General conditions of the patient and advantages and disadvantages of the each of these therapies should be fully considered to make individualized plans.

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.

UroLift for Treating Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: A NICE Medical Technology Guidance Update

Lower urinary tract symptoms (LUTS) commonly occur as a consequence of benign prostatic hyperplasia (BPH), also known as prostate enlargement. Treatments for this can involve electrosurgical removal of a section of the prostate via transurethral resection of the prostate (TURP), Holmium laser enucleation of the prostate (HoLEP), or prostatic urethral lift using the UroLift system. The UroLift system implants to pull excess prostatic tissue away so that it does not narrow or block the urethra. In this way, the device is designed to relieve symptoms of urinary outflow obstruction without cutting or removing tissue. National guidance recommending the use of UroLift in the UK NHS was first issued in 2015 by the National Institute for Health and Care Excellence (NICE MTG26). We now report on the process to update the economic evaluation of UroLift, leading to updated NICE guidance published in May 2021 (NICE MTG58). The conclusions of the available clinical evidence were mixed and suggested that whilst UroLift improves symptoms over time, this improvement is smaller than that of TURP for symptom severity (IPSS) and urological outcomes. However, UroLift appears to be superior to Rezum for symptom severity and measures of erectile dysfunction and ejaculatory dysfunction. The updated economic model estimated that using UroLift as a day-case procedure for people with prostate of volume 30-80 mL creates a saving of £981 per person compared with bipolar TURP, £1242 compared with monopolar TURP, and £1230 compared with HoLEP.

[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.

Outcomes of prostatic urethral lift in a medically complex population at a veterans affairs hospital

Objective

The objective of this study is to report "real-world" outcomes of prostatic urethral lift (PUL) in a medically complex US military veteran population while employing liberalized procedural indications.

Methods

A retrospective review was conducted of patients who underwent PUL at our institution. There were no prostatic size requirements, patients were accepted on anti-platelet/anticoagulant therapy, no benign prostatic hyperplasia (BPH) medication washout was required, and there was no maximum post-void residual PVR. Pre- and post-operative International Prostate Symptom Score (IPSS), uroflowmetry, and PVR were recorded. Statistical comparisons were performed using simple t tests.

Results

From 2013 to 2019, 91 patients underwent PUL. Mean age was 70 (range 55-92) years. The majority of our patients were classified as American Society of Anesthesiologists (ASA) class 3 versus the general population at ASA class 2. Post-operatively, IPSS decreased by an average of 43% (23 to 13, p < 0.001). There was a mean 41% decrease in PVR (179 to 101 cc, p = 0.009), which was durable for a follow-up of up to 54 months. Maximum urinary flow rate improved by an average of 32% (9.3 to 12.3 cc/s, p = 0.003), which was also durable throughout follow- up. Forty-four patients required catheterization pre-operatively and 16 required catheterization post-operatively. Therefore, 27 patients (61.4%) were rendered catheter-free by PUL. Thirty-nine patients were taking antiplatelet medications peri-operatively, and 13 took anticoagulants. Only one patient (on warfarin) experienced hematuria requiring re-admission with catheter placement.

Conclusions

PUL produced effective and durable results in our veteran population, including in patients with significant pre-operative bladder decompensation and those on antiplatelets/anticoagulants.

Large Pelvic Hematoma after UroLift® Procedure for Treatment of BPH with Median Lobe

The UroLift® procedure is a minimally invasive technique used to treat benign prostatic hyperplasia (BPH) in the office or hospital setting. As of 2021, over 200,000 of these procedures have been performed, with an excellent safety profile. We present a case report of a patient who underwent the UroLift® procedure and was found to have a 16.5 cm pelvic hematoma within 16 hours. This study was done as a retrospective chart review. In addition, a comprehensive review of the literature was performed, and all relevant government and company websites were reviewed for thorough evaluation. The patient had an uncomplicated inpatient UroLift® procedure for BPH using 5 implants and was discharged from the hospital without incident. The patient presented to the emergency department with abdominal pain 16 hours after the procedure, and a 16.5 cm pelvic hematoma was found on computerized tomography (CT) scan. Since 2015, there have been 27 cases of pelvic hematoma after UroLift® reported to the United States Food and Drug Administration (FDA), and only 2 cases published in the literature. Our patient required hospital admission for 3 days and 3 units of packed red blood cells, but no surgical exploration or intervention. The procedure was technically successful as it improved the patient's voiding and lower urinary tract symptoms (LUTS) as of 2-month follow-up. Potential etiologies include implant firing depth beyond the extent of the prostate, as well as treatment of the median lobe.

Meta-analysis with individual data of functional outcomes following Aquablation for lower urinary tract symptoms due to BPH in various prostate anatomies

OBJECTIVES

To evaluate functional outcomes following Aquablation in various prostate volume and anatomical subgroups.

DESIGN

A meta-analysis with individual patient data undergoing Aquablation therapy from four prospective, global, clinical studies that have been conducted with Aquablation; WATER, WATER II, FRANCAIS WATER and OPEN WATER.

SETTING

Australia, Canada, Lebanon, Germany, New Zealand, UK and the USA.

PARTICIPANTS

425 men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with 1-year follow-up.

INTERVENTIONS

Aquablation therapy is an ultrasound guided, robotically executed waterjet ablative procedure for the prostate.

MAIN OUTCOME MEASURES

The analyses focus International Prostate Symptom Score (IPSS), uroflowmetry, postoperative Incontinence Severity Index (ISI) and surgical retreatment.

RESULTS

425 men with prostates ranging in size from 20 to 150 mL underwent Aquablation therapy. The outcomes from the seven questions in the IPSS questionnaire were grouped by the following; prostates <100 mL, prostates ≥100 mL, prostate anatomy with an obstructive median lobe identifed by imaging, and prostate anatomy without an obstructive median lobe. Regardless of subgroup, all outcomes are consistent and demonstrate a significant improvement from baseline. Specifically, improvements in frequency, urgency and nocturia demonstrated bladder function improvement. Patients entering treatment with severe incontinence, ISI score >4, and regardless of prostate size, showed a reduction in incontinence during patient follow-up. Surgical retreatment due to BPH symptoms occurred in 0.7% (95% CI 0.1%-2.0%).

CONCLUSIONS

Across a variety of prostate anatomies, Aquablation therapy showed remarkable functional improvements following the index procedure. Additionally, men with moderate to severe LUTS/BPH and overactive bladder resulting in urge incontinence showed a reduction in incontinence symptoms postprocedure.

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.

Office-Based Procedures for BPH

PURPOSE OF REVIEW

Benign prostatic hyperplasia (BPH) is a common disease in men. A rapidly rising demand for safe and effective therapy for BPH has generated novel minimally invasive surgical treatments (MISTs). With multiple procedural options in the urology armamentarium for BPH therapy, we describe the current therapies and outcomes for office-based procedures for BPH including quality of life, voiding symptoms, and sexual function.

RECENT FINDINGS

There are three FDA-approved MISTs (Rezūm, Urolift, and iTind) and three emerging MISTs for BPH. Preliminary data suggest improvement in voiding symptoms and quality of life while minimizing unwanted sexual side effects. Long term data is required on the durability and safety of MISTs for BPH. MISTs mark a paradigm shift in BPH management. Sandwiched between conservative medical management and conventional transurethral surgery, these novel technologies promise to combine efficacy approaching that of TURP while sparing the negative side effects. We envision a future where BPH can be diagnosed and treated in an office-based setting with a standard cystoscope in one procedure.

New Technologies for Treatment of Benign Prostatic Hyperplasia

BPH is a common disease in aging men which impacts quality of life. With advancing age expectation coupled with the rising demand for BPH therapy, new technologies have been developed that target rapid recovery and symptom relief, low complication rates, and the ability to perform the procedure in an outpatient setting with local anesthesia. MIST technologies have fostered BPH medical care with ejaculation preservation. Techniques and outcomes for BPH technologies including Aquablation, Rezūm, UroLift, iTind, Optilume BPH, XFLO, Zenflow, and Butterfly are reviewed and evaluated. Given the novelty of these technologies, long-term data are required to assess safety and efficacy.

[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.

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.

Minimally invasive surgery for benign prostatic obstruction: new insights and future technical standards

PURPOSE OF REVIEW

This review aims to give a brief description of the latest minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic obstruction (BPO).

RECENT FINDINGS

In recent years technological advances have made the implementation of MISTs in the armamentarium of BPO surgery possible and in many cases could replace standard procedures.These techniques offer many advantages -short recovery time, rapid symptomatic relief, few adverse effects, lower risk of sexual/ejaculatory dysfunction, acceptable durability and most can be performed as an outpatient procedure.Many of the newer MISTs can be performed outside the operating room under local anesthesia, hence the term office-based MIST.

SUMMARY

A tailored BPO surgical treatment should not only take into account the prostate volume, but also many other factors including possible adverse events and the patient's expectations.Further studies and long-term data are necessary to standardize methods for evaluating the outcomes of these new procedures and to see which will pass the test of time and end-up replacing the gold standard procedures.

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.

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.

An Update on the Outcomes of Patients Treated with Urolift for Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a ubiquitous urologic disease affecting aging men. Patients often experience bothersome lower urinary tract symptoms (LUTS) that warrant urologic evaluation and management. Routinely, patients are initially treated with medical therapies with the goal of both relaxing the bladder neck and shrinking the prostate in order to relieve obstruction secondary to prostatic enlargement. Transurethral resection of the prostate (TURP) serves as a first-line surgical intervention in those who fail medical therapy. Recently, novel minimally invasive surgical techniques for BPH management have emerged. Of these, prostatic urethral lift (PUL or Urolift) has gained attention given its presumed effectiveness and minimal risk of sexual side effects when compared to the standard TURP. The purpose of this review is to describe past and current trends in the implementation of PUL for BPH and to highlight important outcomes.

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

PURPOSE

This study aimed at reporting a head-to-head comparison between water vapor thermal therapy using the Rezūm™ system and prostatic urethral lift using the Urolift™ system in men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

From December 2017 to November 2019, consecutive patients who underwent Rezūm™ and Urolift™ procedures in two urology centers have been retrospectively considered. Only patients with a prostate size less than 80 mL were included. We used the PSM method to adjust baseline differences between both groups. The co-primary endpoint included the change in International Prostate Symptom Score (IPSS) and IPSS- quality of life (QoL) from baseline to 12 months.

RESULTS

A total of 61 (52.1%) and 56 (47.9%) patients underwent Rezum™ and Urolift™ procedures, respectively. After PSM adjustment, 24 patients were included in both groups. No serious adverse events occurred (> Clavien II) in both groups. At 12 months, higher IPSS improvement was observed in the Rezum™ group (median:4 [IQR 3-5]) than in the Urolift™ group (median:8 [IQR 7-12]), without statistical difference (p = 0.08). The improvement in term of QoL at 12 m was similar (p = 0.43). The retreatment rates were 25% (Urolift™) and 8.3% (Rezum™), p = 0.24. Erection and ejaculatory function scores did not change significantly in either treatment group. Results in the full cohort showed that Rezum™ appeared to deliver greater improvements for IPSS and IPSS-QoL (p < 0.001 and p = 0.006, respectively) and lower reintervention rate (p = 0.006) than Urolift™.

CONCLUSIONS

In this small retrospective study, our results indicate that both Rezum™ and Urolift™ provide a clinically significant improvement in symptoms and QoL, although some of these improvements were greater in the Rezum™ arm. Future studies are needed to definitively assess which treatment would be best suited for each patient.

Prostatic urethral lift (UroLift): a real-world analysis of outcomes using hospital episodes statistics

BACKGROUND

To determine real-world outcomes of prostatic urethral lift (UroLift) procedures conducted in hospitals across England.

METHODS

A retrospective observational cohort was identified from Hospital Episode Statistics data including men undergoing UroLift in hospitals in England between 2017 and 2020. Procedure uptake, patient demographics, inpatient complications, 30-day accident and emergency re-attendance rate, requirement for further treatment and catheterization were captured. Kaplan-Meier and hazard analysis were used to analyse time to re-treatment.

RESULTS

2942 index UroLift procedures from 80 hospital trusts were analysed; 85.3% conducted as day-case surgery (admitted to hospital for a planned surgical procedure and returning home on the same day). In-hospital complication rate was 3.4%. 93% of men were catheter-free at 30 days. The acute accident and emergency attendance rate within 30 days was 12.0%. Results of Kaplan Meier analysis for subsequent re-treatment (including additional UroLift and endoscopic intervention) at 1 and 2 years were 5.2% [95% CI 4.2 to 6.1] and 11.9% [10.1 to 13.6] respectively.

CONCLUSIONS

This real-world analysis of UroLift shows that it can be delivered safely in a day-case setting with minimal morbidity. However, hospital resource usage for catheterization and emergency hospital attendance in the first 30 days was substantial, and 12% required re-treatment at 2 years.

New Endoscopic In-office Surgical Therapies for Benign Prostatic Hyperplasia: A Systematic Review

CONTEXT

In recent years, new technologies have been developed to treat benign prostatic enlargement (BPE). Three of these devices may be utilized in office and are promising additions.

OBJECTIVE

To systematically review all clinical trials investigating prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND), with emphasis on clinical efficacy and complications.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed/Medline database in November 2020 according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

EVIDENCE SYNTHESIS

Of 168 articles identified, 18 met the inclusion criteria. Evidence consisted of few randomized controlled trials, and multiple single-arm prospective and retrospective studies. Among the three modalities, PUL demonstrates rare occurrence of serious complications but higher retreatment rates at short- and long-term follow-up. WVTT offers lower retreatment rates with a similar safety profile. TIND studies report varying rates of retreatment and complications. All technologies offer low rates of erectile and ejaculatory dysfunction, although the risk appears to be highest for WVTT (<10.8%).

CONCLUSIONS

Among the emerging technologies introduced to treat BPE, the in-office PUL, WVTT, and TIND systems are valuable additions to the current surgical options. These systems offer unique advantages that should be considered in the shared decision-making process.

PATIENT SUMMARY

In this report, we identified all clinical trials reporting on the efficacy and safety of the in-office prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND) systems for the treatment of benign prostatic enlargement. We found that PUL and WVTT demonstrate acceptable outcomes in terms of functional improvement, retreatment, and complications. More data with longer follow-up are required to further evaluate TIND, but early results are promising.

Putting Patients Ahead by Leaving Nothing Behind: An Emerging Treatment Paradigm in Minimally Invasive Surgical Therapy for Benign Prostatic Hyperplasia

Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) are highly prevalent in older men. The long-term clinical utility of lifestyle modification and oral medications for LUTS is limited. There is a great clinical need for safe, effective, and durable BPH therapies for men who unsuccessfully attempt conservative measures. Enthusiasm for transurethral resection of the prostate has declined due to surgical risk, high rates of postoperative sexual dysfunction, and the perceived invasive nature therein. Consequently, interest has grown in developing minimally invasive surgical treatments (MISTs) that are efficacious but with a more favorable risk profile in order to better align with patient preferences. This review evaluates currently available MISTs for BPH. Further, we critically examine a "Leave Nothing Behind" philosophy in MIST for BPH since implantation of permanent metallic devices may be associated with increased long-term failure rates.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

Prostatic Urethral Lift in Patients With Obstructive Median Lobes: A Single Surgeon Experience at an Academic Center

OBJECTIVE

To examine the long-term efficacy of prostatic urethral lift (PUL) for treating men, with or without an obstructive median lobe (OML), who suffer from lower urinary tract symptoms attributed to benign prostatic hyperplasia.

MATERIALS AND METHODS

A retrospective review was performed on all consecutive PUL cases with or without OML from October 2017 to November 2019 by a single academic surgeon. Outcomes were measured using the International Prostate Symptoms Survey (IPSS) with quality of life (QoL) scores. Comparative testing and mixed-effects linear regression analysis were utilized with significance set at α = 0.05 and performed with Stata (College Station, TX).

RESULTS

A total of 110 PUL procedures were performed on 106 patients (4 repeat surgeries) with a median age of 66.5 (interquartile range: 60.4-73.7). Twenty-three patients (21.7%) had an OML. Following PUL, patients in both groups showed significant improvements in IPSS (P <.001) and QoL (P <.001) scores. When stratifying by OML and controlling for confounding, IPSS scores in both groups displayed statistically significant improvement at follow-up visits, with no statistically significant intergroup difference (P = .32). The same held true for QoL improvements, with no statistically significant difference between groups (P = .18). The presence of an OML resulted in minimal effects on perioperative outcomes and complications but required significantly more implants (P = .008).

CONCLUSION

PUL is a minimally invasive procedure effective at reducing lower urinary tract symptoms and improving the lives of men with benign prostatic hyperplasia without incurring risks of serious complications. These improvements were equivalent and upheld in patients who presented with OML.

Urethral Lift as a Safe and Effective Procedure for Prostatic Hyplasia Population: A Systematic Review and Meta-Analysis

Background: Prostatic urethral lift (PUL) is a relatively new minimally invasive treatment procedure for benign prostatic hyperplasia (BPH). In order to analyze the sustainability of this new protocol, a systematic review and meta-analysis is performed based on the published articles.

Methods: We performed a critical review according to the preferred reporting items for systematic review and meta-analysis (PRISMA) and MOOSE guidelines. A total of 818 published articles matched our search terms, and 11 studies met the inclusion criteria. Data of each follow-up time point (1, 3, 6, 12, and 24 months) were analyzed in terms of baseline characteristics and functional and sexual health outcomes. The merged means of each time point were calculated using R package meta and shown in the tendency plot.

Results: A total of 1,443 patients who underwent PUL are available for the research. At 24 months, the changes of the three indicators are statistically significant (IPSS 9.40 points, p < 0.001; Qmax 3.39 ml/s, p < 0.001; QoL 1.99 points, p < 0.001) but were not as effective as TURP (from literature). The trend plot shows that, as time goes on, the effect of PUL tends to increase first and then weaken. Three items fitted a meaningful curve: IPSS (slope = −1.378 t = −12.395, p < 0.001), Qmax (slope = −1.382 t = −6.429, p < 0.001), and QoL (slope = −0.218, t = −10.058, p < 0.001). Fitted curves of SHIM and PVR are not statistically significant. The regression reveals that IPSS, Qmax, and QoL could be predicted after accepting PUL.

Conclusion: PUL appears to be a safe and effective procedure in selected patients with BPH and can improve the symptoms of urinary tract obstruction. However, it is not as effective as TURP and shows no influence to the objective indicators like PVR.

Prostatic Urethral Lift Versus Medical Therapy: Examining the Impact on Sexual Function in Men with Benign Prostatic Hyperplasia

BACKGROUND

Sexual dysfunction is a common side effect of medical therapy for benign prostatic hyperplasia (BPH), whereas prostatic urethral lift (PUL) offers safe and effective relief of lower urinary tract symptoms while preserving sexual function.

OBJECTIVE

To compare the long-term impact on sexual health of PUL or daily medical therapy of doxazosin or finasteride alone or in combination in BPH patients.

DESIGN, SETTING, AND PARTICIPANTS

This was a comparative analysis of sexual function outcomes from PUL studies (L.I.F.T. [n=107], Crossover [n=42], and MedLift [n=39]) and the Medical Therapy of Prostatic Symptoms (MTOPS) trial. The men included were sexually active with International Prostate Symptom Score ≥13, Qmax ≤12ml/s, and prostate volume 30-80 cm³. MTOPS subjects completed the Brief Male Sexual Function Inventory, while PUL subjects completed the International Index of Erectile Function and the Male Sexual Health Questionnaire for Ejaculatory Function.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Mean percentage changes from baseline in erectile, ejaculatory, and sexual satisfaction domains were compared at 12, 24, 36, and 48 mo.

RESULTS AND LIMITATIONS

PUL significantly improved erectile function through 24 mo, and ejaculatory function and sexual satisfaction across all time points. Medical therapy did not improve sexual function at any time point. Finasteride significantly decreased erectile function at 48 mo, and combined therapy significantly reduced ejaculatory function at 12 and 24 mo. Comparatively, PUL was superior to finasteride in preserving erectile function at 24 and 48 mo, and superior to doxazosin and combined therapy at 12 mo. PUL outperformed all three medical therapies at all time points in improving ejaculatory function and sexual satisfaction. Limitations include the use of distinct patient-reported questionnaires and narrowed data on comorbidities that influence male sexual function.

CONCLUSIONS

Indirect comparison reveals that PUL is superior to BPH medical therapy in preserving erectile and ejaculatory function and sexual satisfaction.

PATIENT SUMMARY

In our non-head-to-head study, only patients undergoing PUL for an enlarged prostate experienced improvements in sexual health. Conversely, patients on medical therapy experienced worsening of erectile and ejaculatory function.