24-month durability after crossover to the prostatic urethral lift from randomised, blinded sham

Surgery for benign prostate enlargement in England: 10-year retrospective study of 155 874 patients

OBJECTIVES

To analyse the trend in surgical interventions of benign prostate enlargement (BPE) in the UK National Health Service (NHS) in England (prostatic urethral lift, transurethral water vapour therapy, prostate artery embolisation, photoselective vaporisation of the prostate, transurethral incision of the prostate, holmium laser enucleation of the prostate, transurethral vaporisation of the prostate, transurethral resection of the prostate [TURP], and open surgery) and report prevalence of peri-procedural complications and subsequent risk of re-intervention.

PATIENTS AND METHODS

A retrospective observational study using Hospital Episode Statistics to identify patients with BPE that received their first surgical treatment in any NHS hospital in England between April 2012 and November 2022. Patients were followed longitudinally until the end of the study or date of death. In-hospital (complications, length of stay), and longer-term outcomes (re-admission, re-treatment, death) were reported. A multivariable logistic regression model was built to analyse the relationship between associated odds of in-hospital complication and surgical modality. Kaplan-Meier analysis (stratified by age) and multivariable Cox regression analysis was performed to investigate the relationship between associated risk of re-intervention between treatments.

RESULTS

A total of 155 874 patients underwent their first surgical intervention to treat BPE. Less invasive treatments were associated with significantly decreased odds of in-hospital complication (compared to TURP). The effect of comorbidities and catheter on admission varied between treatments. Re-intervention rate within 5 years for interventions where there was sufficient follow-up varied from 3.1% (2.8-3.4%) to 19.6% (16.1-22.9%), less invasive treatments were associated with a significantly higher risk of re-intervention compared to TURP.

CONCLUSION

There is an increased uptake in minimally invasive treatments that require a shorter hospital stay and are associated with lower odds of treatment-related complications. However, the long-term effectiveness of these treatments varied, which should be taken into consideration by patients, clinicians and commissioners.

Efficacy and safety of prostatic urethral lift according to preoperative urinary retention and prostate volume: A Japanese real-world multicenter data

OBJECTIVES

Prostatic urethral lift (PUL) for benign prostatic hyperplasia has recently been initiated in Asia; therefore, few studies with real-world data have been reported. This study evaluated the efficacy and safety of PUL using Japanese real-world multicenter data.

METHODS

Indications for PUL were based on relevant guidelines in Japan. The preoperative patient status, postoperative progress at 1 and 3 months, and perioperative complications were evaluated. Also, we compared preoperative urinary retention and nonurinary retention patients, and prostate volumes <30, 30 to <50, and ≥50 mL.

RESULTS

A total of 160 patients were included in the study. The mean age was 75 years and the mean prostate volume was 44 mL. The International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual volume significantly improved 1 and 3 months postoperatively compared to preoperatively. The catheter-free rates in the preoperative urinary retention group were 58.1%, 72.1%, 83.7%, and 88.4% on postoperative days 1, 7, 30, and 90, respectively. The catheter-free rates in the nonurinary retention group were 94.9%, 98.3%, and 100% on postoperative days 1, 7, and 14, respectively. The group with a prostate volume ≥50 mL had a longer operation time and used significantly more implants; however, no difference was observed in the postoperative urinary status among the three groups.

CONCLUSIONS

PUL can be considered a safe and effective procedure for both preoperative urinary retention and nonurinary retention patients with prostate volumes <100 mL in older patients with comorbidities.

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.

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.

Initial outcomes and surgical techniques of prostatic urethral lift for benign prostatic hyperplasia in Japan

OBJECTIVES

The prostatic urethral lift (PUL) has been used as a minimally invasive surgery for benign prostatic hyperplasia (BPH) since April 2022 in Japan. This study evaluated the initial outcomes and surgical techniques of PUL for BPH.

METHODS

In this prospective, single-center study, indications were based on the proper use guidelines for PUL in Japan. Preoperative patient status, postoperative progress at 1 and 3 months, and perioperative complications were evaluated. The surgical technique was changed twice, and the subgroup analysis and technique were evaluated.

RESULTS

Of the 50 patients who underwent surgeries performed by a single surgeon, the median age and prostate volume were 71 years and 42.0 mL, respectively. Furthermore, the median operative time and number of implants used were 20 min and 5, respectively. No postoperative fever or severe hematuria requiring reoperation occurred. All patients were discharged from the hospital the day following the PUL, as scheduled. Postoperative International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual volume at 1 and 3 months were significantly improved compared with the preoperative values. A significant improvement in maximum flow rate was observed in the subgroup analysis from 1 month postoperatively in the group with an anterior channel creation focus.

CONCLUSIONS

PUL is effective and safe in cases with prostate volumes of <100 mL. Lifting the bladder neck is important for opening an anterior prostatic urethral channel and improving urinary function during the early postoperative period.

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.

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.

Minimally invasive surgical therapies (MISTs) for lower urinary tract symptoms (LUTS): promise or panacea?

ABSTRACT

The increasing importance of treatment of lower urinary tract symptoms (LUTS), while avoiding side effects and maintaining sexual function, has allowed for the development of minimally invasive surgical therapies (MISTs). Recently, the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia (BPH) to the management of nonneurogenic male LUTS. The aim of the present review was to evaluate the efficacy and safety of the most commonly used MISTs: ablative techniques such as aquablation, prostatic artery embolization, water vapor energy, and transperineal prostate laser ablation, and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device (iTIND). MISTs are becoming a new promise, even if clinical trials with longer follow-up are still lacking. Most of them are still under investigation and, to date, only a few options have been given as a recommendation for use. They cannot be considered as standard of care and are not suitable for all patients. Advantages and disadvantages should be underlined, without forgetting our objective: treatment of LUTS and re-treatment avoidance.

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. [...].

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.

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.

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.

Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function

CONTEXT

Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO).

OBJECTIVE

To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907).

EVIDENCE SYNTHESIS

A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] -0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI -0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD -1.37 pts; 95% CI -3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD -0.80 pts; 95% CI -2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006).

CONCLUSIONS

Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk.

PATIENT SUMMARY

Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

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.

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.

Symptomatic Improvement of Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia: A Comparative Systematic Review and Meta-Analysis of 4 Different Minimally Invasive Therapies

PURPOSE

To review and compare the outcomes of prostatic artery embolization (PAE) with 3 other minimally invasive surgical treatments for benign prostatic hyperplasia, including photoselective vaporization (PVP), prostatic urethral lift (PUL), and water vapor thermal therapy (WV).

METHODS

A literature review was used to identify 35 publications, which included 2,653 patients (studies, patients): PVP (13, 949), PUL (9, 577), WV (3, 330), and PAE (10, 728). The international prostate symptom score (IPSS) and the international index of erectile function (IIEF-5) and quality of life (QOL) scores were recorded at baseline, 6 months, and 12 months. Meta-analyses, pooling the standardized mean difference between scores recorded before and after treatment, were conducted for each modality and time point to assess the magnitude of a therapy's effect to yield pooled effect sizes. A negative score indicates IPSS and QOL improvement. A positive score indicates IIEF-5 improvement.

RESULTS

At 6 and 12 months, the IPSS and QOL were most improved after PVP, followed by that after PAE, PUL, and, lastly, WV (measured only at 12 months). Between 6 and 12 months, the IPSS and QOL improved with PAE and worsened with PVP and PUL. Only PAE demonstrated statistical improvement in the IIEF-5, which improved from 6 to 12 months.

CONCLUSIONS

PVP and PAE resulted in the largest improvements in the IPSS and QOL. Only PAE resulted in improvement of the IIEF-5.

Prostatic Artery Embolization: An Alternative Treatment for Benign Prostatic Hyperplasia

Purpose Prostatic artery embolization (PAE) has emerged as a minimally invasive alternative for patients with prostates >80 mL and has demonstrated lower morbidity rates. We sought to evaluate PAE at a single tertiary medical center. Methods A retrospective review of all patients who underwent PAE was completed. Demographic, clinicopathologic, procedure, and outcome data were collected to include international prostatic symptom score (IPSS) and quality of life (QoL) assessments. Results The pre-PAE mean prostate-specific antigen (PSA) was 8.4 ng/mL, mean prostate volume was 146.9 mL (9% >200 mL), and mean postvoid residual (PVR) was 208.2 mL (21.9% 200–300 mL). IPSS mean was 19.8 and QoL was “mostly dissatisfied.” Following PAE, mean PSA was reduced by 3.2 ng/mL (38.1%, p = 0.3014), the mean prostate volume reduction was 59.2 mL (40.3%, n = 19, p < 0.0001), and the average PVR reduction was 150.3 mL (72.2%, n = 27, p = 0.0002). Average IPSS score was also lower (11.9; 60.1%, n = 25, p < 0.0001) and QoL was reduced to “mostly satisfied” (p < 0.0001). Technical success was 100% with 24% minor morbidities. Conclusion PAE is a successful treatment for patients with BPH resulting in large prostates that are not good candidates for simple prostatectomy, providing optimal care with less operative and postoperative complications.

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.

Post-Surgical Complications After Bladder Outlet Reducing Surgery: An Analysis of The FDA Manufacturer and User Facility Device Experience (MAUDE) Database

OBJECTIVE

To examine voluntary reports in the Food & Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, categorize complications and assign device-related causality with transurethral resection of the prostate (TURP), prostatic urethral lift (PUL), and transurethral water vapor therapy (TWVT).

METHODS

A review was performed using the terms "Urolift," "Rezum," and "transurethral resection of the prostate" between 01/01/2015 and 12/31/2019. Duplicate and incomplete reports were excluded. The Gupta system was used to report complications and device related causality.¹ Pearson's Chi-square analysis was performed to compare minor (Level 1) versus major (Levels 2-4) complications.

RESULTS

A total of 548 events were examined. After removal of duplicates (n = 60), irrelevant reports (n=65), and incomplete information (n = 14), we included 409 events (74.6%). Of the 409 events, 214 were for TURP, 112 for TWVT, and 83 for PUL. In aggregate, 39.4% of events were minor/Level 1 (n=161/409). The proportion of subjects with Level 2-4 complications versus Level 1 complications was significantly higher for PUL than TURP or TWVT [X² (2, N = 408) = 41.4023, P < .00001]. Device causality was attributable to device malfunction in 60.4% of cases (n=247/409).

CONCLUSION

Device malfunction was noted in all groups and 39.4% of these were minor (Level 1). However, the majority of PUL reports noted a Level 3 or 4 complication (50.6%, 42/83), primarily bleeding related. Previous studies have not revealed significant risk of bleeding and suggests a discrepancy between study data and real-world experience that may alter patient counseling practices.

Mechanical and Ablative Minimally Invasive Techniques for Male LUTS due to Benign Prostatic Obstruction: A Systematic Review according to BPH-6 Evaluation

The treatment of male lower urinary tract symptoms (LUTS) due to benign prostatic obstruction represents one of the major interesting aspects in urological clinical practice. Although transurethral resection of the prostate is still considered the surgical gold standard for treatment of benign prostatic hyperplasia with prostate volume <80 mL, various minimally invasive surgical treatments (MITs) have been developed to overcome the limitations of the "conventional" surgery. To date, there are no validated tools to evaluate the surgical outcomes of MITs; however, in the past, BPH-6 has been used for this purpose. In this systematic review, we evaluated the efficacy and safety of MITs according to BPH-6 score system. We focused our attention on MITs based on mechanical devices (prostatic urethral lift and the temporary implantable nitinol device) and techniques for prostate ablation (image guided robotic waterjet ablation and convective water vapor energy ablation). Evidence shows that MITs are capable of leading to an improvement in LUTS without having an overwhelming impact on complications and are a valid alternative to other treatments in patients who wish to preserve their sexual function or in case of inapplicability of conventional surgery. However, comparative studies between these techniques are still missing.

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.

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.

[An update on the most recent mini-invasive surgical and interventional techniques in the management of benign prostatic obstruction]

INTRODUCTION

New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies.

MATERIAL

A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France.

RESULTS

The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries.

CONCLUSION

These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.

Can surgical treatment for benign prostatic hyperplasia improve sexual function? A systematic review

INTRODUCTION

Erectile dysfunction is an established, well known risk of any operative management of benign prostatic hyperplasia (BPH). However, there are some cases reported in which surgical treatment has paradoxically improved erectile function. Here, we present a systematic review of the literature pertaining to the effect of surgery on sexual function, focusing on reports of improvement in erectile function following surgery.

MATERIALS AND METHODS

We searched PUBMED, EMBASE, Web of Knowledge, and SCOPUS databases for the following keywords: (("sexual function" OR "erectile function") AND "improvement" AND "benign prostatic hyperplasia" AND "surgery").

RESULTS

Sixteen studies (total n = 2087) were reviewed which reported a significant improvement in any aspect of erectile function. Ten of these studies had a follow-up period of 12 months or more while five had a follow up less than 12 months. Various surgical methods were included in the 16 studies; however, five reported TURP outcomes specifically. Eleven studies reported outcomes using the International Index of Erectile Function (IIEF). Overall, a further 87 studies showed no significant change and 8 studies showed a significant reduction.

CONCLUSIONS

The majority of studies report no change in erectile function following surgical intervention for BPH. There seems to be no obvious correlating factor between the studies reporting an improvement in erectile function. Further research is needed to guide us in how to consent our patients for erectile function outcomes for BPH surgery.

The STREAM Trial (Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia) 24-Month Clinical and Radiological Outcomes

PURPOSE

To establish factors predictive of success prior to Prostate Artery Embolization (PAE) with MRI imaging.

MATERIALS AND METHODS

A prospective cohort study of 50 patients with Benign Prostatic Hyperplasia (BPH) were treated with PAE in a single institution. Patients had moderate to severe symptoms of BPH refractory to medical management for at least 6 months. Patients were imaged with multiparametric MRI imaging pre-PAE and at 3 months, 12 months and 24 months post-PAE. Clinical success was measured with IPSS, IIEF and EQ-5D-5L quality of life questionnaires.

RESULTS

The technical success was 48/50 (96%).The mean age of the group was 67 (range 54-83). The mean IPSS score pre-PAE was 21 and at 24 months was 8 (p < 0.001). There was no deterioration in erectile function. The mean volume of the prostate post-PAE was reduced at 3 and 12 months post-PAE but not significantly different at 24 months. This did not correlate with the IPSS score. Patients with median lobe enlargement has similar symptomatic improvement as those without median lobe enlargement. Internally within the prostate patients with adenomatous-dominant BPH initially did better than patients with stromal enlargement; however, at 24 months patients with stromal enlargement of the prostate improved greatest. Initial volume of the prostate was not a good predictor of clinical success.

CONCLUSION

PAE is a safe and effective treatment strategy for treating men with BPH. Patients with Adenomatous BPH clinically do better until 12 months but not at 24 months. Initial prostate volume does not affect outcome, and patients with median lobe enlargement do as well as those without.

A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH

PURPOSE OF REVIEW

To explore the sexual outcomes following the novel minimally invasive surgical procedures for benign prostatic hyperplasia- (BPH-) related lower urinary tract symptoms (LUTS), with an emphasis on ejaculatory dysfunction (EjD).

RECENT FINDINGS

A database search with a 10-year time restriction was carried out until February 20, 2020 using MEDLINE through the PubMed Platform evaluating minimally invasive treatment modalities for BPH and their effect on EjD. After the article selection, we retrieved data for men randomized in 19 different studies with results in 40 separate published articles investigating minimally invasive BPH surgery and reporting EjD rates. To date, water vapor thermal therapy or Rezūm, prostatic urethral lift (PUL) or UroLift®, prostate artery embolization (PAE), and Aquablation showed acceptable rates (< 2%) of retrograde ejaculation by 1 year and had very low adverse events related to the procedure. Both PUL and Rezūm demonstrated lower rates when compared with PAE and Aquablation. With comparable sexual side effect profiles postoperatively, clinicians may determine which therapeutic modality is optimal for patients based on efficacy and cost-benefit. Further randomized clinical trials are required to directly compare the effect of novel minimally invasive surgical procedures for BPH-related LUTS on ejaculation and sexual function.

Prostatic Artery Embolization and Sexual Function: Literature Review and Comparison to Other Urologic Interventions

Many interventions to treat men with benign prostatic hyperplasia (BPH) associated lower urinary tract symptoms (LUTS) are associated with sexual side effects or complications, such as hematospermia, erectile dysfunction, or ejaculatory dysfunction. As loss of sexual function can significantly impact quality of life, an optimal treatment for BPH associated LUTS would be one without any sexual dysfunction side effects. Prostatic artery embolization is a minimally invasive treatment for men with BPH associated LUTS. The aim of this paper is to review the effects of prostatic artery embolization on sexual function and compare the sexual side effect profile to the other available BPH procedures.

Reasons for new MIS. Let's be fair: iTIND, Urolift and Rezūm

Purpose

To review and discuss the literature regarding iTIND, Urolift and Rezūm and investigate the precise clinical indications of all three different approaches for their application in benign prostatic hyperplasia (BPH) treatment.

Materials and methods

The PubMed–Medline and Cochrane Library databases were screened to identify recent English literature relevant to iTIND, Urolift and Rezūm therapies. The surgical technique and clinical results for each approach were summarized narratively.

Results

iTIND, Urolift and Rezūm are safe and effective minimally invasive procedures for the symptomatic relief of lower urinary tract symptoms (LUTS) due to BPH. iTIND requires the results of ongoing prospective studies, a long-term follow-up and a comparison against a reference technique to confirm the generalizability of the first pivotal study. Urolift provides symptomatic relief but the improvements are inferior to TURP at 24 months and long-term retreatments have not been evaluated. Rezūm requires randomized controlled trials against a reference technique to confirm the first promising clinical results. However, clinical evidence from prospective clinical trials demonstrates the efficacy and safety of these procedures in patients with small- and medium-sized prostates.

Conclusions

Although iTIND, Urolift, and Rezūm cannot be applied to all bladder outlet obstruction (BOO) cases resulting from BPH, they provide a safe alternative for carefully selected patients who desire symptom relief and preservation of erectile and ejaculatory function without the potential morbidity of more invasive procedures.

A Systematic Review and Meta-analysis of Prostatic Urethral Lift for Male Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

CONTEXT

Recently, prostatic urethral lift (PUL) is being used to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Although preliminary clinical studies on PUL are increasing, the long-term efficacy and safety of this procedure are still not well evaluated.

OBJECTIVE

The objective of our study is to synthesize the existing literature evidence, and make a comprehensive and long-term systematic review for the PUL procedure.

EVIDENCE ACQUISITION

A systematic search was performed from the electronic databases including PubMed, Embase, and OVID. The search period was up to January 1, 2020. Comprehensive retrospective and prospective studies on PUL were collected in accordance with specific inclusion and exclusion criteria. Pooled prostatic symptom scores, sexual health scores, and functional outcomes were calculated by using a fixed or random-effect model.

EVIDENCE SYNTHESIS

Nineteen articles meet our determined inclusion and exclusion criteria, and 11 independent patient series were included in the final analysis. Meta-analysis results indicated improvement after the PUL procedure, including International Prostate Symptom Score improvement of 9.73-12.16 points, BPH Impact Index improvement of 3.74-4.50 points, maximum flow rate improvement of 3.44-4.26 ml/s, and quality of life improvement of 2.20-2.55 points. Postvoid residual volume at most of the intervals was not significantly variable. Data regarding sexual function remained stable or improved slightly during the 24-mo follow-up period. Pooled estimates were largely heterogeneous except for sexual function.

CONCLUSIONS

PUL can continue to relieve prostatic symptoms for 24 mo without causing serious complications. The extremely important advantage of the PUL procedure is that it can preserve or slightly improve sexual function. Longer-term and more comprehensive clinical trials are still needed to further clarify the functional outcomes and cost effectiveness of PUL.

PATIENT SUMMARY

Prostatic urethral lift is an attractive option for selected patients who seek rapid and durable relief of lower urinary tract symptoms with complete preservation of sexual function.

Real-World Evidence of Prostatic Urethral Lift Confirms Pivotal Clinical Study Results: 2-Year Outcomes of a Retrospective Multicenter Study

Introduction: This study expands results from recent prostatic urethral lift (PUL) clinical trials by examining outcomes within a large unconstrained multicenter data set. Methods: Retrospective chart review and analysis of 1413 consecutive patients who received PUL in North America and Australia was performed. International Prostate Symptom Score (IPSS), quality of life (QoL), and maximum urinary flow rate (Qmax) were evaluated at 1, 3, 6, 12, and 24 months post-procedure for all nonurinary retention subjects (Group A) and retention subjects (Group B). Within Group A outcomes were further analyzed using paired t-tests and 95% mean confidence intervals under the following parameters: IPSS baseline ≥13, age, prostate size, site of service, prostate cancer treatment, and diabetic status. Adverse events, surgical interventions, and catheterization rates were summarized in detail. Results: Compared with the randomized controlled prosatic urethral lift (L.I.F.T.) study, subjects in this retrospective study were older and less symptomatic. After PUL, mean IPSS for Group A improved significantly from baseline by at least 8.1 points throughout follow-up. No significant differences were observed between Group A and B follow-up symptom scores. Within Group A, subjects with an IPSS baseline ≥13 behaved similarly to L.I.F.T. subjects. Age, prostate volume, site of service, prior cancer treatment, and diabetic status did not significantly affect PUL outcomes. When completed in a clinic office, PUL resulted in less side effects and catheter placement compared to other sites of service. Previous prostate cancer treatment did not elevate adverse events of high concern such as incontinence and infection. Conclusion: PUL performs well in a real-world setting in terms of symptom relief, morbidity, and patient experience for all studied patient cohorts.

Direct mechanical characterization of prostate tissue-a systematic review

BACKGROUND

Direct mechanical characterization of tissue is the application of engineering techniques to biological tissue to ascertain stiffness or elasticity, which can change in response to disease states. A number of papers have been published on the application of these techniques to prostate tissue with a range of results reported. There is a marked variability in the results depending on testing techniques and disease state of the prostate tissue. We aimed to clarify the utility of direct mechanical characterization of prostate tissue in identifying disease states.

METHODS

A systematic review of the published literature regarding direct mechanical characterization of prostate tissue was undertaking according to PRISMA guidelines.

RESULTS

A variety of testing methods have been used, including compression, indentation, and tensile testing, as well as some indirect testing techniques, such as shear-wave elastography. There is strong evidence of significant stiffness differences between cancerous and non-cancerous prostate tissue, as well as correlations with prostate cancer stage. There is a correlation with increasing prostate stiffness and increasing lower urinary tract symptoms in patients with benign prostate hyperplasia. There is a wide variation in the testing methods and protocols used in the literature making direct comparison between papers difficult. Most studies utilise ex-vivo or cadaveric tissue, while none incorporate in vivo testing.

CONCLUSION

Direct mechanical assessment of prostate tissue permits a better understanding of the pathological and physiological changes that are occurring within the tissue. Further work is needed to include prospective and in vivo data to aid medical device design and investigate non-surgical methods of managing prostate disease.

3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction

OBJECTIVES

To report 3-year follow-up results of the first implantations with a temporary implantable nitinol device (TIND^® ; Medi-Tate Ltd., Or Akiva, Israel) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

In all, 32 patients with LUTS were enrolled in this prospective study. The study was approved by the local Ethics Committee. Inclusion criteria were: age >50 years, International Prostate Symptom Score (IPSS) ≥10, peak urinary flow (Q_max ) <12 mL/s, and prostate volume <60 mL. The TIND was implanted within the bladder neck and the prostatic urethra under light sedation, and removed 5 days later in an outpatient setting. Demographics, perioperative results, complications (according to Clavien-Dindo classification), functional results, and quality of life (QoL) were evaluated. Follow-up assessments were made at 3 and 6 weeks, and 3, 6, 12, 24 and 36 months after the implantation. The Student's t-test, one-way analysis of variance and Kruskal-Wallis tests were used for statistical analyses.

RESULTS

At baseline, the mean (standard deviation, sd) patient age was 69.4 (8.2) years, prostate volume was 29.5 (7.4) mL, and Q_max was 7.6 (2.2) mL/s. The median (interquartile range, IQR) IPSS was 19 (14-23) and the QoL score was 3 (3-4). All the implantations were successful, with a mean total operative time of 5.8 min. No intraoperative complications were recorded. The change from baseline in IPSS, QoL score and Q_max was significant at every follow-up time point. After 36 months of follow-up, a 41% rise in Q_max was achieved (mean 10.1 mL/s), the median (IQR) IPSS was 12 (6-24) and the IPSS QoL was 2 (1-4). Four early complications (12.5%) were recorded, including one case of urinary retention (3.1%), one case of transient incontinence due to device displacement (3.1%), and two cases of infection (6.2%). No further complications were recorded during the 36-month follow-up.

CONCLUSIONS

The extended follow-up period corroborated our previous findings and suggests that TIND implantation is safe, effective and well-tolerated, for at least 36 months after treatment.

Thermo-expandable prostatic stents for bladder outlet obstruction in the frail and elderly population: An underutilized procedure?

Purpose

To report our outcomes with the use of a thermo-expandable metallic intraprostatic stent (Memokath) for patients with bladder outlet obstruction (BOO) secondary to prostatic obstruction, and to assess it is a feasible option for many frail and elderly men unsuitable for surgery.

Materials and Methods

We reviewed patients who underwent insertion of a Memokath stent for BOO over 17 years (January 1999 to December 2015) at one regional center over a long follow-up period (median, 7 years). Patients were selected if they had obstructive urinary symptoms or urinary retention with an indwelling catheter in situ, and were ineligible for transurethral resection of the prostate (TURP) under general or spinal anesthesia. Primary outcomes assessed were the improvement in urinary symptoms and voiding parameters, as well as the ability to void spontaneously if catheterized, along with complications.

Results

One hundred forty-four patients who presented with BOO or urinary retention had a Memokath stent inserted. Ninety patients (62.5%) had a successful stent insertion with a significant difference between the median preoperative (550 mL) and postoperative residual volume (80 mL, p<0.0001). Nearly two-thirds of men (64%) returned to unassisted voiding with no increased risk of complications over time. Fifty-four patients (37.5%) experienced stent failure. Main complications requiring stent removal or repositioning were migration, occlusion, refractory urinary retention and irritative voiding symptoms.

Conclusions

In elderly and frail men with BOO deemed unsuitable to undergo TURP, prostatic stent is a safe and practical alternative to long-term catheterization.

Prostatic Urethral Lift Versus Transurethral Resection of the Prostate (TURP)

Lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) represent one of the most common bothersome conditions impairing quality of life in men. Its management comprises conservative treatment, pharmacotherapy, and various surgical techniques. Medication and surgical procedures provide meaningful relief of LUTS, but their therapeutic efficacy has to be counterbalanced against the associated adverse events and morbidity. With the advent of novel minimally invasive treatment options, the surgical standards are challenged for at least equally effective approaches with a much more favorable safety profile. Clinical randomized controlled trials confirmed that PUL is able to provide rapid and durable relief of LUTS without compromising sexual function. However, in order to define the value and true benefit of a novel technique among established surgical procedures, the direct comparison with the reference method TURP is necessary. This was the main objective of the BPH6 study, which evaluated symptom relief, recovery experience, sexual function, urinary continence, and safety of PUL compared to TURP. Over a 2-year follow-up, no relevant negative impact on erectile function, urinary continence, and treatment-related safety was observed for both procedures. Improvement of LUTS was better after TURP, whereas PUL turned out to be superior in terms of quality of recovery, ejaculatory function, and quality of sleep. PUL can be considered in selected patients with bothersome LUTS, with special interest in the complete preservation of sexual function and a rapid and smooth return to daily activity.

Medium-term efficacy of the prostatic urethral lift

Treatment options for patients with benign prostatic hyperplasia have traditionally revolved around pharmacotherapy or invasive surgery, both of which can negatively impact quality of life (QoL). The quest for a suitable minimally invasive surgical therapy as an alternative to long-term medication or conventional surgery, has seen the development of heat-based therapies, most of which have been dismissed because of post-operative complications and unacceptable re-treatment rates. During the late 1980s and 1990s, mechanical approaches such as transurethral balloon dilation and prostatic urethral stenting were investigated; however, re-treatment rates, encrustation and unacceptable migration rate of stents saw these options fall into disuse. In 2004, a new non-thermal, mechanical approach-the Prostatic Urethral Lift (PUL; UroLift®, NeoTract Inc., Pleasanton, CA, USA) was first investigated as a minimally invasive therapy for men with lower urinary tract symptoms (LUTS) secondary to BPH. A randomised "sham"-controlled clinical trial of PUL commenced enrolment in 2010. Results of 4-year follow-up have recently been published. This paper reviews these results, the latest literature on PUL and places them in perspective with regard to the proposed criteria for the optimal minimally invasive approach to treating LUTs in men with BPH.

Minimally invasive surgical therapies for benign prostatic hypertrophy: The rise in minimally invasive surgical therapies

The prevalence of benign prostatic hypertrophy (BPH) causing bothersome lower urinary tract symptoms increases with our ageing population. Treatment of BPH traditionally begins with medical therapy and surgical intervention is then considered for those whose symptoms progress despite treatment. Minimally invasive surgical therapies have been developed as an intermediary in the treatment of BPH with the aim of decreasing the invasiveness of interventions. These therapies also aim to reduce morbidity and dysfunction related to invasive surgical procedures. Multiple treatment options exist in this group including mechanical and thermo-ablative strategies. Emerging therapies utilizing differing technologies range from the established to the experimental. We review the current literature related to these minimally invasive therapies and the evidence of their effectiveness in treating BPH. The role of minimally invasive surgical therapies in the treatment of BPH is still yet to be strongly defined. Given the experimental nature of many of the modalities, further study is required prior to their recommendation as alternatives to invasive surgical therapy. More mature evidence is required for the analysis of durability of effect of these therapies to make robust conclusions of their effectiveness.