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

Preservation of sexual function with blue laser vaporization in the treatment of benign prostatic hyperplasia: a prospective study

OBJECTIVE

Sexual function preservation is a paramount concern for patients undergoing benign prostatic hyperplasia (BPH) surgery, increasingly recognized by physicians. Blue laser vaporization, a novel approach for BPH treatment, has yet to be thoroughly investigated for its effects on sexual function. This prospective study assesses the impact of blue laser vaporization on sexual function in BPH patients, focusing on patient perceptions.

METHODS

This study prospectively enrolled BPH patients undergoing blue laser vaporization at our hospital since January 2023. We evaluated the treatment's effectiveness and its impact on preserving sexual function using standardized questionnaires. These included the International Index of Erectile Function (IIEF-5), the Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EjD), and both the International Consultation on Incontinence Modular Questionnaire for Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) and its sexual function component (ICIQ-MLUTSsex).

RESULTS

We included 67 BPH patients with a median age of 65 years in this study, monitoring them for over three months. The results indicate that blue laser vaporization significantly improved International Prostate Symptom Score, Quality of Life, and ICIQ-MLUTS scores in BPH patients (p < 0.001), along with a reduction in post-void residual volume (p < 0.001). Importantly, there were no significant changes in the IIEF-5 score, MSHQ-EjD score, and ICIQ-MLUTSsex score, indicating preservation of sexual function post-surgery.

CONCLUSION

Blue laser vaporization effectively alleviates lower urinary tract symptoms in BPH patients while preserving erectile and ejaculatory functions.

Local anesthesia for Rezūm™: a narrative review of the literature

INTRODUCTION

This narrative review analyzed current practices and protocols for local anesthesia in Rezūm™ and evaluated the feasibility, pain management, and patient comfort associated with this approach.

EVIDENCE ACQUISITION

We included studies reporting the use of local anesthesia in Rezūm™, focusing on patient comfort and pain levels during the procedure. The literature search was performed in June 2024 using Medline, Cochrane, and Embase databases to identify relevant studies published from January 2015 to June 2024. Searches were restricted to publications in English. Owing the heterogeneity of study outcomes and the non-standardized quality appraisal, a narrative synthesis rather than a quantified meta-analysis of data was performed.

EVIDENCE SYNTHESIS

Four studies were included. Various local anesthesia methods, including transurethral intraprostatic anesthesia with the Schelin catheter and prostatic nerve block associated with cold anesthetic gel, are effective in managing pain and can facilitate the performance of Rezūm™ in outpatient settings. Functional outcomes, including improved Qmax, reduced IPSS and QoL scores, and high catheter independence rates, were reported, with minor complications.

CONCLUSIONS

Rezūm™ performed under local anesthesia is feasible, offering significant advantages in terms of patient comfort and potential for outpatient application. However, the lack of standardized protocols and the need for further research on long-term outcomes and comparative efficacy are critical areas for future investigation. Addressing these challenges could optimize Rezūm™, making them more accessible and cost-effective and potentially shifting BPH management toward more office-based procedures.

Rezūm water vapor therapy vs. thulium laser enucleation for the treatment of benign prostatic hyperplasia in patients with large prostates: a multicenter prospective comparative study

BACKGROUND

Despite the growing body of evidence supporting the use Rezūm in patients with benign prostatic hyperplasia (BPH) and large prostates, comparative studies with the current gold standard in this clinical setting are lacking.

AIM

To compare the efficacy and safety of Rezūm and Thulium Laser Enucleation of the Prostate (ThuLEP) in patients with BPH and large prostates.

METHODS

We conducted a multicenter prospective comparative study. Consecutive patients with prostate volume (PV) ≥ 80 mL undergoing ThuLEP or Rezūm were included. Patient evaluation was performed at baseline and at 3, 6, and 12 months after surgery. International Prostate Symptom Score (IPSS)-Total was chosen as the primary outcome, while International Index of Erectile Function (IIEF-EF), four-item version of Male Sexual Health Questionnaire (MSHQ-EjD Short Form), and postoperative complications Clavien-Dindo (CD) grade ≥ III were selected as the secondary outcomes.

RESULTS

A total of 246 patients were enrolled (126 ThuLEP, 120 Rezūm). Mean (SD) PV was 106.0 (16.5) mL in the ThuLEP group and 101.4 (14.8) mL in the Rezūm group (p = 0.55). Mean (SD) IPSS-Total was statistically significantly lower in the ThuLEP group compared to the Rezūm group at every postoperative time point (p < 0.001); however, the difference between the mean values never reached the Minimal Clinically Important Difference (MCID). IIEF-EF score significantly improved in both groups (p < 0.001), with no significant difference between the two procedures. Significant differences in MSHQ-EjD Function and Bothers in favor of Rezūm were observed at all postoperative time points (p < 0.001). Bleeding with clots requiring reintervention (CD ≥ III) for hemostasis and evacuation occurred in 5 (3.96%) men undergoing ThuLEP and 1 (0.83%) man undergoing Rezūm (p = 0.21).

CONCLUSIONS

Both ThuLEP and Rezūm significantly improve urinary symptoms in patients with BPH and large prostates. ThuLEP appears statistically but not clinically superior to Rezūm in improving LUTS.

Anatomic and Clinical Effects of Focal Laser Ablation of the Prostate on Symptomatic Benign Prostatic Hyperplasia

BACKGROUND/OBJECTIVES

Laser ablation is a promising technique for tissue-debulking in patients with symptomatic benign prostatic hyperplasia (BPH). This study evaluated the effects of focused laser ablation of the prostate (FLA) on urinary symptoms for patients with BPH.

METHODS

Since 2018, 62 patients had bilateral prostate FLA for prostate cancer and/or symptomatic BPH, defined as an international prostate symptom score (IPSS) ≥11, and have 6-month follow-up data. Urinary and sexual health were scored with standardized surveys while imaging defined prostate anatomy. FLA was performed as an outpatient procedure with either transrectal MRI-guided (n = 24) or transperineal ultrasound-guided (n = 38) laser fiber placement to debulk the prostate and/or ablate cancer foci plus margins. Enhanced prostate MRI was performed immediately or up to 2 days later to assess the treatment zones. Follow-up then consisted of PSA levels every 6 months and MRI at 6-12 months and then yearly combined with patient sexual/urinary surveys and clinical assessments.

RESULTS

All patients had technically successful FLA and 6-month clinical and imaging follow-up. At 6-month follow-up, mean IPSS was reduced by 43% relative to baseline (10.4 vs. 18.4), mean prostate volume was reduced by 30% (42.2 vs. 60.5 mL), and mean PSA was reduced by 58% (4.3 vs. 10.2 ng/mL). All of these changes were statistically significant (p ≤ 0.008). Compared with baseline, there was no significant change in the SHIM score at 6 months (16.0 vs. 16.8; p = 0.59). In a subset of patients for whom 12-month data were available, there were significant reductions in PSA (61%; 4.1 vs. 10.5 ng/mL; p < 0.002) and IPSS (45%; 9.9 vs. 17.9; p < 0.002), while the 12-month SHIM score was not significantly different from baseline (15.2 vs. 16.0; p = 0.27). Mean laser irradiation time was 19 min with a mean energy deposition of 13,562 J. The most frequent adverse events were prolonged urinary catheterization in 10 patients (16%) and urinary tract infection in 8 (13%).

CONCLUSIONS

FLA is a safe and effective tissue-debulking technique for patients with symptomatic BPH. This outpatient procedure requires minimal procedure time and can be performed without the need for operating rooms or cystoscopy. Our results are consistent with those of previous studies indicating that FLA preserves sexual function.

Will Aquablation Be the New Benchmark for Robotic Minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia?

BACKGROUND AND OBJECTIVE

Aquablation is included in the European Association Urology guidelines as an alternative surgical technique for prostate resection. The evidence summary states that it is subjectively and objectively as effective as transurethral resection of the prostate (TURP) and enucleation, but concerns remain regarding postoperative bleeding. Our aim was to provide an evidence-based overview of the trials, triumphs, and technical challenges of Aquablation.

METHODS

A literature search in the PubMed, EMBASE, and Scopus databases was performed to identify clinical prospective and retrospective studies and reviews on Aquablation. A total of 54 reports were included. A narrative review of current evidence and an overview of the surgical technique are provided.

KEY FINDINGS AND LIMITATIONS

Aquablation demonstrates excellent short- and long-term functional outcomes, with a good safety profile comparable to that of TURP. The procedure is efficient and safe, even for very large prostates, with sustained improvements in functional outcomes well maintained up to 5 yr. The unique ability to conduct robotically controlled precise ablation of enlarged tissue while maintaining the sphincter makes Aquablation a very good ejaculation-sparing BPH treatment option. Initial issues with hemostasis have been successfully overcome with the use of gentle bladder-neck cautery after the procedure, allowing for early catheter removal. The above features make Aquablation an attractive minimally invasive technique and show that it is noninferior to holmium laser enucleation.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Aquablation is a valid alternative to standard resection techniques, showing excellent long-term functional outcomes, good preservation of sexual function, a good safety profile, and good compliance for all prostate sizes and patient ages. Aquablation is still performed in high-volume centers, but the results can easily be emulated in other centers worldwide.

ADVANCING PRACTICE

Our review indicates that if Aquablation outcomes are emulated globally, this technique could easily become a new benchmark in robotic treatment for BPH.

PATIENT SUMMARY

Aquablation is a safe and effective surgical technique for treatment for benign enlargement of the prostate, with excellent medium-term outcomes. Although long-term studies are needed, the results are promising and challenge the current surgical and laser techniques used to reduce the size of the prostate gland.