Water vapor thermal therapy for indwelling urinary catheter removal in frail patients

Minimally invasive surgical therapies for benign prostatic hyperplasia in the geriatric population: A systematic review

BACKGROUND

Geriatric patients, prone to adverse events (AEs) and low compliance with drugs, may benefit from minimally invasive surgical therapies (MISTs) for managing benign prostatic hyperplasia (BPH). We evaluated the efficacy, safety, and procedural characteristics of MISTs in geriatric patients with BPH.

METHODS

PubMed/MEDLINE database was systematically searched for relevant articles through October 1, 2023. Eligible studies focused on geriatric patients (≥65 years) with BPH who were treated with MISTs and evaluated follow-up surgical, micturition, and/or sexual outcomes. Studies were included if there was separate reporting for age subgroups ≥65 years, or if the mean age minus standard deviation was ≥65 years, or if the first quartile was ≥65 years.

RESULTS

Out of 292 screened studies, 32 (N = 3972 patients) met inclusion criteria and assessed prostatic artery embolization (PAE), Rezum, GreenLight, holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), diode laser enucleation of the prostate (DiLEP), and Aquablation. Except for Rezum, all MISTs required a planned overnight stay. While PAE and Rezum could be performed under local anesthesia, the other MISTs needed general or spinal anesthesia. Postoperative catheterization duration was longest for PAE (median 14 days) and Rezum (21 days) and shortest for GreenLight (1.9 days). At 12 months postoperatively, all MISTs exhibited significant percent changes in International Prostate Symptom Score (median -69.9%) and quality of life (median -72.5%). Clavien-Dindo Grade 1 AEs ranged widely, with PAE (5.8%-36.8%), Rezum (0%-62.1%), and GreenLight (0%-67.6%) having the largest range, and HoLEP (0%-9.5%), ThuLEP (2%-6.9%), and DiLEP (5%-17.5%) having the smallest. PAE, Rezum, DiLEP, and Aquablation reported no significant changes in the International Index of Erectile Function.

CONCLUSIONS

Although all the MISTs reviewed in this study effectively treat BPH in geriatric patients, differences in procedural characteristics and safety profiles across MISTs were considerable. Physicians should use shared decision-making processes, considering risks and patient characteristics, when choosing a suitable treatment option for their patients.

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.

Real-world four-year functional and surgical outcomes of Rezum therapy in younger versus elderly men

BACKGROUND

Management of urinary symptoms in elderly patients with benign prostatic hyperplasia (BPH) is complex given challenges with medications and invasive surgeries. Rezum, a minimally invasive water vapor therapy, is an emerging alternative. We compare real-world Rezum outcomes between young and elderly patients over 4 years.

METHODS

We retrospectively analyzed a multiethnic population treated with Rezum at a single center between 2017-2019. Patients were stratified into young (<65 years) or elderly (≥65 years) cohorts. International Prostate Symptom Score (IPSS), Quality of Life (QoL), maximum urinary flow rate (Qmax), decisional regret scores, and adverse events (AEs) were assessed at baseline, 1-, 3-, 6-, 12-, and/or 48-months. Descriptive statistics were compared using t-tests, Chi-squared, or Mann-Whitney U tests. Changes in outcomes were assessed using Wilcoxon signed-rank tests, stratified by age.

RESULTS

256 patients - 146 (57%) young and 110 (43%) elderly - were included. The majority were Asian (33.2%) or non-Hispanic Black (28.9%). Significant improvements were observed in the combined cohort at 4-years in IPSS, QoL, and Qmax when compared to baseline (all p < 0.05). Between the age cohorts, there were no significant differences in IPSS, QoL, or Qmax at any follow-up. Within both cohorts, significant improvements in IPSS and QoL were found from baseline to all follow-ups. In the young cohort, Qmax was significantly improved from baseline to all follow-ups while in the elderly cohort, this was observed only at the 3-month follow-up. No significant differences in AEs or regret was found between cohorts. There was no significant difference in 4-year surgical retreatment rates between cohorts (elderly 4.0% vs young 4.4%, p = 0.86).

CONCLUSIONS

There were no significant differences in IPSS, QoL, or AEs between elderly and younger men over 4 years following Rezum, suggesting comparable benefits and risks. Future research is warranted to clarify the impact of Rezum on Qmax in elderly men.

Water Vapor Thermal Therapy in Men With Prostate Volume ≥80 cm3: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine the safety and effectiveness of water vapor thermal therapy (Rezum) in men with large prostate volumes of at least 80cm3.

METHODS

We performed systematic searches for studies of Rezum therapy in men with prostate volume of at least 80 cm3. Meta-analysis outcomes included the International Prostate Symptom Score (IPSS), IPSS Quality of Life (IPSS-QOL), Qmax, postvoid residual, International Index of Erectile Function-Erectile Function (IIEF-EF), and serious (Clavien-Dindo grade III-V) complications, surgical retreatments. Outcomes were analyzed using a random effects meta-analysis model.

RESULTS

The review included 15 studies (11 retrospective) of 471 men with prostate volume at least 80 cm3 treated with Rezum therapy and followed for a median of 6months (range: 3-17months). Rezum therapy resulted in statistically significant improvements in IPSS (mean change: -11.0; 95% CI: -12.2, -9.7; P < .001), IPSS-QOL (mean change: -2.9; 95% CI: -3.5, -2.4; P < .001), Qmax (mean change: 6.5 mL/s; 95% CI: 4.8, 8.2 mL/s; P < .001), and postvoid residual (mean change: -101 mL; 95% CI: -145, -57; P < .001). No change in IIEF-EF was observed (mean change: 0.3; 95% CI: -1.1, 1.6; P = .71). Serious complications occurred in <0.1% (95% CI: 0.0%, 0.4%) and surgical retreatment in 1.2% (95% CI: 0.0%, 3.5%) of patients.

CONCLUSION

Rezum therapy provides a statistically significant and clinically important short-term improvement in lower urinary tract symptoms with low complication rates in men with prostate volume of at least 80 cm3. Long-term outcomes with Rezum therapy in large prostates remain unclear.

Is water vapor thermal therapy safe and feasible in elderly and frail men? The Italian experience

PURPOSE

In recent years, water vapor thermal therapy (WVTT) has spread as minimally invasive technique in lower urinary tract symptoms due to benign prostatic hyperplasia treatment. Even if its safety and feasibility have been largely proved in young men, nobody has proved the same feasibility and safety in the elderly (men older than 75 years old). Our aim is to compare WVTT safety outcomes in men older than 75 with younger men.

METHODS

We prospectively collected data on men who underwent water vapor thermal therapy from 2019. We compared data on operative time, number of injections, intra-operative and post-operative complications, reinterventions rate.

RESULTS

We enrolled 426 patients; among these, 60 were older than 75 years old, 366 were younger. Our cohorts of patients had similar results in terms of intra-operative and post-operative complications. Operative time accounts about 11 min for both groups (p = 0.535), total number of injections was seven for young men and eight for elderly (p = 0.314). We found no intra-operative complications in elderly men group and only one in the younger group (p = 0.678), while five younger men underwent clot retention, and two elderly men experienced this complication (p = 0.239). Only one transfusion occurred in the elderly group. No differences between groups occurred in terms of length of stay, post-operative urinary retention and reintervention rate, while catheterization time was longer in the elderly men.

CONCLUSION

WVTT is a safe procedure in elderly patients with comparable intra-operative and post-operative complication rate in comparison with younger patients.

Rezŭm water vaporization therapy versus transurethral resection of the prostate in the management of refractory urine retention: matched pair comparative multicenter experience

PURPOSE

To compare the efficacy of Rezūm with a matched cohort of patients undergoing transurethral resection of the prostate (TURP) for catheter-dependent urine retention secondary to benign prostate hyperplasia (BPH).

METHODS

A retrospective review was performed for consecutive catheter-dependent patients who underwent Rezūm for BPH. Patients were matched and compared with a similar cohort undergoing TURP, using non-inferiority analysis on propensity score-matched patient pairs. Patients were followed up at 1, 3, 6 and 12 months by international prostate symptoms score (IPSS), quality of life (QoL) index, peak flow rate (Qmax) and postvoid residual urine (PVR).

RESULTS

Eighty-one patients undergoing Rezūm were compared with equal number of matched patients who undergoing TURP. Patients undergoing Rezūm experienced significantly shorter operation time (25.5 ± 8.7 vs. 103.4 ± 12.6 min; p < 0.001), lower intraoperative bleeding (2.4% vs. 20.7%, p < 0.001), shorter hospital stay (1.2 ± 0.9 vs. 2.4 ± 1.3 d, p < 0.001) and longer catheter time (12.6 ± 6.0 vs. 2.3 ± 1.2 d, p < 0.001), with no need for transfusion. Successful postoperative voiding was comparable between both arms (90.2% vs. 92.7%, p = 0.78), respectively. Despite patients undergoing TURP had significantly better voiding outcomes after 1 and 3 months, both groups were comparable after six and 12 months in terms of mean IPSS (11.1 ± 6.4 vs. 10.8 ± 3.4, p = 0.71), QoL indices (2.4 ± 1.6 vs. 2.1 ± 2.3, p = 0.33) and Qmax (22.0 ± 7.7 v. 19.8 ± 6.9 ml/sec, p = 0.06).

CONCLUSION

This study supports the safety and efficacy of Rezūm in the management of catheter-dependent patients secondary to BPH, with comparable functional outcomes to TURP. Until a randomized clinical comparison is available, long-term data are crucially recommended to compare the recurrence and reoperation rates.

Prospective Trial of Water Vapor Thermal Therapy for Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia in Subjects with a Large Prostate: 6- and 12-month Outcomes

Background

Current guidelines recommend Rezūm water vapor thermal therapy for the treatment of benign prostatic hyperplasia (BPH) for prostate glands ranging in volume from 30 to 80 cm3. Few prospective studies have specifically evaluated the use of Rezūm for larger prostates.

Objective

To evaluate the safety and efficacy of water vapor thermal therapy in patients with a prostate gland >80 cm3 and ≤150 cm3.

Design setting and participants

In this prospective, single-arm study at seven centers in the USA, subjects were males aged >50 yr with symptomatic BPH and prostate volume of >80 cm3 and ≤150 cm3.

Intervention

Rezūm was used to deliver sterile water vapor via a transurethral approach to ablate targeted areas of prostate tissue.

Outcome measurements and statistical analysis

The primary efficacy outcome was response to therapy, defined on a per-patient basis as a ≥30% improvement in International Prostate Symptom Score (IPSS) from baseline to 6 mo. The primary safety outcome was a composite of serious device-related safety events. Secondary outcomes included catheterization for device-related retention. IPSS outcomes over time were analyzed via generalized estimating equations.

Results and limitations

Among 47 eligible patients, prostate volume ranged from 80.8 to 148.1 cm3. All patients completed 6-mo follow-up, and 40/47completed 12-mo follow-up. At 6 mo, 83% were treatment responders according to the primary efficacy endpoint. The mean IPSS improvement at 6 mo was 11.9 ± 7.5 points, reflecting significant improvement. The primary safety outcome was met, with no occurrence of device-related composite safety events. The study is limited by the nonrandomized design and early termination, unrelated to safety or effectiveness.

Conclusions

Our results are consistent with previous findings for prostate glands of up to 80 cm3, and indicate the safety and efficacy of Rezūm for BPH in patients with a larger prostate.

Patient summary

Rezūm therapy, in which water vapor is used to treat targeted areas of the prostate, is currently recommended for patients with benign enlargement of the prostate and a prostate size of up to 80 cm3. We found that this treatment was also effective and safe in patients with a larger prostate of 80-150 cm3.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Procedural Intervention for Benign Prostatic Hyperplasia in Men ≥ Age 70 Years - A Review of Published Literature

Objective

We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥70 years of age.

Methods

A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: "BPH", "elderly", "surgical", "ablation", "resection", "embolization", and "aging".

Results

We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population.

Conclusion

There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population.

Efficacy and safety of Water Vapor Thermal Therapy in the treatment of benign prostate hyperplasia: a systematic review and single-arm Meta-analysis

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common chronic condition among men aged 50 or older, causing voiding and obstructive lower urinary tract symptoms. Water vapor thermal therapy (WVTT) using the Rezūm® system is a new minimally invasive surgical technique that is increasingly reported as a treatment for BPH.

METHODS

The protocol was submitted to the PROSPERO registry. We searched PubMed, Web of Science, Embase, Cochrane Library and ClinicalTrials.gov up to July 29, 2022. Quality assessment was carried out by a 20-item checklist form prepared by the Institute of Health Economics (IHE). Double arcsine transformation was performed to stabilize the variance of the original ratio. When I² > 50%, the random effect model was used to calculate the pooled parameters. Otherwise, the fixed effect model was used. 95% confidence intervals (CIs) were calculated. A leave-one-out sensitivity analysis was performed to evaluate the impact of each study on the pooled outcomes, and finally, Egger's test was used to assess publication bias.

RESULTS

A total of seven single-arm observational studies and one random controlled trial, including 1015 patients, were included. One year after WVTT, the International Prostate Symptom Score decreased by 11.37 (95% CI: -12.53, -10.21), the IPSS Quality of Life scale decreased by 2.59 (95% CI: -2.92, -2.26), the maximum urine flow rate increased by 5.26 ml/s (95% CI: 4.53, 5.99), and the postvoid residual decreased by 13.18 ml (95% CI: -24.32, -2.03). The most common complication was dysuria, with a pooled incidence of 21% (95% CI: 14%, 29%), and the second most common complication was hematuria, with a pooled incidence of 14% (95% CI: 10%, 18%). The pooled incidence of retreatment was 3% (95% CI: 2%, 5%).

CONCLUSIONS

WVTT is an attractive alternative to medication or more invasive surgical procedures and can serve as first-line therapy for men with BPH.