Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation

Transperineal Laser Ablation of the Prostate for Symptomatic Benign Prostatic Hyperplasia: Long-Term Follow-Up in 40 Patients

PURPOSE

To evaluate the durability, effectiveness, and safety of transperineal laser ablation (TPLA) of the prostate.

MATERIALS AND METHODS

Patients with symptomatic benign prostatic hyperplasia (BPH) underwent TPLA with a 1,064-nm continuous-wave diode laser. International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), and prostate volume were evaluated at baseline and successive timepoints.

RESULTS

Forty prospectively enrolled patients had follow-up of ≥36 months; median duration of follow-up was 57 months (range, 36-76 months). Compared with baseline, the median reduction in IPSS at 12-month follow-up was 74% (interquartile range [IQR], 60%-81%) (P < .001). Median QoL score at 12 months was improved from 5 (IQR, 4-5) at baseline to 1 (IQR, 0-1) (P < .001). Median PVR at 12 months decreased from 108 mL (IQR, 38-178 mL) to 13.5 mL (IQR, 0-40.5 mL) (P < .001), a median reduction of 88% (IQR, 61%-100%). At 12 months, median prostate volume was significantly reduced from 66 mL (IQR, 48.5-86.5 mL) to 46 mL (IQR, 36-65 mL) (P < .001), a median reduction of 32% (IQR, 21%-45%). For all of these parameters, the benefit of TPLA persisted at last follow-up, and all changes were statistically significant compared with baseline. There were no intraprocedural adverse events; periprocedural adverse events consisted of 1 case of prostatitis and 1 case of urinary tract infection (both Society of Interventional Radiology [SIR] Grade I).

CONCLUSIONS

TPLA for symptomatic BPH produced durable benefits across a range of clinical outcomes and was well tolerated in follow-up at median duration of 57 months.

Transperineal laser ablation (TPLA) of the prostate for benign prostatic obstruction: the first 100 patients cohort of a prospective, single-center study

PURPOSE

Transperineal laser ablation (TPLA) is a new minimally-invasive surgical treatment for patients with benign prostatic obstruction (BPO). We report the perioperative and mid-term functional results of the first 100 consecutively patients undergoing TPLA at our institution.

METHODS

Clinical data from consecutive patients undergoing TPLA at our institution from April 2021 to July 2023 were prospectively collected. Primary endpoints were the postoperative changes in IPSS, QoL and MSHQ 3-item questionnaires and in Qmax and post-void residual volume (PVR).

RESULTS

Overall, 100 consecutive patients underwent the procedure. Median age and prostate volume were 66 (IQR 60-75) years and 50 (IQR 40-70) ml, respectively. In the cohort, 14 (14%) patients had an indwelling catheter and 81 (81%) were under oral BPO therapy at the time of TPLA. Baseline median Qmax (ml/s) and PVR (ml) were 9.1 (IQR 6.9-12) and 90 (IQR 50-150), respectively, while median IPSS and QoL were 18 (IQR 15-23) and 4 (IQR 3-4). At all the follow-up timepoints, the evaluated outcomes on both symptoms and functional parameters showed a statistically significant improvement (p < 0.001). Antegrade ejaculation was preserved in all sexually active patients. No postoperative Clavien-Dindo > 2 complications were recorded.

CONCLUSIONS

TPLA represents a safe option for selected well-informed patients swith LUTS due to BPO. Our prospective study confirms the feasibility and favorable perioperative and functional outcomes in a real-world cohort with heterogenous prostate volumes and patient characteristics.

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

INTRODUCTION AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ejaculation sparing of classic and minimally invasive surgical treatments of LUTS/BPH

BACKGROUND

The surgical landscape for Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH) has evolved with the introduction of Minimally Invasive Surgical Therapies (MISTs), recognizing the impact of sexual function on patients' well-being, and prioritizing ejaculation-sparing approaches.

METHODS

This systematic review explored ejaculation sparing after classic endoscopic procedures and MISTs (iTind, Rezūm, Urolift, Aquablation, and TPLA) and a literature search yielded 41 studies.

RESULTS

While all procedures demonstrated efficacy in improving LUTS/BPH symptoms (IPSS, QoL, Qmax), a subset of studies evaluated ejaculatory function. Positive outcomes were noted, challenging the historical association of BPH surgeries with ejaculatory dysfunction. Variations in study design, patient cohorts, and limited long-term data present challenges. Notably, the lack of baseline specificity, use of alpha-blockers, and non-specific sexual function assessments underscore potential biases.

CONCLUSIONS

Despite limitations, the review tentatively concluded that MISTs, including iTind, Rezūm, Urolift, Aquablation, and TPLA, appear comparable in sparing ejaculation. Long-term studies are essential to validate sustainability, and comparative research should assess trade-offs between MISTs and traditional surgeries. Incorporating patient-reported outcomes and quality of life assessments will enhance future investigations, refining MISTs as standard therapeutic options for LUTS/BPH.

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.

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.