Transurethral needle ablation for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia: outcome after 1 year

A systematic review and network meta-analysis comparing Rezūm with transurethral needle ablation and microwave thermotherapy for the management of enlarged prostate

Objectives

We aim to compare efficacy and safety of water vapour therapy (Rezūm), transurethral needle ablation (TUNA) and transurethral microwave therapy (TUMT) for treating men with moderate to severe benign prostatic hyperplasia (BPH) symptoms.

Materials

PubMed/MEDLINE, EMBASE and Cochrane Library were searched from inception to 30 July 2023, followed by reference searching and dual-independent study selection. We analysed only randomized clinical trials. RoB-2, NIH-quality assessment tool and GRADE guidelines were used for quality-of-evidence (QoE) assessment. Relevant prospective studies without a critical risk-of-bias were included.

Results

At 12 months, Rezūm showed similar efficacy to TUNA and TUMT for improvement in International Prostate Symptoms Score - Rezūm versus TUMT: 1.33 points (95% CI: -1.66 to 4.35) favouring TUMT (QoE: Moderate) and Rezūm versus TUNA: 0.07 points (95% CI: -3.64 to 3.88) favouring TUNA (QoE: Low). Rezum had similar outcomes to TUNA and TUMT for Maximum Peak-Flow Rate (Qmax): Rezūm versus TUMT: 1.05 mL/s (95% CI: -4.88 to 2.82) favouring Rezūm (QoE: Low) and Rezūm versus TUNA: 0.37 mL/s (95% CI: -4.61 to 4.21) favouring TUNA (QoE: Low). Furthermore, post-void residual volume (PVR) comparisons demonstrated that Rezūm was similar, or inferior to other techniques at 12 months - Rezūm versus TUMT: 11.20 mL (95% CI: -32.40 to 10.30) favouring TUMT (QoE: Low) and Rezūm versus TUNA: 24.10 mL (95% CI: 2.81 to 45.10) favouring TUNA (QoE: Low). Rezūm also had a similar surgical retreatment rate with TUMT and TUNA up to 3-years - TUMT versus Rezūm RR: 1.21 (95% CI: 0.20 to 15.90) (QoE: Low) and TUNA versus Rezūm showed RR: 1.81 (95% CI: 0.2 to 24.60) (QoE: Low). In the first 12 months after treatment, Rezūm had a higher rate of serious adverse events (Clavien-Dindo ≥ Grade 3) than TUMT and TUNA. TUMT versus Rezūm with RR = 0.53 (95% CI: 0.13 to 3.14) (QoE: Low) and TUNA versus Rezūm with RR = 0.38 (95% CI: 0.04 to 3.49) (QoE: Low).

Conclusions

Moderate to weak evidence suggests that Rezūm is not superior to TUNA and TUMT in all domains studied.

Cost-effectiveness analysis of six therapies for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia

OBJECTIVE

To conduct a cost-effectiveness analysis from payers' perspectives of six treatments for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) and to examine positioning of these modalities in the marketplace for the best use of health care funds and quality-of-life benefits for patients.

METHODS

The economic analysis was conducted with a Markov model to compare combination prescription drug therapy (ComboRx), minimally invasive therapies (MITs) including convective radiofrequency (RF) water vapor thermal therapy (Rezūm®), conductive RF thermal therapy (Prostiva®), and prostatic urethral lift (UroLift®), and invasive surgical procedures including photovaporization of the prostate (Greenlight® PVP) and transurethral resection of the prostate (TURP). Effects assessed with International Prostate Symptom Score, adverse events, and re-treatment rates were estimated from medical literature; treatments effects were modeled using a common baseline score. Starting with each therapy, patients' transitions to more intensive therapies when symptoms returned were simulated in 6-month cycles over 2 years. Incremental cost-effectiveness ratios (ICERs) were calculated for pairs of treatments; uncertainty in ICERs was estimated with probabilistic sensitivity analyses.

RESULTS

ComboRx was least effective and provided one-third of the symptom relief achieved with MITs. UroLift was similar in effectiveness to Prostiva and Rezūm but costs more than twice as much. The cheaper MITs were ~$900 more expensive than the cost of ComboRx generic drugs over 2 years. TURP and PVP provided slightly greater relief of LUTS than MITs at approximately twice the cost over 2 years; typically, they are reserved for treatment of more severe LUTS.

CONCLUSION

The analysis evaluated the costs and symptom relief of six treatment options in the continuum of care from a common baseline of LUTS severity. Identification of treatments for LUTS/BPH that demonstrate cost-effectiveness and provide appreciable symptom relief is paramount as reimbursement for patient care moves from volume-based services to value-based services.

Résultats fonctionnels de la radiofréquence par Prostiva© dans le traitement de l’hypertrophie bénigne de la prostate (HBP) non compliquée résistante aux traitements médicamenteux

Objectif

Évaluer prospectivement les résultats fonctionnels de la thermothérapie prostatique par radiofréquence (Prostiva©) sur la gêne urinaire et la vie sexuelle dans le cadre du traitement d’une hypertrophie bénigne de la prostate (HBP) symptomatique non compliquée résistante aux traitements médicamenteux.

Patients et méthodes

Les patients répondant aux critères d’éligibilité à ce traitement édités selon la HAS ont été traités dans notre unité d’urologie. Ils ont été convoqués de façon systématique à un mois pour un examen clinique et paraclinique (débit urinaire maximum [Qmax], résidu postmictionnel [RPM], International Prostate Symptom Score [IPSS]). Ils ont été contactés en décembre 2009 et soumis à un hétéroquestionnaire téléphonique portant sur des scores de gêne urinaire (IPSS), de qualité de vie (question 8 de l’IPSS), d’évaluation des fonctions sexuelles (IIEF, DAN SEX), et d’évaluation subjective du traitement (échelle de Likert).

Résultats

De décembre 2006 à janvier 2009, 20 patients (âge médian: 63 ans) ont été traités par Prostiva©. Quatre patients ont présenté une rétention aiguë d’urine dans le postopératoire immédiat nécessitant un sondage vésical en urgence. Nous avons réalisé l’évaluation systématique de l’ensemble des patients à un mois et en décembre 2009. Le suivi médian était de 20,6 mois (valeurs maximales [12–37 mois]). On a constaté une amélioration significative de l’IPSS (−6,7 points; IC95= [−10,3; −3,1]), une amélioration des fonctions sexuelles, des scores de qualité de vie, et un sentiment d’amélioration globale des symptômes urinaires (+ 1,08 = amélioré sur l’échelle de Likert). Quatre patients ont été considérés comme des échecs du Prostiva©: trois patients ayant repris un traitement médicamenteux, un patient ayant bénéficié d’une résection de la prostate.

Conclusion

Notre étude monocentrique réalisée chez des patients sélectionnés selon les critères de l’HAS a conforté les résultats de la littérature avec des résultats positifs sur la gêne urinaire, une faible morbidité et une amélioration de la qualité de vie déclarée. Elle a démontré l’innocuité de la thermothérapie sur la sexualité des patients et mieux encore, l’impact positif du traitement sur la qualité des érections et la satisfaction des rapports.

[Tuna: clinical retrospective study addressing mid-term outcomes]

PURPOSE

To estimate the efficiency and morbidity of the radiofrequency (Tuna) for treatment of symptomatic benign prostatic hyperplasia (BPH) in patients with medical treatment failure.

MATERIAL AND METHODS

Between September 2003 and July 2007, 31 patients, mean age 59,5 years (50-76), were treated for BPH with Tuna. Patients had initially received medical treatment, which happened to fail and Tuna was offered as surgical treatment. Available clinical data of 28 patients was retrospectively analyzed. Mictionnel status was estimated with International Prostatic Symptoms Score (IPSS), urinary peak flow (UPF) and post void residual urine (PVR). Quality of life issues were also addressed. Efficiency of treatment was estimated on the evolution of these parameters after an average follow-up of 20 months (5-47). To estimate morbidity of treatment, peroperative and late complications were assessed.

RESULTS

Twenty-eight patients were included in the study. At a mean follow-up of 20 months, a significant improvement of the mictionnel status was found for the IPSS, the quality of life, the Qmax (p<0,001) and the PVR (p<0,005) and quality of life. Morbidity was verified as minimal in the series. At a follow-up period of 20 months, 15 patients (53,6%) had stopped medical treatment, 10 patients (35,7%) pursued medical treatment and three patients (10,7%) had undergone another type of surgical treatment for BPH. The rate of re-treatment in the series was 46,4%. Among the group of patients without any medical treatment (15 patients), 10 patients reported satisfactory quality of life.

CONCLUSION

Tuna is a technique with significant good results for the treatment of LUTS-BPH. The main advantage of this technique is its low morbidity, however, the rate of retreatment was observed as high. Series of patients with long-term follow-up should provide evidence to objectively define the role of Tuna in BPH surgical treatment.

Transurethral needle ablation of the prostate

PURPOSE OF REVIEW

The review aims at reviewing the evidence published in the peer review literature or otherwise available with particular focus on articles published over the last 2 years on the transurethral needle ablation of the prostate in the treatment of benign prostatic hyperplasia. Prospective noncomparative and comparative studies as well as meta-analyses were considered. Information from the European Real Life database on transurethral needle ablation was also included.

RECENT FINDINGS

The evidence currently available confirms a clinically relevant improvement of lower urinary tract symptoms and quality of life. Impact on voiding dynamics including flow rates, detrusor pressure at maximum flow and postvoid residual, as well on prostate volume, remains marginal.

SUMMARY

All major guidelines in the management of lower urinary tract symptoms in patients with benign prostatic enlargement include transurethral needle ablation of the prostate as a valuable treatment option in patients with severe symptoms and low degree of bladder outlet obstruction, patients at high risk for surgery and patients who wish to avoid surgery or regional/general anaesthesia.

Systematic review and meta-analysis of Transurethral Needle Ablation in symptomatic Benign Prostatic Hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) constitutes a major clinical problem. Minimally invasive therapies for the treatment of symptomatic BPH include Transurethral Needle Ablation (TUNA), but it is unclear what impact this technique has on the disease and its role among other currently available therapeutic options. The objective of this study is to ascertain the efficacy and safety of TUNA in the treatment of BPH.

METHODS

Systematic review of the literature until January 2005 and meta-analysis of clinical studies assessing TUNA in symptomatic BPH. Studies were critically appraised. Estimates of effect were calculated according to the random-effects model.

RESULTS

35 studies (9 comparative, 26 non-comparative) were included. Although evidence was limited by methodological issues, the analysis of relevant outcomes indicates that while TUNA significantly improves BPH parameters with respect to baseline, it does not reach the same level of efficacy as TURP in respect to all subjective and objective variables. Further, its efficacy declines in the long-term with a rate of secondary-treatment significantly higher than of TURP [OR: 7.44 (2.47, 22.43)]. Conversely, TUNA seems to be a relatively safe technique and shows a lower rate of complications than TURP [OR:0.14 (0.05, 0.14)] with differences being particularly noteworthy in terms of postoperative bleeding and sexual disorders. Likewise, TUNA has fewer anesthetic requirements and generates a shorter hospital stay than TURP [WMD: -1.9 days (-2.75, -1.05)]. Scarce data and lack of replication of comparisons hinder the assessment of TUNA vs. other local therapies. No comparisons with medical treatment were found.

CONCLUSION

The body of evidence on which TUNA has been introduced into clinical practice is of only moderate-low quality. Available evidence suggest that TUNA is a relatively effective and safe technique that may eventually prove to have a role in selected patients with symptomatic BPH. TUNA significantly improves BPH parameters with respect to baseline values, but it does not reach the same level of efficacy and long-lasting success as TURP. On the other hand, TUNA seems to be superior to TURP in terms of associated morbidity, anesthetic requirements and length of hospital stay. With respect to the role of TUNA vis-à-vis other minimally invasive therapies, the results of this review indicate that there are insufficient data to define this with any degree of accuracy. Overall cost-effectiveness and the role of TUNA versus medical treatment need further evaluation.

Minimally Invasive Therapy for Benign Prostatic Hyperplasia: Practice Patterns in Minnesota

BACKGROUND AND PURPOSE

Benign prostatic hyperplasia (BPH) affects more than 50% of men by the age of 60 and 90% by age 85. Many of these men are not candidates for surgical procedures such as transurethral resection of the prostate (TURP), stimulating the development of less-invasive forms of therapy. We studied the utilization of these newer therapies by urologists practicing in Minnesota.

MATERIALS AND METHODS

An anonymous questionnaire was sent to 174 members of the Minnesota Urological Society, of which 58 were available for analysis. A case scenario was presented of a patient with BPH refractory to medical therapy. The options were traditional and minimally invasive therapies. The physician was asked to select whether he or she would offer each option and perform the procedure or refer the patient within or outside the practice. Statistical analysis was performed using chi-square and two-sample t-tests on Minitab software. The results were considered significant at P < 0.05.

RESULTS

While 59% of the respondents would offer both minimally invasive and traditional alternatives, 10% would offer only minimally invasive therapy, while 29% would offer only traditional therapy (P = 0.01). The most common minimally invasive therapies offered were transurethral microwave thermotherapy and (55%) and transurethral needle ablation (33%). If they offered a form of minimally invasive therapy, the majority of respondents would perform the procedure themselves. Rural urologists were less likely to offer minimally invasive therapy (43%) than metro physicians (81%; P = 0.035). There was no significant difference in the use of minimally invasive therapies by rural and urban urologists (P = 0.409) or urban and metropolitan urologists (P = 0.119). Urologists completing their training between 1960 and 1980 were less likely to offer minimally invasive therapy. There was no significant difference in the likelihood of offering traditional versus minimally invasive alternatives according to the percent of managed care in the practice.

CONCLUSIONS

Urologists closer to the completion of their residency training are more likely to include a minimally invasive technique in their treatment plan, while urologists practicing in rural Minnesota are less likely to offer minimally invasive procedures. Further emphasis should be placed on increasing the availability of minimally invasive techniques in rural settings.