Water vapor thermal therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia: Systematic review and meta-analysis

Minimally invasive connective water vapor energy method for benign prostatic hyperplasia

The Rezūm system has emerged as a promising treatment option for benign prostatic hyperplasia (BPH) by employing endoscopic removal of prostate tissue. This meta-analysis aimed to evaluate the benefits and drawbacks of Rezūm therapy in recent studies. A systematic literature search was conducted in EMBASE, PubMed, and the Cochrane Library databases until December 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search utilized keywords such as water vapor thermal therapy, Rezūm, convective water vapor thermal therapy, and convective radiofrequency water vapor thermal therapy. A total of 21 studies were included in the analysis, comprising 5 prospective randomized studies, 2 case series, 2 randomized controlled trials, 1 crossover study, and 11 retrospective studies. The collective sample involved 2090 patients with a mean follow-up period of 14.42 ± 18.08 (1-72) months and a mean age of 68.12 ± 4.79 years. Significant improvements were reported in the International Prostate Symptom Score (IPSS), quality of life (QoL), maximal flow rate (Qmax), postvoid residual urine volume (PVR), prostate volume (PV), and International Erectile Index Function (IIEF) values. Unlike other BPH treatments that often require general or regional anesthesia, the connective water vapor energy system can be administered with sedo-analgesia and local anesthesia, potentially leading to improved sexual function scores. Considering the relief of symptoms, Rezūm therapy may serve as a viable alternative to transurethral surgery for patients with prostate volumes ranging from <30 to >80 cc.

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.

Longitudinal deterioration in lower urinary tract symptoms after artificial urinary sphincter implantation in patients with a history of pelvic radiation therapy

OBJECTIVES

To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non-irradiated patients.

METHODS

This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non-RT group, respectively) who were treated with primary AUS implantation for post-radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model.

RESULTS

In the RT and non-RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow-up of 38 months, ICIQ-SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non-RT groups. In the RT group, ICIQ-SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non-RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ-SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non-RT group (p < .001, and .015, respectively).

CONCLUSIONS

Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.

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. [...].

Water Vapor Thermal Therapy: Minimally Invasive Treatment for Benign Prostatic Hyperplasia

Water vapor thermal therapy is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that uses steam to ablate prostatic tissue to relieve lower urinary tract symptoms associated with BPH. It is an option for 30 to 80 g prostates in well-selected patients, and may avoid sexual side effects seen in other more invasive BPH treatments. It is a simple procedure with a short learning curve that can be performed in-office under local and oral anesthesia. Water vapor therapy should be offered to ideal candidates along with information regarding its risks, benefits, and outcomes.

Minimally invasive treatments for benign prostatic hyperplasia: a Cochrane network meta-analysis

OBJECTIVE

To assess the comparative effectiveness and ranking of minimally invasive treatments (MITs) for lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

We searched multiple databases up to 24 February 2021. We included randomized controlled trials assessing the following treatments: convective radiofrequency water vapour thermal therapy (WVTT; or Rezūm); prostatic arterial embolization (PAE); prostatic urethral lift (PUL; or Urolift); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT) compared to transurethral resection of the prostate (TURP) or sham surgery. We performed a frequentist network meta-analysis.

RESULTS

We included 27 trials involving 3017 men. The overall certainty of the evidence of most outcomes according to GRADE was low to very low. Compared to TURP, we found that PUL and PAE may result in little to no difference in urological symptoms, while WVTT, TUMT and TIND may result in worse urological symptoms. MITs may result in little to no difference in quality of life, compared to TURP. MITs may result in a large reduction in major adverse events compared to TURP. We were uncertain about the effects of PAE and PUL on retreatment compared to TURP, however, TUMT may result in higher retreatment rates. We were very uncertain of the effects of MITs on erectile function and ejaculatory function. Among MITs, PUL and PAE had the highest likelihood of being the most efficacious for urinary symptoms and quality of life, TUMT for major adverse events, WVTT and TIND for erectile function and PUL for ejaculatory function. Excluding WVTT and TIND, for which there were only studies with short-term (3-month) follow-up, PUL had the highest likelihood of being the most efficacious for retreatment.

CONCLUSIONS

Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and quality of life compared to TURP at short-term follow-up.

Minimally invasive surgery for benign prostatic obstruction: new insights and future technical standards

PURPOSE OF REVIEW

This review aims to give a brief description of the latest minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic obstruction (BPO).

RECENT FINDINGS

In recent years technological advances have made the implementation of MISTs in the armamentarium of BPO surgery possible and in many cases could replace standard procedures.These techniques offer many advantages -short recovery time, rapid symptomatic relief, few adverse effects, lower risk of sexual/ejaculatory dysfunction, acceptable durability and most can be performed as an outpatient procedure.Many of the newer MISTs can be performed outside the operating room under local anesthesia, hence the term office-based MIST.

SUMMARY

A tailored BPO surgical treatment should not only take into account the prostate volume, but also many other factors including possible adverse events and the patient's expectations.Further studies and long-term data are necessary to standardize methods for evaluating the outcomes of these new procedures and to see which will pass the test of time and end-up replacing the gold standard procedures.

Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis

BACKGROUND

A variety of minimally invasive treatments are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). However, it is unclear which treatments provide better results.

OBJECTIVES

Our primary objective was to assess the comparative effectiveness of minimally invasive treatments for lower urinary tract symptoms in men with BPH through a network meta-analysis. Our secondary objective was to obtain an estimate of relative ranking of these minimally invasive treatments, according to their effects.

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science and LILACS), trials registries, other sources of grey literature, and conference proceedings, up to 24 February 2021. We had no restrictions on language of publication or publication status.

SELECTION CRITERIA

We included parallel-group randomized controlled trials assessing the effects of the following minimally invasive treatments, compared to TURP or sham treatment, on men with moderate to severe LUTS due to BPH: convective radiofrequency water vapor therapy (CRFWVT); prostatic arterial embolization (PAE); prostatic urethral lift (PUL); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model for pair-wise comparisons and a frequentist network meta-analysis for combined estimates. We interpreted them according to Cochrane methods. We planned subgroup analyses by age, prostate volume, and severity of baseline symptoms. We used risk ratios (RRs) with 95% confidence intervals (CIs) to express dichotomous data and mean differences (MDs) with 95% CIs to express continuous data. We used the GRADE approach to rate the certainty of evidence.

MAIN RESULTS

We included 27 trials involving 3017 men, mostly over age 50, with severe LUTS due to BPH. The overall certainty of evidence was low to very low due to concerns regarding bias, imprecision, inconsistency (heterogeneity), and incoherence. Based on the network meta-analysis, results for our main outcomes were as follows. Urologic symptoms (19 studies, 1847 participants): PUL and PAE may result in little to no difference in urologic symptoms scores (MD of International Prostate Symptoms Score [IPSS]) compared to TURP (3 to 12 months; MD range 0 to 35; higher scores indicate worse symptoms; PUL: 1.47, 95% CI -4.00 to 6.93; PAE: 1.55, 95% CI -1.23 to 4.33; low-certainty evidence). CRFWVT, TUMT, and TIND may result in worse urologic symptoms scores compared to TURP at short-term follow-up, but the CIs include little to no difference (CRFWVT: 3.6, 95% CI -4.25 to 11.46; TUMT: 3.98, 95% CI 0.85 to 7.10; TIND: 7.5, 95% CI -0.68 to 15.69; low-certainty evidence). Quality of life (QoL) (13 studies, 1459 participants): All interventions may result in little to no difference in the QoL scores, compared to TURP (3 to 12 months; MD of IPSS-QoL score; MD range 0 to 6; higher scores indicate worse symptoms; PUL: 0.06, 95% CI -1.17 to 1.30; PAE: 0.09, 95% CI -0.57 to 0.75; CRFWVT: 0.37, 95% CI -1.45 to 2.20; TUMT: 0.65, 95% CI -0.48 to 1.78; TIND: 0.87, 95% CI -1.04 to 2.79; low-certainty evidence). Major adverse events (15 studies, 1573 participants): TUMT probably results in a large reduction of major adverse events compared to TURP (RR 0.20, 95% CI 0.09 to 0.43; moderate-certainty evidence). PUL, CRFWVT, TIND and PAE may also result in a large reduction in major adverse events, but CIs include substantial benefits and harms at three months to 36 months; PUL: RR 0.30, 95% CI 0.04 to 2.22; CRFWVT: RR 0.37, 95% CI 0.01 to 18.62; TIND: RR 0.52, 95% CI 0.01 to 24.46; PAE: RR 0.65, 95% CI 0.25 to 1.68; low-certainty evidence). Retreatment (10 studies, 799 participants): We are uncertain about the effects of PAE and PUL on retreatment compared to TURP (12 to 60 months; PUL: RR 2.39, 95% CI 0.51 to 11.1; PAE: RR 4.39, 95% CI 1.25 to 15.44; very low-certainty evidence). TUMT may result in higher retreatment rates (RR 9.71, 95% CI 2.35 to 40.13; low-certainty evidence). Erectile function (six studies, 640 participants): We are very uncertain of the effects of minimally invasive treatments on erectile function (MD of International Index of Erectile Function [IIEF-5]; range 5 to 25; higher scores indicates better function; CRFWVT: 6.49, 95% CI -8.13 to 21.12; TIND: 5.19, 95% CI -9.36 to 19.74; PUL: 3.00, 95% CI -5.45 to 11.44; PAE: -0.03, 95% CI -6.38, 6.32; very low-certainty evidence). Ejaculatory dysfunction (eight studies, 461 participants): We are uncertain of the effects of PUL, PAE and TUMT on ejaculatory dysfunction compared to TURP (3 to 12 months; PUL: RR 0.05, 95 % CI 0.00 to 1.06; PAE: RR 0.35, 95% CI 0.13 to 0.92; TUMT: RR 0.34, 95% CI 0.17 to 0.68; low-certainty evidence). TURP is the reference treatment with the highest likelihood of being the most efficacious for urinary symptoms, QoL and retreatment, but the least favorable in terms of major adverse events, erectile function and ejaculatory function. Among minimally invasive procedures, PUL and PAE have the highest likelihood of being the most efficacious for urinary symptoms and QoL, TUMT for major adverse events, PUL for retreatment, CRFWVT and TIND for erectile function and PUL for ejaculatory function.

AUTHORS' CONCLUSIONS

Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and QoL compared to TURP at short-term follow-up. They may result in fewer major adverse events, especially in the case of PUL and PAE; resulting in better rankings for symptoms scores. PUL may result in fewer retreatments compared to other interventions, especially TUMT, which had the highest retreatment rates at long-term follow-up. We are very uncertain about the effects of these interventions on erectile function. There was limited long-term data, especially for CRFWVT and TIND. Future high-quality studies with more extended follow-up, comparing different, active treatment modalities, and adequately reporting critical outcomes relevant to patients, including those related to sexual function, could provide more information on the relative effectiveness of these interventions.

Rezum therapy, a feasible and safe treatment for the larger prostate

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Rezum is a novel approach to treating BPH symptoms in patients with prostates <80 cc while maintaining sexual function.

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Based on our case, Rezum may also be considered as a MIT for BPH in patients with larger prostates, with a good safety profile.

Benign prostatic hyperplasia (BPH) is the leading cause of Lower Urinary Tract Symptoms (LUTS) in men worldwide. Urinary frequency, nocturia and incomplete emptying are common symptoms experienced by men with BPH, which significantly reduce their quality of life. Treatment for this dysfunction includes surgical and non-surgical modalities such as watchful waiting, lifestyle modification and medication. Historically, Transurethral Resection of the Prostate (TURP) had been considered the gold standard mainstay of treatment; however, in recent years, minimally invasive techniques which offer similar outcomes, fewer complications and cost-effectiveness have gained popularity. Rezum, is a relatively new minimally invasive modality used to treat BPH which has been recommended for prostate volumes of ≤80 cc. Herein, we present a successful case of managing BPH in a middle-aged patient with a prostate volume of 186 cc.

Analysis of the relationship between asthma and benign prostatic hyperplasia: A STROBE-compliant study

The purpose of this study was to evaluate the association between asthma and benign prostatic hyperplasia (BPH) in an adult Korean population and to evaluate this association based on the treatment status of asthmatics.We utilized the Korean genome and epidemiology study health examinee 2004 to 2016 database. A total of 47,186 participants (825 asthmatics and 46,361 controls) were selected and their BPH histories were analyzed. We categorized the participants according to their asthma treatment status: "well controlled"; "being treated"; and "not being treated". The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for BPH were analyzed using multiple logistic regression. Subgroup analyses were performed according to age (60 years).The results showed that the prevalence of BPH was higher among asthma patients (17.1%) than among controls (8.7%, P < .001). Asthma patients had a higher risk of having BPH (OR = 1.64, 95% CI = 1.37-2.01, P < .001) than controls, after adjustment for age, income, body mass index (BMI), smoking, alcohol consumption, frequency of physical activity, and the past medical diseases. The ORs for BPH were 1.35 (95% CI = 1.04-1.76) in those aged >60 years and 2.24 (95% CI = 1.70-2.96) in those aged ≤60 years. The ORs for BPH were 1.82 (95% CI = 1.16-2.87, P = .009) in the "well-controlled" group, 1.05 (95% CI = 0.74-1.49, P = .794) in the "being treated" group, and 2.24 (95% CI = 1.69-2.97, P < .001) in the "not being treated" group.We found that there is a correlation between asthma and BPH in the adult Korean population. There is a stronger association between asthma and BPH in younger adults and in those who are not receiving treatment for asthma.

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.

Introduction of Rezum system technology to Ireland for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a pilot study on early outcomes and procedure cost analysis

OBJECTIVE

Rezum technology uses heat from radiofrequency-generated water vapour to ablate prostate tissue. We evaluate the introduction of this thermal therapy to an Irish teaching hospital for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia.

METHODS

A pilot study of men with moderate to severe lower urinary tract symptoms who underwent Rezum treatment to the prostate was performed. Perioperative efficacy was evaluated using international prostate symptom score (IPSS), quality of life score (IPSS-QOL), uroflowmetry and post-void residual (PVR) volumes. Costs were evaluated and compared against matched patients undergoing the standard of care, transurethral resection of the prostate (TURP).

RESULT

Ten patients with a mean age of 70 ± 9 years who met the inclusion criteria underwent Rezum treatment. Mean PSA was 4.73 ± 4 ng/mL and mean prostate volume 72 ± 30 cc. Rezum therapy significantly improved both IPSS by 74% from mean baseline score of 20.8 ± 4 to 5.3 ± 1.49 (p < 0.001) and IPSS-QOL score by 84% from mean baseline score of 4.4 ± 0.7 to 0.6 ± 0.7 (p < 0.001) at 3 months. Maximum flow rate increase by 44% from 9.26 ± 2.5 to 13.34 ± 2.3 mL/s (p < 0.001). When compared to ten matched patients undergoing TURP in the same period, there was a significant cost saving of €1986.52 per patient for Rezum, overall up-front cost saving of €22,819 with an additional 19 bed days and 5 theatre hours spared.

CONCLUSION

Rezum, a minimally invasive thermal therapy, provides significantly improved symptom relief and quality of life with a significant cost saving to the institution.