Second-generation of temporary implantable nitinol device for the relief of lower urinary tract symptoms due to benign prostatic hyperplasia: results of a prospective, multicentre study at 1 year of follow-up

Systematic review and network meta-analysis of re-intervention rates of new surgical interventions for benign prostatic hyperplasia

OBJECTIVE

To assess the re-intervention rates of new surgical benign prostatic hyperplasia (BPH) interventions, as the clinical durability of new surgical interventions for BPH is not widely known.

METHODS

A critical review of new surgical BPH therapies namely 'UroLift®', 'Aquablation', 'Rezum', 'prostatic artery embolisation (PAE)' and 'temporary implantable nitinol device (iTIND)' was performed on PubMed, the Cochrane Library, and Embase databases between May 2010 and December 2022 according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. All relevant articles were reviewed, and the risk of bias was evaluated using the Cochrane risk assessment tool and Newcastle-Ottawa Scale.

RESULTS

Of the 32 studies included, there were 10 randomised controlled trials and 22 prospective observational cohorts. A total of 2400 participants were studied with a median patient age of 66 years, a median prostate volume of 51.9 mL, and a median International Prostate Symptom Score of 22. The lowest re-intervention rate at 12 months was for Aquablation at 0.01%, followed by Rezum at 0.02%, iTIND at 0.03%, and PAE at 0.05%. Network meta-analysis (NMA) showed that the best-ranked treatment at 12 months was transurethral resection of the prostate (TURP), followed by Aquablation, iTIND, Rezum, and UroLift. Re-intervention rates with these new BPH interventions are comparable, although some interventions reported better outcomes than TURP in the shorter term.

CONCLUSIONS

While this systematic review and NMA showed that the re-intervention rate with these new surgical BPH interventions appears to be comparable to TURP in the short term, further studies are required to directly compare these various BPH procedures.

[Minimally-Invasive Surgical Techniques (MIST): Shedding Light on the Mist]

As life expectancy increases and there is growing demand for BPH treatments, innovative technologies have been developed, allowing for swift recovery, symptom relief, low complication rates, and the possibility of performing procedures on an outpatient basis, often under local anaesthesia. This review aims to describe the outcomes of newly developed minimally-invasive surgical therapies (MIST) for BPH treatment in terms of functional voiding parameters and sexual function. These therapies are categorized into primarily ablative (Aquablation [Aquabeam]), non-ablative (Prostatic Urethral Lift (PUL, Urolift), temporary implantable devices [iTind]), and secondarily ablative procedures (convective water vapor ablation, Rezum, Prostate Artery Embolization [PAE]). All MIST technologies have advanced the medical care of patients with BPH while preserving ejaculation. However, there is a shortage of long-term data specifically addressing re-intervention rates and the preservation of functional voiding parameters. Although there is promising data from regulatory trials and randomized studies, all MIST therapies are potentially associated with severe complications. Patients considering such methods must be thoroughly informed about their inferiority compared with established transurethral procedures like TUR-P and enucleation.

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.

Impact of minimally invasive surgical procedures for Male Lower Urinary Tract Symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review

BACKGROUND

Surgical treatments for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are affected by potentially bothersome side effects on sexual, and, above all, ejaculatory function. Several minimally invasive techniques have been proposed in the last years in order to overcome these consequences. Our aim is to summarize and evaluate the efficacy on LUTS relieve and the impact on sexual/ejaculatory function of Rezum, prostate artery embolization (PAE), implantation of a prostatic urethral lift (PUL) and the temporary implantable nitinol device (TIND).

METHODS

A systematic review of the English-language literature was conducted using the MEDLINE, Embase, and Web of Science databases from January 2000 to October 2022, according to the PRISMA guidelines (PROSPERO ID: CRD42023466515). Randomized controlled trials (RCTs), prospective studies and non-comparative or comparative studies assessing the impact on functional and ejaculatory function after minimally invasive surgical therapies for Male LUTS were evaluated. Risk of bias assessment was performed according to the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for comparative studies, and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for RCTs.

RESULTS

Overall, 47 studies were included (n = 4 for TIND; n = 9 for Rezum; n = 13 for PUL; n = 21 for PAE). Most studies relied on prospective patient cohorts and were rated as low risk of bias. Across studies assessing the efficacy of Rezum, a significant improvement in terms of IPSS (ranging from -47% to -56%) and Qmax (ranging from +39% to +87%) was reported. On the other hand, according to IIEF-5 score, Rezum had a minimal impact on sexual function (ranging from -1% to -3%). PUL showed a positive impact on IPSS (ranging from -35% to -58.2%) and Qmax (ranging from +49.9% to +114.7%) and sexual function. Finally, PAE showed encouraging functional results with IPSS score reducing from -12.8% to 63.3% and Qmax improving from +8% to 114.9% but the available evidence regarding the potential impact of PAE on sexual outcomes were limited.

CONCLUSION

Rezum, PAE, PUL and TIND are safe and feasible techniques associated with a significant functional improvement. While available data suggest a minimal impact of Rezum and PUL on ejaculatory function, the evidence after PAE and TIND are still limited. Therefore, our review lays the foundation for further research aiming to identify the criteria to select best candidates for uMIST to tailor the management in light of specific patient- and disease- factors.

Evaluating the Impact of Benign Prostatic Hyperplasia Surgical Treatments on Sexual Health

Benign prostatic hyperplasia (BPH), a prevalent condition in older men, is often managed through various surgical interventions. This narrative review aims to explore the impact of these surgical treatments on sexual function, a critical aspect of patient quality of life often overlooked in BPH management. The methodology encompassed a thorough review of contemporary surgical techniques for BPH, including prostate resection, enucleation, vaporization, and minimally invasive therapies such as UroLift, Rezum, and Aquablation. Additionally, the focus was on patient-centered outcomes, with a special emphasis on sexual health following surgery. Findings reveal that, while surgical interventions effectively alleviate BPH symptoms, they often have significant repercussions in sexual function, including erectile and ejaculatory dysfunction. However, emerging techniques demonstrate potential in preserving sexual function, underscoring the need for patient-centric treatment approaches. The study highlights the complex interplay between BPH surgery and sexual health, with minimally invasive treatments showing promise in balancing symptom relief and sexual function preservation. In conclusion, the study advocates for an integrated, interdisciplinary approach to BPH treatment, emphasizing the importance of considering sexual health in therapeutic decision-making. This narrative review suggests a paradigm shift towards minimally invasive techniques could optimize patient outcomes, marrying symptom relief with quality-of-life considerations. The need for further research in this domain is evident, particularly in understanding long-term sexual health outcomes following different surgical interventions for BPH.

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. [...].

Temporary implantable nitinol device for benign prostatic hyperplasia-related lower urinary tract symptoms: over 48-month results

BACKGROUND

This study (MT02) reports >48-month (50-79 months) results of a prospective, single-arm, multicenter study (NCT02145208) of temporary implantable nitinol device (iTind®) in men with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS).

METHODS

Men with symptomatic BPH (International Prostate Symptom Score [IPSS] ≥10, Maximum flow rate [Qmax] <12 mL/s, and prostate volume <75 mL) from 9 centers were enrolled from December 2014 to December 2016. Total 50/81 (62%) patients at 3/9 sites (Italy, Switzerland, and Belgium), pursued the study beyond 36 months following iTind® device, per study protocol. Due to COVID-19, follow-up was amended. Each patient was assessed once during 50-79 months postoperatively for IPSS and IPSS-quality of life (IPSS-QoL), change in medication, need for surgical re-treatment and adverse events telephonically.

RESULTS

Post 36 month-follow-up, 5 patients were lost to follow-up and 2 patients died unrelated to iTind® device placement. Two patients (36-48 months follow-up) required surgical re-treatments (1 transurethral resection of prostate, 1 Thulium laser enucleation of prostate). >48 months results were available for 41 patients wherein iTind® device treatment showed significant improvement in symptoms (IPSS: -45.3%, P<0.0001 and IPSS-QoL: -45.1%, P<0.0001) from baseline to 79 months post-procedure; mean±SD of 11.26±7.67 and 2.10±1.41 points, respectively. No complications were recorded between 36 up to 79 months; no patient required additional medication.

CONCLUSIONS

iTind® device provided significant and durable symptom reduction and improved IPSS-QoL for >48 months post treatment. No late postoperative complications were reported beyond 36 months of follow-up. Surgical re-treatment rate for >36 months was 4%.

A scoping review of office-based prostatic stents: past, present, and future of true minimally invasive treatment of benign prostatic hyperplasia

PURPOSE

To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively.

RESULTS

Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed.

CONCLUSION

Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits.

Complications associated with minimally invasive surgical therapies (MIST) for surgical management of benign prostatic hyperplasia: a Manufacturer and User Facility Device Experience (MAUDE) database review

PURPOSE

MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures.

METHODS

The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures.

RESULTS

We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment.

CONCLUSION

MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process.

Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures

Lower urinary tract symptoms due to benign prostatic hyperplasia constitute a substantial burden, affecting the quality of life of those affected by this condition. While watchful waiting and medical management using a wide array of pharmaceuticals can be effective, surgery has been one of the most definite solutions for those highly affected by this condition. Transurethral resection of the prostate (TURP) is the gold standard surgical procedure, but other alternatives using laser (HoLEP and ThuLEP) and robotic water jets (Aquablation) are emerging treatments aimed at reducing postoperative morbidity. Minimally invasive procedures conducted in outpatient settings and under local anesthesia or sedation are increasingly being used, especially in those patients with high surgical risk due to comorbidities. These procedures include prostatic arterial embolization, water vapor thermal therapy (Rezum), prostatic urethral lift (Urolift), temporary implantable nitinol device (TIND/iTIND), and transurethral microwave thermotherapy (TUMT). The evidence supporting these treatments is growing, but some uncertainties remain as to what is the magnitude of their advantages and disadvantages compared to TURP. Innovations in the technologies involved in these new procedures may improve their profile for effectiveness and safety. Moreover, new devices are being investigated for marketing approval. Issues around costs and patients' preferences are also yet to be elucidated, thus their evolving role needs to be weighed against the aforementioned considerations.

[Minimally Invasive Therapy: What Is The Status In 2021 - What's Coming, What's Going?]

Due to the large number of men affected and a variable clinical presentation, the widespread disease "benign prostatic syndrome" requires individual treatment options tailored to the patient's specific clinical characteristics and wishes. If surgical treatment is indicated, there is a wide range of invasive procedures available. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard, but these procedures are associated with increased morbidity and limitations in sexual function. Therefore, there is now an increasing call for minimally invasive treatment options that will provide effective and safe treatment in the outpatient setting. Over the past years, a variety of technologies and procedures have been developed and tested, but only a few of them have found their way into clinical practice, mostly due to insufficient functional results. For instance, transurethral needle ablation, transurethral microwave thermotherapy, intraprostatic botulinum toxin A or PRX302 injections as well as prostatic stents are no longer recommended. In contrast, the European Association of Urology is currently recommending UroLift, Aquablation and prostatic artery embolisation, which achieve significant long-term improvements in functional parameters while providing a good safety profile and preserved sexual function. Promising data are also available for the temporarily implanted nitinol device (iTIND), Rezūm, intraprostatic injection of fexapotide triflutate and transperineal laser ablation of the prostate, but the efficacy and safety of these procedures need to be confirmed in further studies.

Functional Results after First- and Second-Generation Temporary Implantable Nitinol Device (TIND) for BPH: A Narrative Review of the Literature

Purpose of review

In the last decades, new promising technologies for the treatment of BPH-related lower urinary tract symptoms (LUTS) have been widely experienced in clinical practice, with the aim of offering fewer complications but similar functional outcomes compared with the gold standard transurethral resection of the prostate (TURP). Among these so-called minimally invasive approaches, transurethral implantation of first- and second-generation temporary implantable nitinol device (TIND and iTIND, respectively) (Medi-Tate; Medi-Tate Ltd., Or Akiva, Israel) has been included by the European Association of Urology (EAU) Guidelines as one of the available alternative treatments to TURP. In the present paper, we conducted a systematic review of the current literature on TIND and iTIND implantation focusing on functional outcomes. Medline, Embase, and Cochrane databases were queried for relevant Literature in May 2021.

Recent findings

Data regarding the use of temporary implantable nitinol device for BPH are still very limited, with only seven studies currently available in Literature. All the studies report that both TIND and iTIND procedures are safe, effective, and well tolerated. Moreover, such treatments seem to not affect patient’s sexual and ejaculatory functions.

Summary

Current clinical evidence suggests that temporary implantation of first- and second-generation temporary implantable nitinol devices are valid options for the minimally invasive surgical treatment of BPH-related LUTS. Further studies are required in order to confirm the functional results, especially over a long-term follow up.

New Technologies for Treatment of Benign Prostatic Hyperplasia

BPH is a common disease in aging men which impacts quality of life. With advancing age expectation coupled with the rising demand for BPH therapy, new technologies have been developed that target rapid recovery and symptom relief, low complication rates, and the ability to perform the procedure in an outpatient setting with local anesthesia. MIST technologies have fostered BPH medical care with ejaculation preservation. Techniques and outcomes for BPH technologies including Aquablation, Rezūm, UroLift, iTind, Optilume BPH, XFLO, Zenflow, and Butterfly are reviewed and evaluated. Given the novelty of these technologies, long-term data are required to assess safety and efficacy.

[Minimally invasive treatment options for the management of benign prostatic hyperplasia]

Benign prostatic hyperplasia is one of the most common diseases of aging men. Hyperplasia of the glandular tissue can cause distressing lower urinary tract symptoms, which can be treated with both drugs and interventions. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard of surgical treatment. In order to be able to offer patients an outpatient treatment with few complications, shorter hospital stays and high efficiency, a variety of minimally invasive treatment options have been developed. While recommendations have already been made for the excision by focused waterjet, prostatic urethral lift, and prostatic artery embolization, there are several other very promising procedures for which, however, long-term data and data from comparative studies with reference procedures must still be awaited.

Do Minimally Invasive Benign Prostatic Hyperplasia Treatments Preserve Sexual Function? A Contemporary Review of the Literature

PURPOSE OF REVIEW

The aim of this study is to compare the sexual function outcomes related to minimally invasive surgical therapies (MISTs) (UroLift^®, Rezum™, Aquablation^®, prostate artery embolization, and iTind^®) for the treatment of benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Clinical trials and retrospective data evaluating MISTs for BPH have demonstrated improved or stable sexual function outcomes when compared to sham control or transurethral resection of the prostate. Outcomes were assessed at baseline and following treatments using patient-reported outcome measures. Rezum and Aquablation demonstrated preservation of overall ejaculatory function and erectile function at 36-month follow-up. Similar outcomes occurred with UroLift after a 60-month follow-up. Erectile function was preserved following prostate artery embolization and iTIND up to 12 months. MIST for the management of BPH has been demonstrated to be effective in improving urinary function and appears to minimize potential collateral damage on sexual function following treatment.

Characterization of a Novel Implant Intended to Expand and Reshape the Prostatic Urethra for the Treatment of Benign Prostatic Hyperplasia: A Pre-Clinical Feasibility Study in the Canine Model

OBJECTIVE

To evaluate the safety, feasibility, and tissue response of a novel device for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia, using the first-generation Urocross Expander System (Mercury Expander System).

METHODS

The implant was deployed and retrieved using flexible cystoscope in 8 adult male canines, separated into three study arms by retrieval date (1-, 6-, and 12- months post-deployment). Cystoscopy and urethrograms verified implant position/diameter; bladder neck and external sphincter function/changes; prostatic tissue response; and implant condition. One-month post-retrieval, the prostate and surrounding tissue was sectioned and evaluated by a veterinary pathologist.

RESULTS

All implants were successfully deployed in the prostatic urethra. Urethral width was increased (6.9 ± 1.8 mm to 10.2 ± 0.6 mm, P = .012) and preserved through the dwell period. Urethral length and sphincter diameters didn't significantly change. All subjects (n = 8) remained continent without obstruction or retention. Adverse events included incisional site bleeding (n = 2) and transient hematuria (n = 3). One implant migrated into the bladder and spontaneously repositioned into the prostatic urethra. Post-retrieval, explant surfaces demonstrated no tissue growth, encrustation or stone formation. Imaging revealed contact site erythema and indentation, but no stones, strictures, perforations, erosions, nor ulcerations. Histopathology revealed glandular acinar changes, inflammation, and fibrosis.

CONCLUSION

The first generation of the Urocross Expander System demonstrated a favorable safety profile in the canine model. Changes in the prostatic urethra shape were noted with an increase in urethral width during the dwell period with minimal tissue changes. Further, the implant didn't demonstrate any encrustation, tissue growth or stone formation.

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.

The Mechanism of Action of cTIND for Minimally Invasive Ischemic Incision of the Prostate: In Vivo Study

OBJECTIVES

To understand the histologic changes of prostate tissue induced by temporary implantable nitinol device (cTIND) in a canine model.

METHODS

The cTIND is a small, symmetric device comprised of nitinol wire loops welded together on an axis, which exert radial force on the tissue to induce a targeted ischemic effect. The cTIND was implanted in three live canine models, which were monitored for 14 days post-index procedure. Device placement was monitored via serial fluoroscopy and biologic effects of cTIND were studied via histopathology.

RESULTS

The cTIND was successfully placed in the canine models and remained securely in position until the animal was sacrificed on postoperative day 14. The cTIND treated tissue demonstrated an abrupt transition from normal, viable prostatic glandular tissue to an area of shrunken necrosis and fibrosis between the two.

CONCLUSION

In the canine models, the cTIND created focal areas of ischemic necrosis resulting in incisions in the peri-urethral prostate with minimal inflammation.

Feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation for the treatment of benign prostatic hyperplasia: a single institutional experience

PURPOSE

To evaluate the feasibility, safety, and efficacy of ultrasound-guided transperineal laser ablation (TPLA) as a new minimally invasive surgical therapy (MIST) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Under local anesthesia and conscious sedation up to two laser fibers for each prostatic lobe were inserted under US-guidance by a percutaneous approach. TPLA was performed using a continuous wave diode laser (SoracteLite-EchoLaserX4) able to generate a light-induced thermal heating and subsequent coagulative necrosis of the prostatic tissue. Patients were evaluated at 3, 6, and 12 months after TPLA.

RESULTS

Twenty-two consecutive patients were prospectively enrolled (median age 61.9 years). All procedures were well tolerated and no procedural complications were recorded. Median catheterization time was 7 days, while the median hospitalization time was 1 day. Three out of twenty-two patients (13.6%) experienced acute urinary retention and two (9.1%) of them urinary tract infection requiring major antibiotic treatment. At 3, 6, and 12 months, median prostate volume significantly decreased by a - 21.3%, - 29%, and - 41%, respectively. At the same time point, median IPSS was 8 (- 63.6%), 5 (- 74%), and 6 (- 75%), while median QoL score was 1 in all the scheduled timepoints of follow-up. The median postoperative Qmax at 3, 6, and 12 months improved by + 57.8%, + 98%, and + 115.8%, respectively. Ejaculatory function was preserved in 21 out of 22 patients (95.5%).

CONCLUSIONS

TPLA of the prostate appears to be a promising MIST for BPH. Long-term results and comparative studies against standard treatments are warranted before implementations of this technique in the urologist's armamentarium.

Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised, Open-label, Single-centre Trial

BACKGROUND

Prostatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation.

OBJECTIVE

To compare the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 yr of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

A randomised, open-label trial was conducted. There were 103 participants aged ≥40 yr with refractory LUTS/BPO.

INTERVENTION

PAE versus TURP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

International Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 yr were tested for differences between the two interventions with standard two-sided tests.

RESULTS AND LIMITATIONS

The mean reduction in IPSS after 2 yr was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04-5.72]; p =  0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs 10.23 ml/s, difference of -6.33 [-10.12 to -2.54]; p <  0.001), reduction of postvoid residual urine (62.1 vs 204.0 ml; 141.91 [43.31-240.51]; p =  0.005), and reduction of prostate volume (10.66 vs 30.20 ml; 19.54 [7.70-31.38]; p =  0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs 78, p =  0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 yr due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study.

CONCLUSIONS

Inferior improvements in LUTS/BPO and a relevant re-treatment rate are found 2 yr after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling.

PATIENT SUMMARY

Prostatic artery embolisation is safe and effective. However, compared with transurethral resection of the prostate, its disadvantages regarding subjective and objective outcomes should be considered for individual treatment choices.

Pharmacological and interventional treatment of benign prostatic obstruction: An evidence‐based comparative review

Introduction

The recommended treatment for bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) after the failure of behavioral therapy and fluid modification includes pharmacological, minimally invasive interventional, and surgical approaches. Each option has different risk and benefit profiles, and the urologist must be aware of the unique characteristics of each option in order to be able to accurately counsel the patients based on their individual values and preferences. We provide a comparative review of the commonest pharmacological and most widely performed interventional/surgical treatments for BPO, discussing the evidence for the treatment characteristics that are most useful for the practicing urologist.

Methods

A search of the PubMed database was performed for articles reporting on the following treatments for LUTS due to BPO: α‐blockers, 5α‐reductase inhibitors, phosphpdiesterase‐5 inhibitors, prostatic urethral lift (Urolift), convective radiofrequency water vapor thermal therapy (Rezum), Temporary implantable Nitinol Device (iTIND), prostate artery embolization (PAE), transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), Aquablation, and anatomical endoscopic enucleation of the prostate (AEEP). We performed a narrative review focussing on the following outcomes: efficacy, safety, durability, duration of catheterization, length of stay, re‐treatment rate, efficacy in special situations (enlarged median lobe, prostate size, urinary retention, and anticoagulant use), and sexual adverse events.

Results

AEEP offers the greatest long‐term improvement in maximum flow rate, IPSS, and prostate volume reduction, with lowest re‐treatment rate, followed by PVP, TURP, and Aquablation. Urolift, Rezum, and PAE have similar efficacy for prostate volume up to 80cc, and all are more effective than the pharmacological treatment. Urolift offers the lowest rate of sexual dysfunction, followed by Rezum, and both can be performed as a day case under local anesthesia.

Conclusion

Several treatment options exist to treat voiding LUTS due to BPO. Newer minimally invasive treatments reduce the hospital stay and postoperative complications, whereas AEEP provides the greatest long‐term symptom improvement at the expense of higher morbidity and sexual dysfunction. Men should be counseled regarding all suitable treatment options as some may favor reduced efficacy in association with reduced side effects.

Interventional therapy in benign conditions of the prostate

Interventional therapies (IT) are increasingly popular treatment options for benign prostatic hyperplasia (BPH). IT aim to reduce morbidity and side effects related to invasive surgical procedures. To date, IT are considered experimental, though they are evolving rapidly and starting to challenge established surgical strategies. With gradually increasing evidence for the benefits of IT in BPH, several techniques are moving out of the realm of research and into everyday clinical practice. As such, IT provides encouraging mid-term functional outcomes with improved health-related quality of life (QoL), particularly in terms of better preservation of ejaculation. The distinct role IT could play as a bridge between exhausted drug-based treatment options and surgery is yet to be defined. Further studies are required before IT can be recommended as alternatives to invasive therapies. Systematic trials are needed to identify subgroups of patients who can benefit particularly from IT in comparison to other treatments, to identify features of the prostate particularly suited to a specific IT, and to analyze the durability of success for each technique.

Modern advancements in minimally invasive surgical treatments for benign prostatic obstruction

A wide variety of minimally invasive surgical techniques are now being offered for treating voiding lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). These options offer an alternative to both medical therapy and traditional surgical options. Minimally invasive surgical treatments in LUTS/BPO boast both day case and local anaesthetic options, with a potentially reduced side effect profile compared to traditional surgical interventions matching the needs for a range of patients. We provide a narrative review of minimally invasive surgical treatments available for BPO in terms of the technology, efficacy, safety, institutional recommendations, cost and potential future developments.

A state-of-art review on the preservation of sexual function among various minimally invasive surgical treatments for benign prostatic hyperplasia: Impact on erectile and ejaculatory domains

There is a strong association between benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and sexual dysfunction. While transurethral resection of the prostate (TURP) is considered the standard BPH treatment, it is however associated with a high rate of erectile and ejaculatory dysfunctions. Over the past decade, new and novel minimally invasive BPH therapies have been shown to improve various parameters of voiding domains while minimizing adverse sexual effects. These minimally invasive BPH therapies can be largely be divided into those with cavitating technology (Rezum, Histotripsy, Aquablation), intra-prostatic injections (Botulinum neurotoxin Type A, Fexapotide Triflutate, prostate specific antigen-activated protoxin PRX-302), and mechanical devices which include intraprostatic stents (Urospinal 2™, Memotherm™, Memokath™, and Allium triangular prostatic stent™) and intraprostatic devices (iTIND™, Urolift™), as well as prostatic artery embolization. Published literature on these technologies showed reasonable preservation of erectile function with limited data reported on ejaculatory domain. Further validation of the performance of these novel minimally invasive treatment options for LUTS due to BPH in well-designed and multi-centre studies are desired, to evaluate their role (or lack of such a role) in clinical practice and whether these BPH therapies can provide equivalent standard or better than TURP.

[An update on the most recent mini-invasive surgical and interventional techniques in the management of benign prostatic obstruction]

INTRODUCTION

New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies.

MATERIAL

A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France.

RESULTS

The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries.

CONCLUSION

These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.

The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicenter, Randomized, Controlled Trial

OBJECTIVE

To report the results of a multicenter, randomized, controlled trial with a temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Hadera, Israel) compared to sham for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

MATERIALS AND METHODS

Men 50 years or older were randomized 2:1 between iTind and sham procedure arms. A self-expanding, temporary nitinol device was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 1.5, 3, and 12 months postoperatively using the IPSS, peak urinary flow rate, residual urine, quality of life, and the International Index of Erectile Function. Unblinding occurred at 3 months.

RESULTS

A total of 175 men (mean age 61.1 ± 6.5) participated (118 iTind vs 57 sham). A total of 78.6% of patients in the iTind arm showed a reduction of ≥3 points in IPSS, vs 60% of patients in the control arm at 3 months. At 12 months, the iTind group reported a 9.25 decrease in IPSS (P< .0001), a 3.52ml/s increase in peak urinary flow rate (P < .0001) and a 1.9-point reduction in quality of life (P < .0001). Adverse events were typically mild and transient, most Clavien-Dindo grade I or II, in 38.1% of patients in the iTind arm and 17.5% in the control arm. No de novo ejaculatory or erectile dysfunction occurred.

CONCLUSION

Treatment with the second-generation iTind provided rapid and sustained improvement in lower urinary tract symptoms for the study period while preserving sexual function.

3-Year results following treatment with the second generation of the temporary implantable nitinol device in men with LUTS secondary to benign prostatic obstruction

BACKGROUND

To report the 3-year results of a prospective, single arm, multicenter, international clinical study with the second generation of the temporary implantable nitinol device (iTIND; Medi-Tate Ltd®, Israel) on men suffering lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO).

METHODS

Eighty-one men with symptomatic BPO (IPSS ≥ 10, peak urinary flow <12 ml/s, and prostate volume <75 ml) were enrolled in this study between December 2014 and December 2016. Subjects were washed-out 1 month for alpha-blockers and 6 months for 5-ARIs. The implantation was performed under light sedation and the removal 5-7 days later with topical anesthesia. Perioperative results including OR-time, pain (VAS) postoperative complications (Clavien-Dindo-Grading System), functional results (Qmax, IPSS, PVR) and quality of life (QoL) were assessed at 1, 3, 6 months, 1, 2, and 3 years. Sexual and ejaculatory function were evaluated using two yes/no questions.

RESULTS

Thirty-six month functional results were available for 50 patients and demonstrated that iTIND efficacy remained stable through 3 years, with averages IPSS, QOL, Qmax and PVR of 8.55 + 6.38, 1.76 + 1.32, 15.2 + 6.59 ml/s and 9.38 + 17.4 ml, improved from baseline by -58.2, -55.6, +114.7, and -85.4% (all significantly different from their corresponding baseline values, p < 0.0001). Even considering the Intention to Treat analysis (ITT), the 36-month results confirmed significant improvements of the functional outcomes if compared with baselines values (all p < 0.0001). No late post-operative complications were observed between 12 and 36 months. Sexual function was stable through 3 years, with no reports of sexual or ejaculatory dysfunctions. No patients underwent alternative treatments between 24 and 36 months.

CONCLUSION

Treatment of BPO-related LUTS with iTIND demonstrated a significant and durable reduction in symptoms and improvement of functional parameters and quality of life at 3 years of follow-up. No late post-operative complications, ejaculatory dysfunction or additional treatment failures were observed between 24 and 36 months.

Reasons for new MIS. Let's be fair: iTIND, Urolift and Rezūm

Purpose

To review and discuss the literature regarding iTIND, Urolift and Rezūm and investigate the precise clinical indications of all three different approaches for their application in benign prostatic hyperplasia (BPH) treatment.

Materials and methods

The PubMed–Medline and Cochrane Library databases were screened to identify recent English literature relevant to iTIND, Urolift and Rezūm therapies. The surgical technique and clinical results for each approach were summarized narratively.

Results

iTIND, Urolift and Rezūm are safe and effective minimally invasive procedures for the symptomatic relief of lower urinary tract symptoms (LUTS) due to BPH. iTIND requires the results of ongoing prospective studies, a long-term follow-up and a comparison against a reference technique to confirm the generalizability of the first pivotal study. Urolift provides symptomatic relief but the improvements are inferior to TURP at 24 months and long-term retreatments have not been evaluated. Rezūm requires randomized controlled trials against a reference technique to confirm the first promising clinical results. However, clinical evidence from prospective clinical trials demonstrates the efficacy and safety of these procedures in patients with small- and medium-sized prostates.

Conclusions

Although iTIND, Urolift, and Rezūm cannot be applied to all bladder outlet obstruction (BOO) cases resulting from BPH, they provide a safe alternative for carefully selected patients who desire symptom relief and preservation of erectile and ejaculatory function without the potential morbidity of more invasive procedures.

Transperineal interstitial laser ablation of the prostate, a novel option for minimally invasive treatment of benign prostatic obstruction

BACKGROUND

In the algorithm of treatment of benign prostatic obstruction (BPO), the shift from medical therapy to surgery is steep in terms of invasiveness. Recently, a lively interest has developed on alternative micro-invasive options. Transperineal interstitial laser ablation (TPLA) was recently proposed for BPO treatment.

OBJECTIVE

This work aims to illustrate feasibility, efficacy and safety profile of TPLA in BPO treatment.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively analyzed the results of TPLA performed between September 2018 and March 2019 for LUTS due to BPO, in men with prostate volume <100 ml.

SURGICAL PROCEDURE

TPLA was performed in OR, under local anesthesia, using Soracte Lite-EchoLaserX4. Diode laser light is conveyed through 300 μm optical fibers introduced transperineally by 21 Ga needles and placed at a security distance from urethra and bladder neck. EchoLaser Smart Interface eases needle positioning and increases the safety.

MEASUREMENTS

The primary endpoint was the variation of Qmax and IPSS at 1, 3 and 6 months. We also assessed the ejaculatory function and recorded complications. These outcomes were further investigated at 12 months by phone call.

RESULTS AND LIMITATIONS

21 men with prostate volume of 43.5 ± 8.5 ml underwent TPLA. All were discharged after 24 h, keeping the transurethral catheter for 8.7 ± 2.5d. At one month all patients but one discontinued medical therapy, showing significant advantage in Qmax (+3.4 ± 5.7 ml/s; p < 0.01) and IPSS (-5.6 ± 7.0; p < 0.01). Functional results were still progressing at 6 months, with Qmax (+4.7 ± 6.0 ml/s; p < 0.01) and IPSS improvement (-13.1 ± 4.7; p < 0.01). The ejaculatory function was preserved as the MSHQ-EjD increased (p < 0.05). The only complication was a prostatic abscess, treated with transperineal drainage and antibiotic.

CONCLUSIONS

TPLA is a micro-invasive treatment for BPO showing good functional and safety outcomes.

PATIENT SUMMARY

This work illustrates the results of TPLA to treat LUTS due to BPO, showing high efficacy, preservation of the ejaculation, and low complication rate.

Urinary and sexual function after treatment with temporary implantable nitinol device (iTind) in men with LUTS: 6-month interim results of the MT-06-study

PURPOSE

To evaluate the functional outcomes as they relate to the preservation of urinary continence and sexual function after treatment with the temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Israel); a novel minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

METHODS

Men with symptomatic BPH (IPSS ≥ 10, Q_max < 12 ml/s, and prostate volume (PV) < 120 ml) were invited to participate in this single-arm, prospective multicenter study (MT06). Patients were not washed out of BPH medications before the procedure. The iTind was implanted through a 22F rigid cystoscope under intravenous sedation and was removed 5-7 days later through a 22F Foley catheter under local anesthesia. Post-operative VAS and complications (Clavien Dindo-Grading System) were recorded. Preservation of urinary continence and erectile and ejaculatory function were assessed according to ISI, MSHQ-EjD and SHIM questionnaires. Post-operative IPSS, QoL, Q_max and PVR were also assessed at 1, 3, and 6 months post-operatively.

RESULTS

This interim report includes data out to 6 months on the first 70 patients enrolled in the study. The median age was 62.31 years, and the mean prostate volume was 37.68 ml (15-80 ml). Baseline and follow-up data are reported in Table 1. No intraoperative complications were observed, the average post-operative VAS score was 3.24 ± 2.56. On average patients returned to daily life after 4.3 days following the retrieval procedure. Sexual function and urinary continence were preserved in all subjects according to the ISI, SHIM and MSHQ-EjD questionnaires and significant improvements (p < 0.0001) from baseline levels were recorded in IPSS, QoL and peak flow.

CONCLUSION

iTind is a well-tolerated, minimally invasive treatment for BPH-related LUTS which preserves sexual function and urinary continence, offers a rapid recovery and return to daily life, and a significant improvement of symptoms and urinary flow at 6-month follow-up.

Indications, techniques, and role of new minimally invasive benign prostate hyperplasia surgical options

Novel emerging techniques for the surgical treatment of benign prostate hyperplasia (BPH) related to lower urinary tract symptoms are being investigated very seriously to help search for a better method, and the studies are getting their place in the literature. In this review article, UroLift^® system, (i)TIND^®, Aquablation^®, Rezūm® system, and prostatic artery embolization have been discussed according to the literature and both European and American urological guidelines. All related randomized controlled trials are discussed under the appropriate headings. Indications, technique, and the role of these minimally invasive surgical options for BPH are assessed. These methods, which are still being studied, are promising for the future. As the studies get completed, the indications will become clearer, and these techniques will find their respective places as the personalized treatment options.

A Systematic Review and Meta-analysis of Prostatic Urethral Lift for Male Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

CONTEXT

Recently, prostatic urethral lift (PUL) is being used to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Although preliminary clinical studies on PUL are increasing, the long-term efficacy and safety of this procedure are still not well evaluated.

OBJECTIVE

The objective of our study is to synthesize the existing literature evidence, and make a comprehensive and long-term systematic review for the PUL procedure.

EVIDENCE ACQUISITION

A systematic search was performed from the electronic databases including PubMed, Embase, and OVID. The search period was up to January 1, 2020. Comprehensive retrospective and prospective studies on PUL were collected in accordance with specific inclusion and exclusion criteria. Pooled prostatic symptom scores, sexual health scores, and functional outcomes were calculated by using a fixed or random-effect model.

EVIDENCE SYNTHESIS

Nineteen articles meet our determined inclusion and exclusion criteria, and 11 independent patient series were included in the final analysis. Meta-analysis results indicated improvement after the PUL procedure, including International Prostate Symptom Score improvement of 9.73-12.16 points, BPH Impact Index improvement of 3.74-4.50 points, maximum flow rate improvement of 3.44-4.26 ml/s, and quality of life improvement of 2.20-2.55 points. Postvoid residual volume at most of the intervals was not significantly variable. Data regarding sexual function remained stable or improved slightly during the 24-mo follow-up period. Pooled estimates were largely heterogeneous except for sexual function.

CONCLUSIONS

PUL can continue to relieve prostatic symptoms for 24 mo without causing serious complications. The extremely important advantage of the PUL procedure is that it can preserve or slightly improve sexual function. Longer-term and more comprehensive clinical trials are still needed to further clarify the functional outcomes and cost effectiveness of PUL.

PATIENT SUMMARY

Prostatic urethral lift is an attractive option for selected patients who seek rapid and durable relief of lower urinary tract symptoms with complete preservation of sexual function.

[Novel surgical techniques for treatment of benign prostatic hyperplasia]

In recent years new surgical techniques to treat benign prostatic hyperplasia have been introduced into urological practice and evaluated in clinical studies. Complications of standard procedures, e.g. transurethral resection of the prostate (TURP), can be avoided while maintaining equivalent clinical outcomes. The main goal is preservation of erectile and ejaculatory function. Furthermore, outpatient treatment associated with a rapid patient recovery would be desirable. This article presents the course of the interventions, the mechanisms of action and current clinical evidence for novel mechanical approaches of recanalization, water-based ablation as well as prostate artery embolization. Initial study results partially indicate that in the future practically all patients can be offered an individualized surgical technique, which provides optimal symptomatic and functional improvements with a minimized risk of complications.

iTIND: the second-generation temporary implantable nitinol device for minimally invasive treatment of benign prostatic hyperplasia

iTIND is the second-generation version of the temporary nitinol implantable device (TIND), which has emerged over the past decade as one of the latest additions to the library of minimally invasive surgeries now available to treat bothersome lower urinary tract symptoms (LUTS) caused by benign prostate enlargement. While the key procedural steps remain the same, it now carries specific modifications designed to improve its efficacy and safety profile further. With the option to perform implantation under local anaesthesia, it can be delivered on an ambulatory basis and in the office setting. While the formal position of iTIND in current guidelines is yet to be determined, 12-month data demonstrates that it can improve both objective and subjective outcome measures, which are sustained at short-term follow up.

The Role of Aquablation for the Surgical Treatment of LUTS/BPH

PURPOSE OF REVIEW

To explore the potential applicability of a novel, heat-free, and robotically controlled ablative therapy for surgical management of benign prostatic enlargement.

RECENT FINDINGS

With the emergence of new technology to provide personalized care and overcome the complications associated with options such as TURP, holmium laser enucleation of the prostate, GreenLight laser, or simple prostatectomy, Aquablation has been studied across a variety of prostate volumes. The functional outcome of Aquablation seems to be uncompromised by prostate volume. The sexual profile seems superior to TURP and the risk of retrograde ejaculation is lower. The robotic system provides a reproducible ablation, independent of prostate volume, without requiring extensive training for performing the procedure. The mean ablation time in the prostate as large as 150 ml does not exceed 9.1 min, and the blood transfusion rates do not seem to be higher than open prostatectomy.