Transurethral Microwave Therapy Research Articles

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

AbstractObjectivesWe 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.MaterialsPubMed/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.ResultsAt 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).ConclusionsModerate to weak evidence suggests that Rezūm is not superior to TUNA and TUMT in all domains studied.

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.

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

Exploring the Legal Implications of Benign Prostatic Hyperplasia Surgeries in the United States: A Comprehensive Analysis of Two Decades of Lawsuits.

The United States (US) currently faces a medical malpractice crisis, and a survey done in 2006 informed that 63% of urologists faced an average of 2.1 medical malpractice lawsuits. Surgery for benign prostatic hyperplasia (BPH) is performed by 95% of US urologists. Hence, we postulated that these procedures might be responsible for a substantial number of medical malpractice lawsuits. We examined claims related to BPH surgery in various US courts. Data were collected from Westlaw and LexisNexis databasesusing the keywords "benign prostatic hyperplasia," "enlarged prostate," "surgery," and "malpractice" to search for cases from the entire US from January 2000 to December 2021. We extracted details such as the type of procedure, the plaintiff and defendant, the nature of the allegation, the alleged complications, the verdict, and the compensation amount. We found 30 casesin which the most common procedure was transurethral resection of the prostate (37%), with inadequate postoperative care as the most frequent reason for claims (33%). Urologists were the most frequently processed professionals (57%). The postsurgical outcomes that resulted in lawsuits were urinary incontinence (23%), erectile dysfunction (13%), and urinary retention (13%). Interestingly, 43% of the patients were inmates. Plaintiffs won only two (7%) cases: colon perforation after interstitial laser coagulation with Indigo laser and recto-urethral fistula after transurethral microwave therapy. Most lawsuits were related to postoperative incontinence and erectile dysfunction, with the verdict favoring the defendant in most cases. Inmates were the plaintiffs in a relatively high percentage of cases. Only two cases resulted in a plaintiff victory, wherein both cases presented unexpected and serious postsurgical complications.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

MP13-03 COMPLICATIONS ASSOCIATED WITH MINIMALLY INVASIVE SURGICAL THERAPIES (MIST) FOR SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH): A MANUFACTURER AND USER FACILITY DEVICE EXPERIENCE (MAUDE) DATABASE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP13-03 COMPLICATIONS ASSOCIATED WITH MINIMALLY INVASIVE SURGICAL THERAPIES (MIST) FOR SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH): A MANUFACTURER AND USER FACILITY DEVICE EXPERIENCE (MAUDE) DATABASE ANALYSIS João Porto, Ruben Blachman Braun, Dimple Chanamolu, and Hemendra Shah João PortoJoão Porto More articles by this author , Ruben Blachman BraunRuben Blachman Braun More articles by this author , Dimple ChanamoluDimple Chanamolu More articles by this author , and Hemendra ShahHemendra Shah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003233.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MAUDE database houses medical device reports of suspected device related complications received by Food and Drug Administration (FDA). In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures. METHODS: The FDA, MAUDE database website was queried using keywords: rezum, urolift, prostate artery embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (ITIND) on 10/1/22. Details related to the device problem, complications, aborted/canceled procedures, use of anticoagulant drugs, blood transfusion, operative intervention, hospitalization were extracted from the cases. We used the Gupta classification system to stratify complications. Statistical analysis was performed with SPSS v.28. Chi-square was used to compare frequency of complications among surgical procedures. RESULTS: We found a total of 780 cases of MIST procedures and after removing irrelevant/no information (n=58) and duplicate cases (n=30), we included 692 cases. (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4 and ITIND-1). Level I complications were commonest (62%) and most of these (95%) were related to devices. The screen display error was responsible for 93% and 83% aborted cases in rezum and TUNA, respectively. The PAE showed 40% of device component detachment/fracture. Most of the level II-III complications were not related to device or user (Table 1). Urolift had 49% of II-III complications, especially due to pelvic/retroperitoneal hematoma, which was associated with hospitalization and blood transfusion. There were 10 deaths reported after urolift, 2 after rezum and 1 after TUMT mostly due to cardiovascular events, which, according to the physicians involved, were not associated with the proposed treatment. CONCLUSIONS: Although MIST for BPH is a procedure with low complication rates, it is important to point out that adversities can happen. Our data should assist urologists and patients in selecting appropriate MIST procedure with shared decision-making process. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e174 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information João Porto More articles by this author Ruben Blachman Braun More articles by this author Dimple Chanamolu More articles by this author Hemendra Shah More articles by this author Expand All Advertisement PDF downloadLoading ...

MP76-20 TRENDS IN SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA: DATA FROM THE AUA QUALITY (AQUA) REGISTRY

You have accessJournal of UrologyCME1 Apr 2023MP76-20 TRENDS IN SURGICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA: DATA FROM THE AUA QUALITY (AQUA) REGISTRY Charles Jones, Benjamin Breyer, Rachel Mbassa, William Meeks, Raymond Fang, and Matthew Cooperberg Charles JonesCharles Jones More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Rachel MbassaRachel Mbassa More articles by this author , William MeeksWilliam Meeks More articles by this author , Raymond FangRaymond Fang More articles by this author , and Matthew CooperbergMatthew Cooperberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003350.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The list of surgical options for benign prostatic hyperplasia (BPH) has exploded in recent years, but little is known about the uptake of these new procedures in community urology practice. In this study we aimed to examine surgical BPH practices and trends across the country using the American Urological Association Quality Registry (AQUA). METHODS: The AQUA Registry was launched in 2014 to centralize quality reporting and improvement, primarily among community-based urology practices. Data regarding surgical BPH management from 2014-2021 were accessioned directly from electronic health records at 245 practices across the country. Procedures were grouped by CPT code. These included prostatic urethral lift (Urolift), transurethral incision of the prostate (TUIP), transurethral resection of the prostate (TURP), repeat TURP, laser coagulation of the prostate, laser vaporization of the prostate, holmium laser enucleation of the prostate (HoLEP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral destruction of the prostate by water vapor thermal therapy (Rezum), simple prostatectomy, and other genitourinary procedure. Patients were characterized by race and age. Practice location was also examined. RESULTS: The mean age of BPH diagnosis was 66.4 years old. 72% were White, 7% Black, 1% Asian, and 20% unknown. A total of 300,215 BPH procedures were recorded from 2014-2021. TURP had the greatest overall decline from a relative incidence of 40.1% of total BPH procedures in 2016 to 25.6% in 2021. TURP was used for 32% of White patients, 34% of Black patients, and 26% of Asian patients. Urolift use grew from 0.7% of cases in 2014 to 30.1% in 2021. HoLEP comprised approximately 1% of procedures throughout the time period studied. CONCLUSIONS: There has been a large shift in the procedures of choice for surgical management of BPH within community urology practices in the United States, with Urolift having a significant increase in total and relative proportions of procedures performed since its FDA approval in 2013. There has been a concurrent decrease in TURP, while HoLEP has stayed relatively consistently uncommon in community practice. Source of Funding: AQUA Registry is funded by the American Urological Association © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1100 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Jones More articles by this author Benjamin Breyer More articles by this author Rachel Mbassa More articles by this author William Meeks More articles by this author Raymond Fang More articles by this author Matthew Cooperberg More articles by this author Expand All Advertisement PDF downloadLoading ...

Real-world data comparing minimally invasive surgeries for benign prostatic hyperplasia.

To assess the differences in surgical outcomes between the prostatic urethral lift (PUL) and previous thermal energy procedures for the treatment of benign prostatic hyperplasia (BPH). We present an observational population-based study of 2694 men with BPH in New York State and California who received PUL, transurethral needle ablation (TUNA), or transurethral microwave therapy (TUMT) in outpatient and ambulatory surgery settings from 2005 to 2018. For these surgical procedures, short-term outcomes were reported and compared using a Chi-square test and mixed-effect logistic regressions. Long-term outcomes were described using Kaplan-Meier failure curves and compared using a Log-rank test and Cox regressions. A significant portion of PUL patients had a comorbidity count ≥ 2 (n = 838, 37.0%). PUL exhibited the lowest 30day and 90-day inpatient or ER readmission rates among all surgical techniques except for 90-day ER readmission (p < 0.05). No differences were observed for 1- and 3-year risks of reoperation between PUL [5.5% (95% CI 4.4-6.8%) and 14.9% (95% CI 10.9-20.1%)], TUNA [7.4% (95% CI 5.0-10.9%) and 11.3% (95% CI 8.3-15.4%)] and TUMT [8.5% (95% CI 4.7-15.2%) and 15.3% (95% CI 9.5-24.0%)]. 1- and 3-year risks of stricture development for PUL were 0.2% (95% CI 0.0-0.7%) and 0.2% (95% CI 0.0-0.07%), respectively. In a patient population with chronic conditions, patients treated with PUL exhibited similar 30- and 90-day inpatient or ER readmission rates when compared to previous reports. However, 1- and 3-year reoperation risks for PUL closely resembled previous thermal energy surgical procedures.

525 Minimally Invasive Surgical Treatment of Benign Prostatic Hyperplasia: A Systematic Review

Abstract Introduction Minimally invasive surgical treatments (MISTs) of benign prostatic hyperplasia (BPH) have evolved to offer men daycase care with preservation of urinary continence and sexual function. This systematic review evaluates trends in minimally invasive BPH surgery over the last decade Method Systematic review (PRISMA) of Embase/MEDLINE databases (2010-2020). MISTs included Rezum, Urolift, Prostatic Artery Embolisation (PAE), Temporary Implantable Nitinol Device (TIND), Intraprostatic Injection, Transurethral Microwave Therapy (TUMT) and Transurethral Needle Ablation (TUNA). Primary outcome: urinary functional change (International Prostate Symptom Score (IPSS)/maximum flow (Qmax)). Secondary outcomes: sexual functional change (International Index of Erectile Function-5 (IIEF-5)), technical failures and complications. Results 74 studies were included (total: 8,917 patients). Primary: all interventions offered improvement in IPSS and Qmax (intervention (no. studies): range IPSS change, range Qmax change, range months follow-up; Rezum (4): -46.7% to -62.7%, +17.6% to + 55.6%, 6-48; Urolift (11): -35.2% to -64.2%, +16.7% to + 89.6%, 1-60; PAE (36): -36.8% to -85.2%, +17.4% to + 155.2%, 3-38; TIND (2): -36.8% to -59.6%, +32.9% to + 95.9%, 12-36; Intraprostatic Injection (14): -24.3% to -62%, +8.7% to + 98.4%, 3-24; TUMT (4): -56.1% to -58.7%, +12.9% to + 60.2%, 6-60; TUNA (3): -17.6% to -63.2%, +3.9% to + 39%, 1-120). Secondary: 33 studies of all interventions bar TIND and TUMT reported IIEF-5 change; sexual function was largely preserved. Technical failures and Clavien-Dindo ≥3 complications were rare. Conclusions MISTs for BPH are efficacious and safe. Randomised comparisons with long-term urinary and sexual follow-up are needed to guide choice; until then, patients should be carefully counselled based on individual priorities and circumstances.

MP28-09 CONTEMPORARY TRENDS IN UTILIZATION AND MEDICARE REIMBURSEMENT FOR AMBULATORY BPH PROCEDURES (2014-2018)

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Epidemiology & Evaluation (MP28)1 Sep 2021MP28-09 CONTEMPORARY TRENDS IN UTILIZATION AND MEDICARE REIMBURSEMENT FOR AMBULATORY BPH PROCEDURES (2014-2018) Evan Garden, Nir Tomer, Osama Al-Alao, Alexander Small, and Michael Palese Evan GardenEvan Garden More articles by this author , Nir TomerNir Tomer More articles by this author , Osama Al-AlaoOsama Al-Alao More articles by this author , Alexander SmallAlexander Small More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002025.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Historically, patients with symptomatic benign prostatic hyperplasia (BPH) underwent either transurethral resection of the prostate (TURP) or simple prostatectomy. However, novel minimally invasive surgical treatments for BPH have been recently introduced to the marketplace. We sought to describe trends in utilization and reimbursement rates for ambulatory BPH procedures in a contemporary, national cohort. METHODS: Using the CMS Provider Utilization and Payment Database (2014-2018), all cases for the following procedures were isolated (with corresponding CPT codes): TURP (52601), laser vaporization [i.e. Greenlight] (52648), laser enucleation [i.e. HoLEP] (52649), transurethral needle ablation [TUNA] (53852), transurethral microwave therapy [TUMT] (53850), and prostatic urethral lift [UroLift] (52441, 52442);. Providers who performed <10 procedures annually were excluded from the database. Descriptive statistics were calculated for total annual case volume and total annual Medicare spending per procedure. RESULTS: From 2014-2018, TURP was the most commonly utilized ambulatory BPH procedure (2014: 50.63% of procedures, 2018: 43.76%). In 2014-2017, Greenlight was the second most common (2014: 32.13%, 2017: 24.63%), but in 2018, UroLift overtook Greenlight (22.41% vs. 22.38%, respectively). Based on total case volume, TURPs were performed nearly twice as frequently as the next most-commonly utilized BPH procedure (2014: 1.58x greater case volume than Greenlight, 2018: 1.95x greater case volume than UroLift). Over time, cumulative Medicare spending rose for UroLift (2015-18: +2,843.9%), HoLEP (2014-18: +35.6%), and TUNA (2014-18: +4.0%), while spending for TUMT (2014-18: -56.5%), Greenlight (2014-18: -24.1%) and TURP (2014-18: -11.7%) decreased (Figure 1). CONCLUSIONS: TURP remains the most performed surgical option for urologists in managing BPH. UroLift has seen a precipitous increase in utilization and a commensurate rise in Medicare spending that has recently surpassed TURP. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e484-e484 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Evan Garden More articles by this author Nir Tomer More articles by this author Osama Al-Alao More articles by this author Alexander Small More articles by this author Michael Palese More articles by this author Expand All Advertisement Loading ...

PD18-05 DOES PRIOR PROSTATE SURGERY AFFECT OUTCOMES OF PATIENTS UNDERGOING ROBOTIC SIMPLE PROSTATECTOMY?

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology III (PD18)1 Sep 2021PD18-05 DOES PRIOR PROSTATE SURGERY AFFECT OUTCOMES OF PATIENTS UNDERGOING ROBOTIC SIMPLE PROSTATECTOMY? Matthew Lee, Chinonyerem Okoro, Jennifer Lee, Aeen Asghar, David Strauss, Griffin Reyes, Shawn Shekar, Ziho Lee, Andrew Harbin, and Daniel Eun Matthew LeeMatthew Lee More articles by this author , Chinonyerem OkoroChinonyerem Okoro More articles by this author , Jennifer LeeJennifer Lee More articles by this author , Aeen AsgharAeen Asghar More articles by this author , David StraussDavid Strauss More articles by this author , Griffin ReyesGriffin Reyes More articles by this author , Shawn ShekarShawn Shekar More articles by this author , Ziho LeeZiho Lee More articles by this author , Andrew HarbinAndrew Harbin More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002007.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical management of patients with enlarged prostates and lower urinary tract symptoms (LUTS) who failed prior prostate surgery may be challenging due to increased prostatic scarring and fibrosis. We compared outcomes of robotic simple prostatectomy (RASP) in patients with a history of prior prostate surgery versus patients without a history of prior prostate surgery. METHODS: We retrospectively reviewed our multi-institutional outcomes for all consecutive patients who underwent RASP between 05/2013 and 01/2021. The indication for RASP included LUTS refractory to medical and/or surgical management, and a prostate volume ≥80 milliliters. Patients were grouped based on whether or not they underwent prior prostate surgery. Postoperatively, urinary function was assessed using the American Urological Association Symptom Score (AUASS) and Quality of Life (QOL) score. Continuous and categorical variables were compared between both groups using independent t-tests and chi-square tests, respectively; p<0.05 was considered significant. RESULTS: Overall, 520 patients met inclusion criteria (Table 1). Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 8 (9.2%), 1 (1.1%), 26 (29.9%) and 3 (3.4%) patients underwent transurethral resection of the prostate, transurethral microwave therapy, water vapor thermal therapy, photoselective vaporization of the prostate or prostatic urethral lift, respectively. There was no difference in mean prostate volume (p=0.40), estimated blood loss (p=0.32), robotic console time (p=0.86) or major 30-day postoperative (Clavien>2) complications (p=0.80) between both groups. With regards to urinary function, the mean improvement in preoperative and postoperative AUASS (p=0.31) and QOL scores (p=0.11) were similar between both groups. CONCLUSIONS: For management of patients with enlarged prostates and LUTS, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery versus those that did not undergo prior prostate surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e356-e357 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Chinonyerem Okoro More articles by this author Jennifer Lee More articles by this author Aeen Asghar More articles by this author David Strauss More articles by this author Griffin Reyes More articles by this author Shawn Shekar More articles by this author Ziho Lee More articles by this author Andrew Harbin More articles by this author Daniel Eun More articles by this author Expand All Advertisement Loading ...

Medication Discontinuation Following Transurethral Prostatectomy: an Unrecognized Effectiveness Measure?

Freedom from medication is a common goal for patients undergoing surgical treatment of benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS). Knowing medication discontinuation rates following various forms of transurethral prostatectomy may aid patient counseling and assessing the comparative effectiveness of different approaches. This review examined discontinuation rates of BPH/LUTS medications following transurethral prostatectomy. Rates of BPH/LUTS medication use after transurethral resection of the prostate varied from 15% to 55%, and discontinuation rates were 54-95% across medications and follow-up periods. For laser prostatectomy, approximately 18% of patients continued medications postoperatively and discontinuation rates ranged from 53% to 75%. Minimal data on holmium laser enucleation existed. For reference, medication discontinuation rates after transurethral needle ablation or microwave therapy were only 15-28%. No recommendations or best practices inform the use of medical therapy following BPH surgery. Rates of BPH/LUTS medication use following transurethral prostatectomy are considerable.

How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?

Our aim was to provide a narrative review regarding the prevalence, the associated pathophysiologic pathways and the potential management methods of sexual dysfunction related to ablative surgical techniques for Benign Prostatic Enlargement (BPE). Men suffering from BPE are at high risk of sexual dysfunction due to the disease itself, comorbidities, and pharmacological/surgical treatments. Transurethral resection of the prostate, as the gold standard treatment option for BPE, has historically been associated with relatively high rates of postoperative sexual dysfunction problems, mainly retrograde ejaculation but also erectile dysfunction. Ablative surgical techniques, including photoselective vaporization of the prostate (PVP), transurethral needle ablation (TUNA), Transurethral Microwave Therapy (TUMT), Convective Water Vapor Energy Ablation (Rezum®) and Aquablation®, have been proposed as treatment methods able to reduce treatment-related complications for BPE patients, including adverse effects on erectile and ejaculatory function, without compromising the efficacy rates for BPE. The neurovascular bundles can be damaged during TURP due to posterolateral capsular perforation. Ablative techniques and especially PVP theoretically seem to skip this hazard, as the distance created from the necrotic area to the capsule is generally larger compared to the distance induced after TURP. However, indirect thermal injury of erectile nerves, which could also be induced by the majority of available ablative techniques, could potentially lead to ED. Two special technical characteristics (physiological saline use for tissue ablation and real time penetration depth control) of Aquablation® could be proved beneficial with regard to the effect of the method on erectile function. In general, ablative techniques seem to have a minor impact on sexual function. However, low methodological quality characterizes most of the studies included in this review mainly due to the impossibility, in many cases, to perform blind randomization. Also, many studies did not have an erectile and ejaculatory function as primary outcomes limiting that way their statistical power to identify significant variations. Management of sexual dysfunction problems arising from ablative surgeries for BPE treatment could be divided into two levels. Firstly, intraoperatively the avoidance of manipulation of crucial structures regarding ejaculatory (bladder neck or ejaculatory ducts) and erectile function (neurovascular bundles) could possibly decrease the negative effect of these procedures on sexual function. Thus, in this direction, modifications of classic ablative techniques have been proposed resulting in encouraging outcomes regarding postoperative sexual function. Secondly, if EjD and/or ED are established, the already known treatment choices should be chosen in order for sexual function rehabilitation to be achieved. Thus, regarding ED: PDE5i daily or on-demand remains the gold standard first-line treatment choice followed by intracavernosal alprostadil injections in cases of failure, while penile prosthesis implantation must be kept as the final definitive solution when all the other methods have failed. Regarding ejaculation disorders (retrograde ejaculation or anejaculation): medical therapy with a-agonists (pseudoephedrine), sperm retrieval from the urine, bladder neck reconstruction, prostatic massage, electroejaculation, penile vibratory stimulation and surgical sperm retrieval are the available treatment options. Furthermore, high-quality studies are required to investigate the potential side effects of BPE surgery on sexual function and efficient treatment methods to manage them.

Comparative Effectiveness of Transurethral Prostate Procedures at Enabling Urologic Medication Discontinuation: A Retrospective Analysis

To test the hypothesis that transurethral prostate procedures (TUPPs) eliminating tissue result in greater medication discontinuation and lower de novo initiation rates than procedures inducing tissue necrosis. Retrospective review of all men undergoing first time TUPPs at a large tertiary center from 2001 to 2016 was completed. Procedure type and urologic medication use before, 3-12 months after, and greater than 12 months after TUPP were analyzed with simple open prostatectomy as a comparator. Tissue-eliminating TUPPs included transurethral resection of the prostate and laser prostatectomy. Tissue-necrosing procedures included microwave therapy (transurethral microwave therapy) and radiofrequency ablation (transurethral needle ablation), which were grouped in analyses. Medication types were 5-alpha reductase inhibitors (5ARI), alpha blockers, anticholinergics, and beta-3 agonists (B3A). A total 5150 TUPPs were analyzed. Preoperative medication use significantly varied across TUPPs for 5ARI (P <.01), alpha-blockers (P .01), and anticholinergics (P .047), but not B3A (P .476). Transurethral resection of the prostate and laser prostatectomy were associated with significantly higher medication discontinuation rates and lower resumption and initiation rates compared to tissue-necrosing procedures. Relative to TUPPs, simple prostatectomy had significantly higher medication discontinuation, as well as the lowest resumption and initiation rates. Tissue-eliminating benign prostatic hyperplasia procedures were associated with better medication discontinuation, resumption, and de novo initiation rates compared to tissue-necrosing benign prostatic hyperplasia procedures.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2020

The AUA Guideline panel provides evidence-based recommendations for the surgical management of male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The Panel amended the Guideline in 2020 to reflect additional literature published through September 2019. When sufficient evidence existed, the Panel assigned the body of evidence a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, the Panel provided additional information as Clinical Principles and Expert Opinions (See table 1[Table: see text]). Amendments to these Guidelines include: 1) an amended statement (Guideline 1) to include conducting a physical examination; 2) a new statement (Guideline 6) discussing concepts of treatment failure and retreatment; 3) an amended statement (Guideline 15) with updated supporting text for prostatic urethral lift (PUL); 4) an amended statement (Guideline 16) for PUL; 5) an amended statement (Guideline 17) with updated supporting text for transurethral microwave therapy (TUMT); 6) an amended statement (Guideline 18) with updated supporting text for water vapor thermal therapy; 7) updated supporting text for water vapor thermal therapy (Guideline 19); 8) an amended statement (Guideline 21) with updated supporting text for laser enucleation; 9) an amended statement (Guideline 22) with updated supporting text for Aquablation; and 10) an amended statement (Guideline 23) with updated supporting text for Prostate Artery Embolization (PAE). These evidence-based updates to the AUA Guidelines further inform the surgical management of LUTS/BPH.

The safety and efficacy of transurethral microwave therapy in high-risk catheter-dependent men.

Previous studies have demonstrated the efficacy of transurethral microwave therapy (TUMT) in the management of high-risk catheter-dependent men, although few have assessed safety in high-risk patients, including those continuing anticoagulation therapy during treatment. Our goal was to assess the safety and effectiveness of TUMT in a population of high-risk catheter-dependent men. A retrospective analysis of patients who underwent TUMT at a single Veterans Affairs facility for the treatment of benign prostatic hyperplasia was completed. The primary outcome was 30-day postprocedural complications by Clavien-Dindo grade, including bleeding events. The secondary outcome was success in catheter removal. We performed TUMT in 157 men, 105 of whom had urinary retention-requiring an indwelling urethral catheter or clean intermittent catheterization. Overall, 86% of patients underwent TUMT while on anticoagulant therapy and 25% were treated while taking warfarin. The median age of the patients was 76.9 years (95% CI 74.9-78.8) median ASA-score was 3, and median follow-up was 26 months (range 1-65). Only two men experienced hematuria requiring treatment postoperatively and no transfusions were required. Only two patients (1.9%) required readmission within 30 days after treatment. There were 24 (22.9%) Clavien-Dindo grade I-II complications without grade III or higher complications. Urinary retention resolved in 63.7% of men after treatment. Our results suggest that TUMT is a safe and reasonably effective treatment for high-risk catheter-dependent men. Furthermore, the low incidence of adverse bleeding events suggests that TUMT is a safe treatment modality for men requiring uninterrupted anticoagulation.

The industrial revolution for the management of benign prostate obstruction: worldwide publication trends for surgical and medical therapies over the past two decades.

IntroductionResearch for management of benign prostate obstruction (BPO) for adult males remains a cornerstone of urology research. This landscape has witnessed the rise and fall of multiple therapies, both surgical and medical. Our aim was to formally evaluate the publication trends for these interventions over the past 20 years.Material and methodsA systematic search was performed in a Cochrane style. Data was analysed using the independent t-test and Pearson's correlation coefficient (SPSS version 24). To observe changes in trends more effectively, data was sub-divided into two time periods: 1997 to 2006 and 2007 to 2016.ResultsOver the past 20 years, 4236 papers have been published concerning for BPO (surgical, n = 2177 and medical, n = 2059). For surgical treatments, these included articles on monopolar transurethral resection of prostate (TURP) (n = 340), bipolar TURP (n = 260), HoLEP (n = 293) and Greenlight laser (n = 395). For medical therapies, these included alpha blockers (848), 5-alpha reductase inhibitors (n = 618) and PDE5I (n = 91). Between the two time periods the change was +18.8% (p = 0.108) for monopolar TURP, +497.1% (<0.001) for bipolar TURP, -54.5% (p <0.001 for prostatic stents and -81.9% (p <0.001) for transurethral microwave therapy (TUMT). There was over 290% rise in number of publications related to BPO laser surgery (p <0.001). For medical interventions, the change was +11.5% (p = 0.397) for alpha blockers, -1.9% (p = 0.867), +49.0%( 0.122) for phytotherapy, +2075% (p <0.001) for PDEI and +2375.0% (p <0.001) for combined alpha blocker and anti-muscarinics.ConclusionsInterventions for BPO have undergone a high volume of research. In particular, minimally invasive laser surgeries and combined medical therapies have seen significant expansion.

Hypothermic Cooling Measured by Thermal Magnetic Resonance Imaging; Feasibility and Implications for Virtual Imaging in the Urogenital Pelvis

To study the combination of thermal magnetic resonance imaging (MRI) and novel hypothermic cooling, via an endorectal cooling balloon (ECB), to assess the effective dispersion and temperature drop in pelvic tissue to potentially reduce inflammatory cascade in surgical applications. Three male subjects, before undergoing robot-assisted radical prostatectomy, were cooled via an ECB, rendered MRI compatible for patient safety before ECB hypothermia. MRI studies were performed using a 3T scanner and included T2-weighted anatomic scan for the pelvic structures, followed by a temperature mapping scan. The sequence was performed repeatedly during the cooling experiment, whereas the phase data were collected using an integrated MR-high-intensity focused ultrasound workstation in real time. Pelvic cooling was instituted with a cooling console located outside the MRI magnet room. The feasibility of pelvic cooling measured a temperature drop of the ECB of 20-25 degrees in real time was achieved after an initial time delay of 10-15 seconds for the ECB to cool. The thermal MRI anatomic images of the prostate and neurovascular bundle demonstrate cooling at this interface to be 10-15 degrees, and also that cooling extends into the prostate itself ~5 degrees, and disperses into the pelvic region as well. An MRI-compatible ECB coupled with thermal MRI is a feasible method to assess effective hypothermic diffusion and saturation to pelvic structures. By inference, hypothermia-induced rectal cooling could potentially reduce inflammation, scarring, and fistula in radical prostatectomy, as well as other urologic tissue procedures of high-intensity focused ultrasound, external beam radiation therapy, radioactive seed implants, transurethral microwave therapy, and transurethral resection of the prostate.

GreenLight XPS™ Vaporisation of the Prostate Has Proven Cost-Effective

Benign prostatic hyperplasia (BPH) is common in men aged &gt;60 years, affecting urinary and bladder function. Due to the progressive nature of the disease, many men initially treated with conservative therapies require surgical intervention for symptom relief. Less invasive techniques, such as transurethral microwave therapy, needle ablation, transurethral resection of the prostate (TURP), and laser treatment, have been developed with TURP being the standard of care for BPH in Europe in prostates &lt;80 mL (volume). For an increasingly ageing male population often receiving anticoagulants for cardiovascular comorbidities, TURP may not be suitable due to high risk of bleeding, requirement for bladder washouts, and blood transfusions. Owing to these requirements and potential complications associated with surgery, TURP is performed as inpatient surgery requiring a 2 to 4-day hospital stay. In the GOLIATH study, the 180 W GreenLight XPS™ laser system demonstrated comparable efficacy with TURP at 6 and 12 months, while maintaining low rates of adverse events, retreatments, or postoperative interventions in low-risk patients. Recovery parameters significantly favoured GreenLight XPS over TURP, thus greatly supporting GreenLight XPS use for BPH treatment during short-term stay. There is a requirement for healthcare services to minimise costs. Estimated on a day-case basis, GreenLight XPS was significantly more cost-effective than TURP with a 25% reduction in procedural cost, lower indirect costs, and lower financial burden based on efficacy and adverse-event outcomes. Therefore, GreenLight XPS represents an appropriate treatment option for day-case surgery and a treatment that can be tailored to individual patient needs.

Anesthesia-free procedures for benign prostate obstruction

Perhaps, 30% of patients with benign prostate obstruction experience no symptom relief with drug therapy, necessitating surgical intervention. General anesthesia can be too dangerous for elderly or frail men, making local anesthesia desirable. Such minimally invasive procedures may offer time-saving, effective, gentle, and well tolerated alternatives. Recent interest has focused on the mechanical devices and intraprostatic injections. The commercially available UroLift system demonstrates promising short-term data in randomized multicenter trials. Rezum steam injection therapy is intriguing, although currently study-based with limited data. NX1207 and PRX302 are new intraprostatic injection drugs demonstrating interesting results in phase I and II studies, whereas conflicting results surround the prostatic injection of botulinum toxin A. For transurethral microwave therapy, definitive evaluations regarding the treatment of chronic urinary retention in nonsurgical patients are ongoing. Although none of these minimally invasive procedures must be performed under general anesthesia, all require local anesthesia with possible sedation. In most studies, pain therapy management is rudimentary or not described. Although good short-term results are described, no long-term data are available.

AB02. UroLift: a new surgical treatment for BPH without sexual side effect

Benign prostatic hyperplasia (BPH) is a chronic and often progressive condition. It affects nearly three in four men by the seventh decade of life. Clinically, BPH is distinguished by progressive development of lower urinary tract symptoms (LUTS) even though not all patients with BPH develop LUTS. Retropubic simple prostatectomy was first described in 1945 and soon became the popular surgical management of BPH. Open prostatectomy was gradually replaced by transurethral resection of the prostate (TURP) as the standard surgical treatment of BPH. With the introduction of medical therapy in the 1980s, the standard treatment for patients with LUTS secondary to BPH shifted to pharmacotherapy with α-blockers and/or 5α-reductase inhibitors. This paradigm shift to pharmacological therapy led to a dramatic decrease in hospitalization for TURP throughout the 1990s. After more than 10 years of decrease in total BPH procedure rates, the trend was reversed after 2002 due to the marked increase in Minimally Invasive Surgical Techniques (MISTs) including transurethral microwave therapy, transurethral needle or ethanol ablation, high intensity frequency ultrasound, and laser resection/ablation as well as transurethral saline plasma vaporization. Unfortunately, all MISTs are associated with various degrees of sexual side effects, mainly ejaculatory dysfunction and erectile dysfunction. The UroLift System is newly approved technology by the FDA for BPH. This versatile implant self-sizes in the prostate and mechanically opens the prostatic urethra without causing any sexual side effects. This presentation will introduce this novel technology for the treatment of BPH.