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CUA guideline: LUTS/BPH

       Prostatic stents                                      44% increase in Qmax. Surgical retreatment rate is 4.4%
       Temporary stents can provide short-term relief from BPO in   at five years.
       patients temporarily unfit for surgery.  In general, stents are
       subject to misplacement, migration, and poor tolerability   We	suggest	that	the	Rezum	system	of	convective	water	vapor
       because of exacerbation of LUTS and encrustation. Given   energy	ablation	may	be	considered	an	alternative	treatment
       these common side effects, prostatic stents have a limited   for	men	with	LUTS	interested	in	preserving	ejaculatory	func-
       role in the treatment of moderate-to-severe LUTS. A newer   tion	with	prostates	<80	cc,	including	those	with	a	median
       generation of stents are currently being evaluated and may   lobe (conditional recommendation, evidence level C).
       provide an alternative surgical option for the management
       of BPH/LUTS in the future.                            Image-guided robotic waterjet ablation
                                                             Aquablation (robotic-guided hydrodissection ablates pros-
       We	suggest	prostatic	stents	only	as	an	alternative	to	cath-  tatic parenchyma while sparing collagenous structures such
       eterization	in	men	unfit	for	surgery	with	a	functional	det-  as blood vessels and the surgical capsule)  has shown com-
       rusor (conditional recommendation, evidence level C).  parable improvements in efficacy and safety compared to
                                                             TURP in men with <80 cc prostates.  Additional studies
       Prostatic urethral lift                               have also demonstrated efficacy and safety in glands 80–150
       The prostatic urethral lift procedure, or UroLift , (small,   cc. Aquablation preserves erectile and ejaculatory function
       permanent, suture-based nitinol tabbed implants compress   in nearly 100% and approximately 90% of patients, respect-
       encroaching lateral lobes delivered under cystoscopic guid-  ively. Five-year retreatment rates are low (6% at five years).
       ance), provides less effective but adequate and durable
       improvements in IPSS and QMax compared to TURP while   We	suggest	that	Aquablation	be	offered	to	men	with	LUTS
       preserving sexual function (no reported retrograde ejacula-  interested	in	preserving	ejaculatory	function	with	prostates
       tion observed at 12 months).  Most complications are mild   <150	cc,	with	or	without	a	middle	lobe (conditional recom-
       and resolve within four weeks but include dysuria (34%),   mendation, evidence level C).
       hematuria (26%), pelvic pain (19%), urge incontinence (7%),
       and UTI (3%). Surgical retreatment was 13.6% over five   Temporary implantable nitinol device
       years.  A recent study (MedLift study) reported on the use   Temporary implantable nitinol device (iTind) is a temporary
       of prostatic urethral lift in patients with a median lobe. For   (five days and then removed under local anesthetic), mech-
       middle lobe deployment, the intravesical tissue is pulled into   anical, stent-like device designed to remodel the bladder
       the prostatic fossa and affixed to either side of the urethra.   neck and the prostatic urethra through pressure necrosis.
       Fort-four patients underwent this technique and results are   Three prospective, randomized clinical trials (n=269) have
       very similar to the pivotal L.I.F.T. trial regarding improved   demonstrated IPSS reduction of 45–60%, Qmax increase of
       IPSS and IPSS quality of life, while preserving ejaculatory   50–110%, no changes in erectile or ejaculatory function,
       function. It should be noted that followup for this study was   and a retreatment rate of 9% at three years. 96-98  Long-term
       only 12 months.                                       durability studies are pending.
       We	suggest	that	prostatic	urethral	lift	(UroLift)	may	be	  We	recommend	that	iTind	may	be	offered	to	men	with
       considered	as	an	alternative	treatment	for	men	with	LUTS	  LUTS	interested	in	preserving	ejaculatory	function,	with
       interested	in	preserving	ejaculatory	function	with	prostates	  prostates	30-80	cc.	Patients	should	be	made	aware	of	the
       <80	cc.	Prostatic	urethral	lift	can	also	be	be	offered	to	  higher	retreatment	rate	at	3	years (conditional recommen-
       patients	with	a	small-to-moderate	median	lobe	and	bother-  dation, evidence level C).
       some	LUTS.	Patients	(with	or	without	a	median	lobe)	should
       be	made	aware	of	the	higher	retreatment	rate	at	five	years   Prostatic artery embolization
       (conditional recommendation, evidence level C).       Prostatic artery embolization (PAE) is a minimally invasive
                                                             treatment option exclusively performed by interventional
       Convective water vapor energy ablation                radiologists at specialized centers. PAE results in significant
       Ablations using the Rezum  system (uses the thermodynamic   IPSS, Qmax, and PVR improvement compared to baseline
       principle of convective energy transfer) report significant   at 12 months,  however, inferior outcomes compared to
       improvement of IPSS and Qmax at three months and sus-  TURP 100-102  or OSP.  Although PAE has reportedly fewer com-
       tained until 12 months,  with preservation of erectile and   plications than TURP, non-targeted embolization may lead to
       ejaculatory function.  Recent five-year results have con-  rare ischemic complications like transient ischemic proctitis,
       firmed durability of the positive clinical outcomes, with a   bladder ischemia, urethral and ureteral stricture, or seminal
       57% reduction in IPSS, 45% increase in quality of life, and   vesicles ischemia.  Efficacy of PAE may be more advanta-
                                                 CUAJ • August 2022 • Volume 16, Issue 8                      251
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