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CUA guideline: LUTS/BPH

Prostatic stents 44% increase in Qmax. Surgical retreatment rate is 4.4%
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Temporary stents can provide short-term relief from BPO in at five years.
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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-
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rusor (conditional recommendation, evidence level C). parable improvements in efficacy and safety compared to
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TURP in men with <80 cc prostates. Additional studies
Prostatic urethral lift have also demonstrated efficacy and safety in glands 80–150
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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
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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
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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
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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
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principle of convective energy transfer) report significant at 12 months, however, inferior outcomes compared to
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improvement of IPSS and Qmax at three months and sus- TURP 100-102 or OSP. Although PAE has reportedly fewer com-
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tained until 12 months, with preservation of erectile and plications than TURP, non-targeted embolization may lead to
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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-
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CUAJ • August 2022 • Volume 16, Issue 8 251