Page 6 - Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH): 2018 update

Nickel et al

We suggest TUMT therapy as a consideration for treat- 2.4.6. New and emerging therapies
ment of carefully selected, well-informed men (conditional Prostatic urethral lift: The prostatic urethral lift procedure
®
recommendation based on moderate-quality evidence). or Urolift (small, permanent, suture-based nitinol tabbed
Transurethral needle ablation (TUNA): The TUNA device implants compress encroaching lateral lobes delivered under
results in short-term voiding symptoms and urinary flow par- cystoscopic guidance) provides less effective, but adequate
ameter improvement, but it does not reach the same level and durable improvements in IPSS and QMax compared to
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of efficacy and long-lasting success as TURP. Scarce data TURP while preserving sexual function (no reported retro-
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and lack of replication of comparisons hinder the assessment grade ejaculation observed at 12 months). Most compli-
of TUNA to other minimally invasive surgical procedures. cations are mild and resolve within four weeks. Surgical
Long-term treatment durability also appears poor, with over- retreatment was 13.6% over five years. 68
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all retreatment rate of 19% at two years. To the best of our We suggest that prostatic urethral lift (Urolift) may be
knowledge, TUNA is no longer offered by any Canadian considered an alternative treatment for men with LUTS
urology centre. This may change if new devices and/or trial interested in preserving ejaculatory function, with prostates
data become available. <80 cc and no middle lobe (conditional recommendation
We suggest TUNA therapy not be offered as a considera- based on moderate-quality evidence).
tion for treatment of BPH/LUTS (conditional recommenda- Convective water vapour energy ablation: Ablation using
tion based on moderate-quality evidence). the Rezum system (uses the thermodynamic principle of
®
Prostatic stents: Temporary stents can provide short-term convective energy transfer), report significant improvement
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relief from BPO in patients temporarily unfit for surgery. In of IPSS and Qmax at three months and sustained until 12
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general, stents are subject to misplacement, migration, and months with preservation of erectile and ejaculatory func-
poor tolerability because of exacerbation of LUTS and encrust- tion. Reported two-year results have confirmed durability
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ation. Given these common side effects, prostatic stents have of the positive clinical outcome. 71
a limited role in the treatment of moderate to severe LUTS. We suggest that Rezum system of convective water
We suggest prostatic stents only as an alternative to vapour energy ablation may be considered an alterna -
catheterization in men unfit for surgery with a functional tive treatment for men with LUTS interested in preserving
detrusor (conditional recommendation based on low- ejaculatory function, with prostates <80 cc, including those
quality evidence). with median lobe (conditional recommendation based on
moderate-quality evidence).
Image-guided robotic waterjet ablation: Aquablation
(robotic-guided hydrodissection
ablates prostatic parenchyma
MLUTS/BPH
while sparing collagenous
Evaluation as per Fig. 1
Storage symptoms structures such as blood vessels
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only and the surgical capsule) has
shown comparable improve-
ments in efficacy and safety
compared to TURP in men with
• Lifestyle MIST
intervention Voiding (± storage symptoms) or <80 cc prostates (approximately
• Behavioural therapy Surgery
• Antimuscarinics Discuss Rx options as per Fig. 3 50% of patients having middle
• B3 agonist Shared decision
lobes) with significant decrease
in risk of anejaculation. 73
We suggest that aquablation
Medical therapy
Nocturnal option be offered to men with LUTS
polyuria Failure
Predominant ED interested in preserving ejacu-
voiding
latory function, with prostates
<80 cc, with or without middle
Larger gland and/or higher
Antimuscarinic Small gland and/or PSA PDE5 lobe. (conditional recommen-
Desmopressin & low PSA α-blockers ± inhibitor dation based on moderate-
α-blockers α-blockers
5α-reductase inhibitors
quality evidence).
Temporary implantable
nitinol device (iTIND): iTIND
FAILURE
is an emerging, temporary (five
Fig. 2. Male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH) management algorithm. days and then removed under
ED: erectile dysfunction; PDE5: phosphodiesterase type 5; PSA: prostate-specific antigen.
308 CUAJ • October 2018 • Volume 12, Issue 10