3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 WATER II trial met the study design goals for both safety (45.5% at 3 months, p < 0.001) and efficacy (mean IPSS improvement of 16.5 points at 3 months, p < 0.001) with significant improvements at 6 months in Qmax (10.1 mL/s increase, p < 0.001) and post-void residual urine (PVR) (84 mL decrease, p < 0.0001). 13 At 12-months follow up, effective and durable results were demonstrated with mean IPSS improvement of 17.0 points (p < 0.0001), mean IPSS QoL improvement of 3.3 points (p < 0.0001), Qmax improvement of 12.5 mL/s, anddecrease inPVRof 171mLin thosewithPVR > 100 at baseline. 14 Additionally, anterograde ejaculation was maintained in 81% of sexually active men. Notably, prostate-specific antigen (PSA) levels were still elevatedat 12monthswithmeanof 4.4ng/mL, improved from baseline mean of 7.1 ng/mL. When these 12-month results were compared to those of the WATER I trial, similar benefits were observed in both 30-80 mL and 80-150 mL prostate sizes. 15 This suggests that Aquablationmay be an effective therapy independent of prostate size. However, there may be an increase in complication risk with patients with larger prostates. Like other surgical BPH treatments, Aquablation carries the risk of blood loss and need for transfusion. In an effort to optimize benefits and minimize blood loss and transfusion rates, refined techniques have been published. Elterman et al compared athermal methods of hemostasis in preventing blood transfusions to the use of cautery across various prostate volumes followingAquablation. 16 Out of 801 patients analyzed in the study, 31 transfusions (3.9%) were reportedwith prostate size andmethod of traction contributingmost to transfusion risk. In prostates ranging from 20-280 mL, an increased risk of transfusion of 0.8%-7.8% was observed when robust traction using a catheter- tensioning device (CTD) without cautery was used, whereas risk of transfusionwas 1.4%-2.5% inmenwho underwent selective bladder neck cauterization with standard traction (catheter taped to the leg, gauze knot synched to themeatus, or no traction). This suggests an important role for transurethral cautery in hemostasis and reduction in transfusion risk. Water vapor thermal therapy (Rezum) The Rezum system (Boston Scientific, Marlborough, MA, USA) is a minimally invasive transurethral water vapor therapy used to treat LUTS secondary to BPH. Current AUA guidelines suggest it may be offered to patients with prostate volume less than 80 grams, especially as an effective option for preservation of erectile and ejaculatory function. 5 Another major advantage of Rezum is its ability to be performed safely as an outpatient procedure under local anesthesia. 17 The procedure is suitable for treating men over the age of 50 with evidence of efficacy in treating enlarged median lobes. However, it is contraindicated in patients with concurrent artificial urinary sphincter or implantable penile prothesis. The Rezum system, approved by the FDA in 2015, creates water vapor (steam) thermal energy through the application of radiofrequency (RF) current against an inductive coil heater in the device’s handle. This steam (103°C) can then be injected into the prostatic transitional zone. Upon contact with prostatic tissue, the steam phase shifts or condenses from vapor to liquid, releasing and convectively delivering large amounts of thermal energy (540 calories/gram). This results in disruption of prostatic cell membranes leading to immediate cell death and necrosis. Mynderse et al demonstrated that the ablative tissue was reduced in volume by 91.5% at 3 months and 95.1% at 6 months after treatment as shown on magnetic resonance imaging (MRI). 18 There was a mean reduction in whole prostate volume of about 28.9% and transition zone volume reduction of 38% on MRI at 6 months compared to baseline 1-week images. The ablative lesions were confined within the targeted treatment zone without compromising the integrity of surrounding structures. This is consistent with the thermodynamic principles of convective heating and allows for minimization of postoperative complication rates by reducing risk of injury to the bladder, rectum, or striated urinary sphincter. 19 To our knowledge, McVary et al performed the only double-blind trial investigating Rezum in a multicenter, prospective, randomized controlled study with reported 5-year outcome data. Their data demonstrated subjective and objective improvements in LUTS observed as early as 2 weeks post-procedure with durable results through 5 years. 20-24 Previously published improvements of IPSS, IPSS-QoL, BPH Impact Index, andQmaxwere sustained to 5 years with improvements of 48%, 46%, 49% and 49%, respectively (p < 0.0001). 24 In addition, their published 4-year data reported clinicallymeaningful improvements of Qmax and IPSS scores for patients who underwent treatment of enlarged median lobes when compared to those who had untreatedmedian lobes. 23 Moreover, urinary incontinence scores (International Continence Society Male Incontinence Scale questionnaire-Short Form [ICS male IS-SF]) significantly decreased by 15% with no reported cases of sexual dysfunction at 4 years (IIEF andMSHQ-EjD scores stable andmaintained). 25 Paired analysis of outcomes was also performed as part of 5 Benign prostatic hyperplasia: an update on minimally invasive therapy including Aquablation