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

© The Canadian Journal of Urology TM : International Supplement, August 2020 a crossover study to negate potential placebo effect, which revealed significantly greater improvements of IPSS, QoL, and Qmax after crossover treatments compared to that of the control period. 21 In a separate pilot study investigating safety and efficacy of Rezum, Dixon et al also demonstrated positive and evident responses as early as 1-month post-procedure with durable results at 2 years. 26,27 In terms of safety, Rezum resulted in very few adverse events, all of which were transient and only mild-to-moderate severity. Most procedure-related adverse events occurred in the first 3 months and resolved spontaneously within 3 weeks. The most common events included dysuria (16.9%), hematuria (11.8%), hematospermia (7.4%), urinary frequency and urgency (5.9%), acute urinary retention (3.7%), and suspected urinary tract infection (3.7%). 20 Serious procedure-related adverse events were rare and included one case of bladder neck contracture and bladder calculi reported 6 months post-procedure and a second case of urosepsis after follow up cystoscopy. At 4 years follow up, there were no late occurring related adverse events, or de novo erectile dysfunction reported. 23 Mean catheterization time was reported as 3.4+/-3.2 days in a total of 90.4% (122/135) of patients in the initial study. 20 However, of these, only 32% (39/122) truly required catheterization due to unsuccessful voiding trials before discharge, whereas the remaining 68% (83/122) were at the surgeon’s discretion of when to remove the catheter. As such, these results may not reflect true catherization rates in real-world practice. In assessing Rezum’s durability, it is important to consider retreatment rates. The 5-year surgical retreatment rates were reported to be 4.4%. 24 This demonstratesRezum’sadvantageoverother conductive thermal ablative devices such as the transurethral needle ablation (TUNA) and transurethral microwave therapy (TUMT), with reported 5-year retreatment rates of 14%-51%and 9%-21%, respectively. 28-33 Additionally, Rezum demonstrates similar, or favorable, durability compared to TURP (retreatment rates 3%-14.5% after 5 years). 34 Evidence for Rezum validates the procedure as a safe, effective, and durable BPH treatment option that can be performed under local anesthesia in an office-based setting with minimal sexual dysfunction. Prostatic urethral lift (PUL, Urolift) PUL using the Urolift system (NeoTract/Teleflex Inc., Pleasanton, CA, USA) is a minimally invasive technique that mechanically retracts the obstructing prostatic lobes to create a wider prostatic urethral lumen from bladder neck to the verumontanum. Urolift, approved by the FDA in 2013, is a tissue- sparing procedure using permanent nitinol and stainless steel implants to anchor luminal tissue to prostatic capsule. Implants are placed under direct cystoscopic vision in an ambulatory setting and are sized in situ to the prostatic lobe after deployment with the Urolift delivery device. While the mechanism of action is primarily mechanical, pre-clinical research on canine and cadaveric models suggests that tissue compression causes acute ischemia and focal atrophy with subsequent tissue remodeling. 35 Whenperforming the PUL, it is recommended to start working from the bladder neck towards the verumontanum distally. Special care should be taken to avoid injury and disruption to the neurovascular bundle by deploying the Urolift implants in the anterior chamber. After implants are deployed, the procedure is considered complete when there is a continuous open channel observed on cystoscopy. Current AUA guidelines recommend its use for men with prostates less than 80 grams with a non-obstructing median lobe. 5 Men undergoing PUL report minimal sexual side affects, an additional attractive advantage over procedures designed to remove tissue. Preservation of sexual function is known to have a significant impact on quality of life, making this procedure a well-suited option for men with this priority. 36 Another advantage of PUL is that it can be performed in an office setting under local anesthesia, including the use of topical anesthetics (lidocaine), oral sedation (benzodiazepines), and/or analgesics (acetaminophen, opioids). 37 Chilled topical lidocaine gel should be applied into the urethra for sufficient anesthetic coverage, with adequate time allowed for preoperative anesthetics to take effect. 38 If additional anesthetic is necessary, a prostatic block using 1% lidocaine injection can be performed, similar to that of a transrectal ultrasound guided prostate biopsy. With PUL gaining popularity and use among clinicians, there is increasing scientific evidence demonstrating its safety, efficacy, and durability in treating BPH. Chin et al performed the first safety and feasibility study for PUL and demonstrated significant improvements in IPSS, QoL, BPHII and Qmax as early as 2 weeks with durable effects at 2 years followup. 35,39 Adverse events were rare, transient, and consistent with those expected for any minimally invasive transurethral treatments. The most common device- related events were hematuria (12 patients), dysuria (11), and irritative symptoms (9), which typically resolved within 1 month. Preservation of sexual function following PUL has also been demonstrated Das ET AL. 6