4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 3 UroLift and Rezum: minimally invasive surgical therapies for the management of benign prostatic hyperplasia Rezum The Rezum system (Boston Scientific, Marlborough, MA, USA) consists of a handheld delivery device and generator that utilizes convective water vapor energy ablation to reduce prostatic tissue and subsequently alleviate obstructive urinary symptoms. The vapor needle resideswithin the insulated lumen of the delivery device until it is deployed into the prostatic tissue. The needle is a flexible braided silicone tubing with 12 small emitter holes spaced around its tip at 120-degree intervals to allow a controlled, uniform circumferential dispersion of water vapor. The convective ablative technology is distinct from conductive heat transfer which results in non-uniform heat gradients and uneven treatment of the prostate gland. 2 This modality is indicated in men ages 50 years and above, and for prostate volumes between 30-80 grams. It is also indicated for treatment in patients with hyperplasia of the central zone and/ormedian lobe. Contraindications to this procedure include the presence of an artificial urinary sphincter or a penile prosthetic implant. The objective of the Rezum procedure is to create a thermal lesion along the length of the prostatic urethra along each lateral lobe. This can be accomplished by creating contiguous, overlapping lesions between the bladder neck and proximal verumontanum, to target the bulk of the adenoma and to follow the natural slope of the urethra. The guidelines for determining the number of lesions are based on the length of the vapor treatment zone, ie the distance between the bladder neck and the verumontanum. If the distance between the bladder neck to the verumontanum is < 2 cm, 2-3 cm or > 3 cm, then 1-2, 2-3, and 3-4 estimated treatments per lobe is necessary, respectively. Excessive treatments may lead to prolonged irritative symptoms that may require prolonged catheterization. There are proprietary training modules developed by the company to allow urologists to familiarize themselves with the Rezum system. McVary et al conducted a pivotal multicentered, randomized sham-controlled trial that randomized patients 2:1 to the thermal therapy (Rezum) versus control (rigid cystoscopy) arm. 3 The final 5-year outcomes were recently reported in 2021 and showed a continuous and substantial improvement in the IPSS (reduced 48%), Qmax (improved 44%), QoL (increased 45%) and BPHII (decreased 48%) scores. Surgical retreatment rates remained stable at 4.4% plus an additional 11.1% for medical treatment after 5 years. Moreover, procedure-related adverse events appeared to be transient and low, with the most common reported symptoms being dysuria (0.8%) and hematuria (0.5%), both of which resolved within 3 months post-procedure. 4 Importantly, there were no reported cases of sexual dysfunction or sustained de novo erectile dysfunction over the period of the study. 5,6 Catheterization post-procedure was performed in over 90% of patients for a mean of 3.4 days, of which, only 32% truly necessitated catheterizations due to unsuccessful void trial prior to discharge. 7 Additional sub-analyses among men with identifiable median lobes within this trial demonstrated that treatment of the median lobe resulted in additional clinically meaningful improvement of IPSS (by 2.2 point) and Qmax (by 4.6 mL/sec). 4 Gupta et al also performed an analysis comparing a subset of patients from the MTOPS trial who met the pivotal Rezum study criteria. 8 They found that symptom improvement (IPSS and Qmax) was significantly greater than either doxazosin or finasteride alone, but similar to that of combination drug use. Similarly, they found that with continued daily medication therapy, patients experienced reduced desire and erectile function with doxazosin, and significantly worse sexual desire, erectile and ejaculatory function with finasteride and combination drug therapy. Rezum therapy, however, was not associated with negative impacts in sexual function throughout the 3-year study period. 9 Overall, contemporary literature has shown that a single water vapor thermal therapy treatment can provide significant and durable improvements in LUTS scores up to 5 years, even when compared to prolonged medication use, with the additional benefit of preserving sexual function. UroLift The prostatic urethral lift (PUL) UroLift (Neotract, Pleasanton, CA, USA) is aminimally invasive technique that utilizes permanent nitinol implants to retract the obstructing lateral lobes towards the prostatic capsule, to allow expansion of the prostatic urethral lumen. 10 This procedure can be performed in an ambulatory setting and the implants are deployedunder cystoscopic guidance with the aid of the UroLift delivery device. Themechanismof action is primarilymechanical which allows luminal expansion via a tissue-sparing approach. Moreover, pre-clinical research on canine models have demonstrated the initiation of acute ischemia over the prostatic tissue from the implants that leads to tissue remodeling and focal atrophy. This may factor into the demonstrated durability of the effect. 11 The largest, multinational, randomized control trial investigating the utility of UroLift to date is