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AUA Highlights on Minimally Invasive Surgical Therapy (MIST) for Benign Prostatic Hyperplasia (BPH)

Op-Med is a collection of original articles contributed by Doximity members.

This article is based on the BPH/LUTS take home messages presentation, presented by Dean Elterman, MD

The recent AUA conference showcased a number of noteworthy presentations on BPH/LUTS, indicating significant growth in this area. With various courses, sessions, and poster/podium presentations, the conference provided insightful updates on the topic.

One area of particular interest was the promising results of various novel minimally invasive surgical therapies (MISTS).

The Pinnacle study, presented by S. Kaplan et al. demonstrated the effectiveness of the Optilume® drug-coated balloon treatment. This treatment achieves an anterior commissurotomy to separate the lateral lobes of the prostate while delivering paclitaxel to maintain luminal patency. The 12-month data showed a significant improvement in peak flow rates, up to 98% at 30 days, and this improvement was sustained to over 113% at one year.

The ZEST-CAN study (Elterman et al.), evaluated the Zenflow Spring system, where a nitinol-based spring is placed into the prostatic urethra resulting in a significant 11-point improvement in IPSS (or 46%), improvements in quality of life (IPSS-QOL improved 56%) as well as flow rates (Qmax improved 45%) at 12 months. There was no change in sexual function.

The 24-month study of ProVee Expander (T. Lynch and P. Anderson), focused primarily on safety and demonstrated no issues with migration, catheterization, urinary retention, de novo ejaculatory or erectile dysfunction, or removals of the device. Secondary endpoints showed improvements in Qmax (63% improvement in 12 months) and IPSS (>30% improvement in 12 months).

The conference also explored some interesting findings on FDA-approved MISTS. For example, 

a study presented by C. Cerralto et al. which compared the effectiveness of a minimal approach of one injection per lobe, versus multiple treatments per lobe using REZUM®. The matched cohort of 146 patients revealed that multiple injections per site led to a higher risk of postoperative de novo retention and urinary tract infection. However, there was no difference in IPSS improvements at three months and up to 12 months between the two approaches. Therefore, a minimal approach to REZUM®  could be considered a safe and effective option for treating men.

In addition, a study by Elterman et al., showed that REZUM® treatment resulted in an average 34% reduction in prostate volume regardless of the prostate size, this included prostates >80 cc. Furthermore, in large prostates (>80 cc), over 29% of patients experienced a greater than 50% volume reduction.

C. Roehrborn analyzed the effectiveness of Prostatic Urethral Lift (PUL) in over 300 patients across five pivotal prospective randomized studies. The study found that PUL had successful durability for up to five years with a decreasing need for retreatment as the number of implants increased. Additionally, earlier intervention when symptoms are less severe was associated with better long-term outcomes. Baseline predictors for five-year durability included a lower quality of life score, lower baseline IPSS total score, and lower obstructive symptoms.

O. Kayes studied the effectiveness of PUL in patients with acute urinary retention (AUR). The study found that real-world studies and the PULSAR study, specifically designed for men with urinary retention, demonstrated catheter-free and surgery-free outcomes for up to 12 months following PUL treatment. The study also found that successful outcomes in AUR patients were associated with earlier intervention.

Of note, R. Bertolo et al. compared transperineal laser ablation (TPLA) versus transurethral resection of the prostate (TURP) in a randomized clinical trial. The study found that TPLA preserved ejaculatory function, while TURP led to greater improvements in peak flow IPSS and quality of life. However, satisfaction rates were higher in TURP patients, with around 50% of men satisfied with TPLA compared to 80% of men satisfied with TURP.

Finally, several studies evaluated the effectiveness of surgical treatments for BPH in large prostates. Aquablation technology was highlighted as a resective treatment for large glands. N. Bhojani presented the final 5-year results of Aquablation for BPH in large prostates (80-150 mL), which showed promising results, including improvements in IPSS and flow rates, while preserving sexual function. The study also demonstrated a low annual retreatment rate. Dr. D. Elterman presented on Aquablation postoperative bleeding risk reduction, which showed bleeding rates between 40 to 100 mL in the majority of cases. With the addition of focal bladder neck cautery technique, the rates of transfusion are now only 0.14%.

In summary, these studies shed light on the effectiveness and durability of various treatment options for benign prostatic obstruction. Overall, these findings highlight the growing significance of MISTS in the treatment of BPH/LUTS, with a range of safe and effective options available for patients.

Dr. Palese and Dr. Larenas have no conflicts of interest to report.

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