Best of EAU: The surgical armamentarium is evolving

New surgical techniques under investigation for the treatment of lower urinary tract symptoms (LUTS) and bladder outlet obstruction caused by benign prostatic hyperplasia (BPH) include the Butterfly, UroLIFT, Rezum, and embolisation. The choice of which technique to use for which patient should be based on the shared goals of patient and physician, such as de-obstruction, symptom relief, quality of life, satisfaction, reduction of (sexual) side effects, and cost-effectiveness.

The surgical armamentarium for the treatment of symptomatic BPH is evolving. Currently available options are resection, vaporisation, and enucleation techniques, which are well established. The vast majority are now recommended in the guidelines, based on level 1 evidence. In the past decade, alternative minimally invasive surgical therapies have been introduced. Prof. Jean-Nicolas Cornu (CHU Charles Nicolle, Rouen, France) presented highlighted abstracts on these new techniques [1].

Butterfly

A prospective, open-label study evaluated the new Butterfly technique in 50 men (Qmax ≤13 mL/sec; international prostate symptom score [IPSS] >12) who were candidates for surgery (NCT03912558) [2]. This device –a removable metallic implant that functions by retracting the lateral lobes of the prostate– was inserted under sedation with no catheter after the intervention. One-year results showed improvements of Qmax by 33%, IPSS reduction by 40%, and sexual quality of life score increase by 38%. No impact on sexual function was reported, with ejaculation preserved in 100% of patients. In 1 patient the device was repositioned; 5 patients chose to remove the device. Seven patients underwent transurethral resection of the prostate (TURP). One patient developed a bulbar urethral stricture.

UroLIFT

The UroLIFT is a trans-prostatic, permanent implant that widens the prostatic urethra. The device was investigated in a large, international, retrospective database, including >2,700 subjects [3]. This study evaluated the predictive factors for likelihood of not undergoing a subsequent intervention for benign prostatic obstruction (BPO), which determines the success of the procedure. Real-world data was compared with the data from the real-world retrospective LIFT trial. “They found that higher IPSS and higher impact on quality of life at baseline may increase the likelihood of subsequent BPH surgery,” Prof. Cornu mentioned. “That was the main predictor. Prostate volume did not have a significant predictive value.”

Rezum

A European, multicentre study evaluating water vapour therapy with the Rezum device included >600 patients [4]. No significant change was shown in erectile function as measured with the IIEF-5 at follow-up (P=0.80). Antegrade ejaculation was present in 90% of patients, which was predicted for this study. Advantages of the Rezum device are that it is a relatively short procedure, has a quick recovery, is not associated with erectile dysfunction, and has a low risk of dry orgasm (5–10%). A disadvantage is that the patient needs a catheter for 1–2 weeks. Furthermore, in line with other transurethral approaches, the procedure is associated with symptoms such as dysuria and storage problems, failure to remove the catheter, and risk of infections.

Embolisation

Two-year outcomes of a non-inferiority study comparing prostatic artery embolisation (PAE) with TURP demonstrated that non-inferiority was not met [5]. TURP was also superior to PAE for Qmax, post-void residual volume, PSA, and prostate volume, demonstrating that the effects were evolving in parallel with the anatomical effects of embolisation. However, PAE was associated with fewer complications than TURP. “Hence, patients could be looking for a trade-off – a less effective option with fewer secondary effects,” Prof. Cornu suggested [1].

Which technique for which patient?

The main question is which technique do we need for which patient? “The patient’s view is lost because there are too many options.” Prof. Cornu said. “The surgeon’s view shows that there is a trade-off between adverse events and de-obstruction efficacy” (see Figure).

Figure: Trade-off between adverse events and de-obstruction efficacy [6]



EEP, Endoscopic Enucleation of the Prostate.
Reprinted from Cornu JL. Eur Urol. 2021;80(1):43–5. DOI: 10.1016/j.eururo.2021.03.034. Copyright 2021, with permission from Elsevier.

The guidelines from the EAU, AUA, and NICE give different advice, mainly based on the acceptance of available evidence. A recent systematic review evaluating patient preferences demonstrated that patients are mainly worried about their sexual function, urinary continence, and pain on urination [7]. They care more about these symptoms than about the obstruction.

Prof. Cornu advised that decisions should be based on shared goals, such as de-obstruction (e.g., Qmax and residual volume), reduction of symptoms (e.g., nocturia, urgency, and voiding) and side effects (mainly sexual), improvement of quality of life and satisfaction, and cost-effectiveness.

1. Cornu JL. Best of EAU21: BPH/LUTS. EAU21 Virtual, 8­–12 July 2021
2. Katz R. P0045, EAU21 Virtual, 8­–12 July 2021.
3. Kayes O. P0051, EAU21, 8­–12 July 2021.
4. Cocci A. P0052, EAU21 Virtual, 8­–12 July 2021.
5. Abt D, et al. Eur Urol. 2021;80(1):34–42.
6. Cornu JL. Eur Urol. 2021;80(1):43-5.
7. Malde S, et al. Eur Urol. 2021;79:796–809.

 

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Posted on 31 August 20216 September 2023