In a recent study presented at the 2021 AUA Annual Meeting, Kevin T. McVary, MD, FACS, and co-authors assessed the 5-year outcomes of Rezum water vapor thermal therapy in patients with BPH, specifically focusing on erectile and ejaculatory function.
Erectile and ejaculatory dysfunction are prominent post-operative symptoms in men who are treated for benign prostatic hyperplasia (BPH) with traditional prostate surgeries, such as transurethral resection of the prostate (TURP). Newer treatment methods, like Rezum or Prostatic urethral Lift (PUL), aim to reduce those symptoms.
In a recent study presented at the 2021 American Urological Association Annual Meeting,¹ Kevin T. McVary, MD, FACS, and co-authors assessed the 5-year outcomes of Rezum water vapor thermal therapy in patients with BPH, specifically focusing on erectile and ejaculatory function. McVary is a professor of urology and director of the Center for Male Health at Loyola University Medical Center, Maywood, Illinois.
The basis of this study was to look at the sexual function aspect of the 5-year Rezum study, the pivotal study that looked at lower urinary tract symptom improvement in men with BPH who had convective water vapor therapy Rezum treatment. We published those pivotal results concerning LUTS improvement about 6 months ago.² It had a marked improvement in lower urinary tract symptoms that were durable for 5 years. Prospectively, in this trial we measured various aspects of sexual function. The purpose of this particular manuscript, which is under review and presented at this year's AUA, was specifically focused on aspects of sexual function over 5 years following a Rezum treatment. It's an ancillary study to the pivotal study of Rezum treatment, but with this investigation we're focused entirely on male sexual health.
I think there's a couple of very important aspects of this study that are worth mentioning. By way of review, men had a significant and durable improvement in lower urinary tract symptoms and flow rates over the 5-year period. And that is represented in our previous published paper this past year. There are several ways of addressing sexual function. A very common way is to track sexual function with the use of sexual function questionnaires. It's considered a quantitative, more objective evaluation of sexual function. One of those is called the SHIM, the Sexual Health Inventory for Men. It's a measurement of their assessment of erection quality over time. In this study, we focused on the men who are in the trial and sexually active, measuring their erectile function. In this you see a very stable response to erection measurement over the 5-year period of time. Rezum does not appear to affect erection, which again confirms what we saw at 3 months, at 1 year, at 2, 3, 4, and now at 5 years at the end of the report, so that's good.
Similarly, we measured ejaculatory function. If you look at the questionnaire data, it's basically a straight and stable line across time and with very narrow confidence intervals, meaning ejaculatory function doesn't change much either.
Additionally, if you look at men who reported a history of sexual dysfunction at the beginning of the study, compared to men that had good sexual function at the beginning of the study, both groups of men had an equal response to improvement in their lower urinary tract symptoms. So, there isn't an influence of sexual function on response to Rezum. That's 1 message that you can tell patients.
There are 2 other important things, and one of which was unexpected. First, the unexpected one. If, at the beginning of the trial, in addition to doing the standard questionnaires, we also asked men about their previous sexual history, questions like, "Have you ever had an alteration in sexual function prior to enrollment in the study?" a man could say, "Yes, I've had sexual dysfunction in the past, but I'm still sexually active," or, "No, I've had no problems in the past." When you follow those sexually active men with no sexual dysfunction in their past and men who reported sexual complaints in the past, you note they diverge. Men that had no history of sexual dysfunction had absolutely no change in their erectile function over time, but men who say in the past, "Yes, I've had episodes," actually have a slight decline over time, which is very consistent with what we saw in a previous trial, the MTOPS trial where we followed sexual function in a placebo group of men with BPH for 5 years.³
So, what does that mean? Well, that means it's still important to ask patients, face to face, "How is erection? How is ejaculation?" because they can give you a clue as to how their natural history of sexual function may be perform going forward. The fact that the questionnaires go straight across is 1 thing, but the fact that the history can help you differentiate who might have a slight decrease over time and who can be very beneficial for a physician to counsel patients. They can gauge expectations. No one's ever done that before. So, in my own view, this new finding should really make a difference in the way we do clinical trials in the future. You still have to stick to the NIH consensus conference of 1990, where it said questionnaire data is important, but you have to talk to men to fully gauge their sexual function. It turns out that same process occurs in men who say that they had an ejaculatory complaint. They also track a little bit different from men who say there was no history of ejaculatory problems. They're not substantial decreases, but they're different than men who say, "No, I've never had a problem in the past." So, that's 1 surprising finding, which I think is a contribution to the field.
The other is a reassurance point that I'm grateful doesn't surprise me. It's that if we rate men at baseline, no sexual dysfunction, mild ED, moderate ED, or severe ED, you'll see over the 5-year period that no one changes their level of sexual function category. If you start with no ED, no history of ED, good sexual function, you remain there over the 5 years of the trial. If you're in mild category, you remain there over the 5 years of the trial. Your score can alter a little bit, but you don't do a categorical shift. So, if a guy says, "Yeah, I have a little problem now and then," then you can say, "Well, that's not getting better. It's not getting categorically worse." So again, the ability to reassure the patients on that is another finding from this study.
It tells us good impact on BPH outcomes, lower urinary tract symptom improvement, and urinary flow rates. It confirms that as well as the fact that sexual function doesn't seem like it influences that. That's one. Second is that you have stable sexual function over a 5-year period of time. You don't do a categorical shift; however, if you do have a history of ED, you actually track differently than men that say, "No, I've been perfect my whole life."
As co-chairman of the AUA BPH clinical guidelines, my comments dovetail identically with the BPH guidelines. So, the first approach is if a man has LUTS he needs to be informed of his options: medicine and surgery. If he is not responding to medications for LUTS/BPH or wishes to avoid medications altogether, you have to inform them of the option of medicine versus various interventional procedures and surgery. If at the start a man is not interested in medications, then it's totally legitimate to proceed directly into an intervention once he understands the range of options. The choice of intervention is based in part on prostate size; how severe and how big is the prostate. The other factor is his willingness to accept risk. That means if we have a man whose prostate size is, let's say 50 grams, and you say, "We have a minimally invasive option versus a more traditional surgical option, like bipolar TURP or PVP," you can discern choice by asking him about his proclivity for wanting to preserve sexual function.
If the man says, "Sexual function is very high on my particular “balance beam of motivation," then choosing a minimally invasive therapy might be a better choice for that guy because it is known that current minimally invasive surgeries do a better job at preserving sexual function. For a man like that, I would encourage him to proceed in that direction. If the man said, "Those days are passed. Sexual function is not really a motivation for me," then many times the discussion turns to durability of procedure. What we can say about MIST, minimally invasive surgical treatment, and in the current guidelines the real players are Rezum and UroLift, there is reliable data to 5 years, but not beyond. And we know about retreatment rates within 5 years. Surgical retreatment rates in terms of Rezum at 5 years is 4.4%, relatively low. In prostatic urethral lift, surgical retreatment rates are much higher. If you add medication retreatments as another way to fail, then both are a little bit worse. So, the discussion is a review of durability of response, and we can only say durability to 5 years because that's the farthest the data goes.
When we look at bipolar TURPs or PVPs, then the durability data is more extensive, because the procedures are more well-established. Some men will say, "I want the procedure with the best durability that you know of," and I’d say, "Well, there are some unknowns with the MIST, so perhaps it might be better for you to choose a laser procedure or a bipolar TURP."
The other aspect is level of invasiveness, regardless of sexual function. There's no question that the MISTs are much easier for men to undergo and recover from. There's no hospital stay, there's no general anesthesia, and that is attractive to men with or without sexual dysfunction. So, if that is a big deal, then the MIST is going to be a better approach for that particular patient. It has to be individualized to the motivations of the patient, and also what I call his "phenotype.” How big is his prostate? How bad is his problem? What is his tolerance for side effects?
Rezum is a durable therapy for lower urinary tract symptoms, secondary to BPH. The adverse event profile is quite favorable, the impact on sexual function is minimal, and retreatment rates are exceedingly low with this therapy.
I think that summarizes where we're going to be because the pivotal trial is over. Looking forward to comparisons of minimally invasive surgery versus medical therapy, that is, at this point, untapped. It's something which we think we have insight into, but we really don't have good data. We have done some modeling in that regard, where minimally invasive surgery compares favorably to medication as seen in the MTOPS cohort, but that is a modeling investigation.4-5 That is not the same as a randomized control trial.
Another area is utilities, quality of life. How do patients rate these types of therapies as impactful in the quality of their life? This is done quantitatively looking at risk tradeoffs. “I will accept this amount of side effect if I can have this amount of quality years in my lifetime,” called a utility or quality of life years. And that's not been done, other than some projects that we're doing right now to address that. It's very exciting.
The other is cost benefit. There's a health policy issue here. We're doing these procedures and there is an expense to our society and our health care system. What are we getting as a nation in return? Are we getting men with a sustained benefit? Are we spending a lot of money for procedures which may or may not be durable? So, cost effectiveness evaluation is also a thing that we need to look forward to. And then there is the question: has anyone really compared these MISTs to more traditional surgeries? The answer is, yes and no. Rezum has not done that. It's a newer therapy. UroLift has done that, not in the US. There was a European trial looking at TURP versus UroLift, and TURP seem to beat urolift in most important aspects, except the patient softer measures about time to recovery, sexual function and those types of things. Regardless, that's additional health policy questions which really need to be addressed.
1. McVary K, El-Arabi A, Roehrborn C. Preservation of sexual function 5-years after water vapor thermal therapy for benign prostatic hyperplasia. Paper presented at: 2021 American Urological Association Annual Meeting; September 10-13, 2021; virtual. Abstract PD18-08.
2. McVary KT, Gittelman MC, Goldberg KA, et al. J Urol. 2021 Sep;206(3):715-724. doi: 10.1097/JU.0000000000001778. Epub 2021 Apr 19
3. McConnell JD, Roehrborn CG, Bautista OM, et al. Medical Therapy of Prostatic Symptoms (MTOPS) Research Group. N Engl J Med. 2003 Dec 18;349(25):2387-98. doi: 10.1056/NEJMoa030656
4. Gupta N, Rogers T, Holland B, et al. Three Year Treatment Outcomes of Water Vapor Thermal Therapy Compared to Doxazosin, Finasteride and Combination Drug Therapy in Men with Benign Prostatic Hyperplasia: Cohort Data from the MTOPS Trial. J Urol. 2018 Aug;200(2):405-413. doi: 10.1016/j.juro.2018.02.3088
5. McVary KT, Rogers T, Mahon J, Gupta NK. Is Sexual Function Better Preserved After Water Vapor Thermal Therapy or Medical Therapy for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia? J Sex Med. 2018 Dec;15(12):1728-1738. doi: 10.1016/j.jsxm.2018.10.006