The management of BPH has had an interesting roller coaster ride over the past 25 years with new medicines, minimally invasive surgical therapies, and a host of novel surgical technologies, including lasers and bipolar electrosurgery.
|Steven A. Kaplan, MD||Dr. Kaplan|
The world has become increasingly fascinated with new technologies, toys, and gadgets. Urologists are no different. Many prospective resident candidates often cite the myriad technological advances in urology as a drawing force to our specialty. But have new technologies translated into more efficient, durable, and meaningful outcomes for our patients?
The management of BPH has had an interesting roller coaster ride over the past 25 years with new medicines, minimally invasive surgical therapies (MIST), and a host of novel surgical technologies, including lasers and bipolar electrosurgery. The arena that has seen the most stops and starts is MIST and includes balloon dilation, urethral stents, transrectal and transurethral microwave thermotherapy, and needle ablation of the prostate.
The past 2 to 3 years has seen a renaissance in MIST technologies, including the FDA-approved prostatic urethral lift (UroLift System) and two new exciting technologies using either targeted sterile water vapor (RezÅ«m) or robot-guided high-energy water ablation (Aquablation). In a pivotal, single-blinded study of RezÅ«m versus control, there appears to be significant improvement in symptoms and uroflow. While we can debate whether there was an adequately blinded control arm, the impressive improvement in uroflow in the treatment versus the sham group suggests that the trial was well conducted. Sexual function was also preserved.
Aquablation is one of the most promising technologies seen over the past decade. A large multicenter clinical trial will begin soon to ascertain its safety and efficacy versus transurethral surgery. The amount of tissue removed in a very short period of time is impressive. At this point, it appears the technology will need to be performed in the operating room and will compete with transurethral surgery.
This is an exciting time in the management of BPH. Ultimately, ease of performance, reproducibility, efficacy and safety, reimbursement, and durability of results will determine the success of each technology. Moreover, urologists will have to be mindful of developing therapeutic algorithms for each of these technologies so that prostate size, presence of a middle lobe, sustainability of results, and ability to do a procedure in the office versus the operating room will help bring the greatest value of these therapies to our patients.
It’s a fun time to be in the BPH space, but we should approach with caution and appropriate degrees of skepticism.
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