Medium-term Real-world Outcomes of Minimally Invasive Surgical Therapies for Benign Prostatic Hyperplasia: Water Vapor Thermal Therapy (Rezum) versus Prostatic Urethral Lift (UroLift) in a High Volume Urban Academic Center

Many novel minimally invasive surgical therapies (MIST) have been developed as treatment options for benign prostatic hyperplasia (BPH). Transurethral water vapor thermal therapy (WVTT, i.e. Rezum) and Prostatic Urethral Lift (PUL, i.e. UroLift) have emerged as increasingly popular options for many reasons, include patient-related factors such as decreased sexual side effects and the convenience of performing in an office-based or ambulatory setting. Despite their increase in popularity and recent incorporation into the AUA guidelines for the surgical management of BPH, there is a paucity of literature comparing WVTT and PUL head-to-head.

Our study recently published in the Journal of Endourology retrospectively analyzed our institutional experience with WVTT and PUL, comparing the real-world clinical outcomes for each procedure performed between January 2017 and September 2021 at a high-volume academic center. The outcomes included both clinical metrics of disease (i.e. maximum flow rate [Qmax], post-void residual volume [PVR], AUA symptom scores [AUA-SS], and BPH medication usage) and postoperative clinical outcomes (i.e. postoperative complications, surgical/medical retreatments, and 90-day ER visits/readmissions).

Overall, 417 patients (WVTT: n = 307; PUL: n = 110) met inclusion criteria and were analyzed as part of this study. Both WVTT and PUL patients saw similar improvements in AUA-SS, PVR, and alpha-blocker utilization, while WVTT patients alone saw improvements in Qmax and increased utilization of anti-spasmodic medications. There were no significant differences in surgical retreatment rates between the procedures as well. On subgroup analysis by prostate volume, both WVTT and PUL patients with prostate sizes 30-50cc demonstrated significant improvements in AUA-SS and Qmax. For the subgroup with prostate size 50-80cc, WVTT patients had significant improvements in Qmax, AUA-SS, and PVR whereas PUL patients only showed improved PVR. This suggests that WVTT may be more effective than PUL in patients with moderately large prostate sizes.

Patients with benign prostatic hyperplasia and bothersome urinary symptoms have numerous minimally invasive surgical options, including PUL and WVTT. The optimal treatment depends on a myriad of factors including prostate size, comorbidities, as well as patient preferences based on side-effect profiles and the expected course of recovery. In comparison to PUL patients, WVTT patients have been shown to require longer catheterization and have a slower postoperative recovery. Our study confirmed that all WVTT patients required postoperative catheters and they also more frequently reported postoperative dysuria and non-clot-related retention. Our subgroup analysis showed that for prostate sizes 50-80ccs, WVTT may be preferable for patients who are willing to tolerate the longer postoperative recovery course of WVTT. This study represents the largest published series to date comparing outcomes following WVTT and PUL head-to-head. We hope that these findings may aid urologists and patients alike when participating in shared decision making for the surgical management of BPH.

Written by:

Kenny Chin BA - Fourth-year medical student, Icahn School of Medicine at Mount Sinai, New York NY
Evan Garden MD - First-year resident, Department of Urology, Icahn School of Medicine at Mount Sinai, New York NY
Michael Palese MD - Chairman, Department of Urology, Mount Sinai Downtown-Union Square

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