Despite their promise, MISTs still lack long-term data and clear patient selection criteria, and only a few are endorsed by current guidelines. In this context, a Delphi consensus was conducted to address key uncertainties and provide expert insights to bridge the gap between guidelines and real-world practice concerning MISTs for BPH.
A Delphi method was employed to reach consensus among a panel of 28 Italian urology specialists with at least five years of experience in the surgical management of BPH, including MISTs. This structured approach, aimed at developing expert-based recommendations, involved two rounds of anonymous voting on 343 statements across 35 debated topics. In the first round, conducted via email, participants rated their agreement on a 9-point Likert scale. Items not reaching predefined thresholds for consensus were identified as "hot topics" and re-evaluated during a consensus conference held in Milan, where all first-round participants reconvened. This second round allowed for in-depth discussion and anonymous re-voting. The panel included a diverse demographic and professional background, ensuring a representative and balanced perspective across clinical settings in Italy.
The Panel agreed in defining Transperineal Laser Ablation of the Prostate (TPLA), Rezum, iTIND, Prostate Artery Embolization (PAE), and Urolift as MISTs, but no consensus was reached regarding Aquablation. Essential characteristics for being defined as MISTs were considered the feasibility in outpatient and one-night stay settings, minimal bleeding risk, early postoperative recovery of daily activities, and a reduced impact on urinary continence and ejaculatory function. The Panel agreed that, compared to TURP, PAE, TPLA, Rezum, iTIND, and Urolift were associated with lower postoperative bleeding rates, lower operative and hospitalization time, lower risk of post- operative incontinence; non consensus on these topics was achieved for Aquablation. The Panel agreed that flow rates after PAE, TPLA, iTIND, and Urolift were worse than TURP; however, no consensus was achieved for Rezum and Aquablation. A high risk of retreatment was recognized for TPLA, iTIND, and Urolift, but this was not the case for Rezum and Aquablation. iTIND and Urolift were deemed as the best options for prostate volume 30 ml, TPLA, Rezum, and Aquablation for prostate volume 30–80 ml while no consensus was obtained for the best approach in larger volumes. No consensus was achieved for various aspects of postoperative management of MISTs.
In conclusion, the findings of this Delphi consensus reflect the increasing integration of MISTs into BPH surgical practice, driven by their favorable safety profile and functional outcomes. However, uncertainties remain regarding long-term durability, retreatment rates, and optimal patient selection. MISTs were considered valuable options in patients with small (< 30 ml) or medium (30-80 ml) prostate volumes, while their role in larger prostates is still debated. Aquablation, despite its versatility and promising outcomes, did not fully meet the Panel’s criteria for MIST classification. Continued research is necessary to refine indications, optimize perioperative management, and establish standardized protocols for emerging technologies in BPH surgery.
Written by: Federica Passarelli,1 Daniele Castellani,2 Silvia Secco,3 Mauro Gacci,4 Mattia Sibona,5 Ioannis Kartalas Goumas,6 Celeste Manfredi,7 Giovanni Ferrari,8 Enrico Finazzi Agrò,9 Andrea Cocci,4 Carlos Miacola,10 Carlo Marenghi,11 Daniele D'Agostino,12 Davide Arcaniolo,13 Emanuele Baldassarre,14 Federico Deho,15 Fabrizio Palumbo,16 Franco Gadda,1 Gianluca Sampogna,3,17 Lorenzo Ruggera,18 Luca Ferrando,19 Mirko Preto,5 Nicolò Schifano,15 Paolo Capogrosso,15 Elisa De Lorenzis,1,23 Yasser Hussein Mohamed Ismail,20 Ludovico Maria Basadonna,1 Giorgio Graps,1 Fabrizio Longo,1 Andrea Salonia,21,22 Emanuele Montanari,1,23 Luca Boeri1
- Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy.
- Urology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
- Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
- Urology Clinic, Department of Surgical Sciences, AOU Città della Salute e della Scienza - Molinette Hospital, University of Turin, Turin, Italy
- Department of Urology, Istituto Clinico Beato Matteo, Vigevano, Italy
- Urology Unit, Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy.
- Department of Urology, C.Ur.E., Centro Urologico Europeo, Hesperia Hospital, Modena, Italy.
- Department of Experimental Medicine and Surgery, Unit for Functional Urology, Tor Vergata University Hospital, Rome, Italy.
- Department of Emergency and Organ Transplantation, Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy.
- ASST Rhodense Garbagnate Milanese, Milano, Italy
- Ospedale Villa Salus, Venezia, Italy
- Urology Unit, Luigi Vanvitelli University, Naples, Italy.
- Division of Urology, Ospedale Parini, Aosta, Italy.
- Department of Medicine and Technological Innovations (DIMIT)/Unit of Urology, Circolo & Fondazione Macchi Hospital, University of Insubria, Varese, Italy.
- Department of Urology, Di Venere Hospital, Bari, Italy.
- Unit of Neuro-Urology - Unipolar Spinal Unit, Niguarda Hospital, Milan, Italy.
- Department of Surgery, Oncology, and Gastroenterology-Urology Clinic, University of Padua, Padua, Italy.
- Azienda Ospedaliera Universitaria San Luigi Gonzaga, Orbassano, Italy
- Urology Unit, Surgical Department, ASST Bergamo Ovest, Treviglio, Italy.
- Division of Experimental Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023-2027