The field of male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) remained a focal point of the recent AUA2023 held in Chicago. There were several courses, including the well-attended hands-on surgical course (Course Director: Dr Amy Krambeck) which highlighted enucleation, morcellation, and ultrasound-guided water-jet ablation. There were additional program in the international society meetings and 3 sponsored industry sessions. There were well over 80 podium and moderated poster presentation abstracts presented to rooms packed with engaged audience members. The highlight of the meeting for BPH enthusiasts was the Society of Benign Prostate Disease program on the final day of the AUA (co-chairs: Dean Elterman and Amy Krambeck). Hot topics in BPH included, “Nocturia: how can I effectively treat it?” (Lori Lerner), “What are the harms of BPH medications?” (Naeem Bhojani), “Does ejaculation matter to patients” (Brad Gill), “Herbal treatments: all my patients buy them but do they work?” (Claus Roehrborn), and “How do I choose between MISTs” (Gregg Eure). There was an excellent overview on the advances in diagnostics in male LUTS by Bilal Chughtai, followed by a series of debates covering medical therapy, prostate artery embolization, and enucleation. The day ended on bringing together “Why the bladder matters,” with Nick Warner. Stay tuned for future Society of Benign Prostate Disease meetings (and consider joining this new society!).

There were too many outstanding presentations to summarize in 1 article. The following are examples of the latest topics and research in the various fields within BPH. Beginning with novel minimally invasive treatments (MISTs) under investigation: the Optilume BPH drug–coated balloon (Urotronic) utilizes a combination of balloon dilatation of the prostate creating an anterior commissurotomy with the antiproliferative effect of paclitaxel, which is absorbed into the tissue from the balloons’ coating. The 12-month data from the Pinnacle pivotal study were presented by Steven A. Kaplan. The maximum urinary flow rate (Qmax) improved by +98% at 30 days and was sustained at +113% through 1 year with a mean International Prostate Symptom Score (IPSS) improvement of 12 points at 12 months (Figure 1).¹

Figure 1. Optilume BPH.

The Zenflow Spring System utilizes a spring-like nitinol coiled implant delivered with a flexible cystoscope (Zenflow). The 12-month outcomes from the first North American study were presented by Dean Elterman.² IPSS, IPSS-QoL (quality of life), and Qmax all significantly improved by 46%, 56%, and 45%, respectively, at 12 months. There were no changes in sexual or ejaculatory function with mild, transient side effects (Figure 2).

Figure 2. Zenflow Spring System.

The ProVee Expander (Proverum) had its 24-month first-in-man data presented by Thomas Lynch.³ This permanent, low metal density, nitinol implant demonstrated no device or procedure related serious adverse events, no surgical retreatments, and 40% improvement in Qmax at 2-year follow-up (Figure 3).

Figure 3. Proverum ProVee.

Several of the already Food and Drug Administration–approved MIST devices had related presentation. Cerrato et al showed in a propensity score matched comparison that a single vapor injection per lobe in water vapor thermal therapy (Rezu¯m) resulted in similar improvements in IPSS compared to multiple injections, however ≥1 injection per lobe saw higher risk of retention and urinary tract infection.⁴ Elterman et al demonstrated that when using Rezu¯m, prostate volume reduction was consistently around −34% regardless of whether gland volume was <80 cc or >80 cc, and was not influenced by the presence of a median lobe. Additionally, 26% (volume <80 cc) and 29% (volume >80 cc) of prostates achieved a >50% volume reduction.⁵ Claus Roehrborn presented the pooled analysis of 330 subjects in prospective trials treated with prostatic urethral lift (UroLift). Regarding durability, undertreatment with ≤4 implants placed resulted in lower 1-year durability, thus implant density is important. Durability at 5 years is primarily negatively affected by poor IPSS obstructive symptoms at baseline.⁶ The outcomes of UroLift for acute urinary retention in both clinical trial and real-world settings were presented by Oliver Kayes. Catheter-free rates at 12 months were 73% in the PULSAR study (evaluating prostatic urethral lift for retention) and 80% in real-world retrospective registry of 388 patients. Advanced age, higher baseline PSA and postvoid residual, and longer preoperative catheter duration drove suboptimal outcomes in acute urinary retention patients.⁷ Lastly in the MIST group of abstracts, Riccardo Bertolo presented a prospective, randomized trial comparing transperineal laser ablation (TPLA) vs transurethral resection of the prostate (TURP). The primary outcome of ejaculatory function demonstrated no change in MSHQ-EjD (Male Sexual Health Questionnaire–Ejaculatory Dysfunction) in the TPLA cohort, but a −30% decrease in the TURP arm. Secondary endpoints showed statistically significant improvements in Qmax, IPSS, and QoL in both groups relative to baseline, with greater Qmax in TURP (26 mL/s [22.0-48.0]) compared to TPLA (15.2 mL/s [IQR 13.5-18.3]).⁸

In surgical resective technologies for BPH, Naeem Bhojani presented the final 5-year results from the prospective WATER II study evaluating Aquablation in glands between 80-150 cc. The IPSS improvement at 5 years was 15.9 (<0.001; baseline 22.6 to 60-month 6.8). Qmax improved from 8.6 mL/s at baseline to 17.1 mL/s at 60 months (Qmax improved by 9.2; P < .001). MSHQ-EjD and International Index of Erectile Function-5 remained stable over 5 years. Also notably, 96.3% of patients avoided a secondary BPH intervention due to recurrent symptoms.⁹ In surgical trends in BPH care, Jacob Feiertag presented national trends in surgical management from 2013-2019 from the TriNetX database. The main take-away was that while the proportion of TURP and photoselective vaporization of the prostate, along with older MISTs such as transurethral microwave therapy and transurethral needle ablation, are being replaced by a growing use of newer office-based MISTs, such as Rezu¯m and UroLift.¹⁰ Lastly, Joao Porto presented MAUDE database analysis of complications associated with MIST therapies. The abstract highlights some key adverse events such as higher rates of ejaculatory dysfunction and LUTS in Rezu¯m patients and higher rates of hematoma and more severe Level III and IV complications in UroLift.¹¹

All in all, it was a spectacular AUA2023, which highlighted the many advancements being made in the field of male LUTS and BPH. Congratulations to the organizers, Board of Directors, and all the presenters.