The most reliable way of predicting the future is creating it.

Abraham Lincoln

When tasked with preparing a state-of-the-art talk on benign prostatic hyperplasia (BPH) at the annual AUA meeting in Chicago, there were many directions and areas to focus on. The good news is that BPH is a very exciting arena to be in and is in its own Renaissance. Primarily driven by innovation entrepreneurs, researchers and clinicians are attempting to transform how we access patients, communicate more effectively, accurately diagnose, and precision-treat men with BPH.

Given the recent chatter about artificial intelligence (AI), what better way to predict the future of BPH than asking ChatGPT? It appears that it wasn’t ready to answer this query and provided a fairly neutral response of: “As an AI language model, I do not have the ability to predict the future with certainty. However, based on historical patterns and current trends, it is possible to make informed predictions about certain events or phenomena.” Therefore, to be more precise and provocative, the talk focused on (1) Artificial Intelligence, (2) Informatics, (3) Diagnostics, (4) Therapeutics, and (5) the Bottom Line (see Figure).

Figure. State-of-the-art talk on benign prostatic hyperplasia topics at the annual AUA meeting in Chicago, 2023.

AI

• Imaging: AI can be used to analyze medical images of the prostate, such as MRI or ultrasound scans, to help diagnose BPH and assess its severity.
• Predictive analytics: By analyzing data from electronic health records, AI can help predict which patients are at higher risk of developing BPH, allowing for early intervention and treatment.
• Treatment planning: AI can help physicians plan and optimize treatment for BPH, taking into account factors such as patient age, severity of symptoms, and other health conditions.
• Surgical assistance: AI can be used to assist surgeons during minimally invasive procedures for BPH, such as transurethral resection of the prostate, helping to improve the accuracy and safety of the procedure.

In summary, AI has the potential to significantly improve the diagnosis and treatment of BPH, helping to reduce the burden of this common condition on patients and health care systems.

Informatics

As in other aspects of life, the Internet is replete with information, some good and lots bad! The world of BPH is no different and while there are 11,900,000 Google BPH hits, 99.2% of them focus on treatments. Unfortunately, cyberchondria runs rampant in the world of BPH. Furthermore, there is a paucity of information directed at underrepresented minorities and men of color. However, this presents enormous opportunities to help educate patients in a more directed fashion.

• Increase awareness: Health care providers can raise awareness of BPH and its symptoms and provide education about the importance of early diagnosis and treatment.
• Improve access to health care: Policymakers can work to improve access to health care for underserved minorities, such as by expanding Medicaid coverage or implementing programs to increase the number of health care providers in underserved areas.
• Culturally sensitive care: Health care providers can take steps to provide culturally sensitive care to underserved minority patients, such as by offering language interpretation services, respecting cultural differences in health care practices, and addressing any biases or stereotypes that may affect patient care.
• Research: Researchers can study the impact of BPH on men and in particular underserved minority communities and develop interventions that are tailored to the specific needs of these populations.

In summary, more comprehensive and trusted information sources will be developed.

Focus on underserved minorities will be a priority to health care professionals, medical centers, and investors.

Diagnostics

The COVID-19 pandemic dramatically changed our world on so many levels. Access to care as well as creating new remote environments for diagnosis and treatment were created and the drive for new technologies accelerated. Noninvasive bladder function tools in the office as well as remote diagnostic management platforms which allow device tracking and connectivity to both the provider and electronic health records are now available. With the advent of more favorable Current Procedural Terminology code reimbursement for remote monitoring, the opportunities in urology and for all of health care are enormous.

The advantages include:

• Convert care time between visits into new reimbursements
• Add additional visits as needed between regular scheduled follow-ups
• Improve patient compliance and retention via app-based automatic reminders
• Reduce readmission and adverse events, and improve quality scores
• Enable focus on high-risk patients and expand numbers of patients per staff member

In summary, efficiencies in diagnostics using wearable devices and remote platforms is here and urology has the opportunity to focus, adapt, and harness the enormous data repositories which lie ahead.

Therapeutics

Although some in the urological community thought that the BPH treatment regimen algorithm peaked more than a decade ago, it is clear that innovation and BPH seem like the perfect interface. While beyond the scope of this article, there will be a huge menu of treatment choices for urologists and their patients.

Medical therapy using oral agents seems to have peaked and is essentially a generic market albeit branded overactive bladder agents (β3-agonists) have taken a significant foothold in men with storage symptoms and BPH. Use of injectable agents into the prostate to help reduce prostate size is being investigated by numerous startups.

In 2021, the total minimally invasive and surgical market in the United States was about $700 million USD with the greatest share being spent on the prostatic urethral lift. Projections by health economists are that this market will top 1 billion dollars within 5 years. However, a number of BPH treatment challenges are on the horizon.

• Economic: Economic and reimbursement realities are setting in and will have significant impact on relative market share in the future. While scientific data are important to obtain regulatory approval, winners and losers are often predicated on reimbursement.
• Real-world data: Defining treatment success and failure in the BPH arena has been elusive. There are few uniform definitions and cross-functional criteria have not been widely accepted. A number of real-world data studies have demonstrated incongruity between reported retreatment and reintervention rates vs those reported in pivotal clinical trials in the literature.
• Are we waiting too long to treat? Emerging data of the impact of delaying interventional therapy in lieu of either watchful waiting and/or medication and ensuing potential bladder deterioration are now garnering attention. When is the appropriate time to treat and to intervene?

The current minimally invasive and surgical market for BPH will continue to evolve. It seems like we are going Back to the Future. Newer lasers, water ablation of the prostate, and improvements in robotic techniques will increase in their usage. On the horizon are various permutations of prostate expanders and springs and a technology using paclitaxel-eluting balloon dilation of the prostate. Many abstracts at the AUA were devoted to early- and mid-stage data on efficacy/safety of these various new technologies.

Bottom Line

Predicting the future of BPH is easy. It will be a major growth area for urology beyond therapeutics. Many of these new technologies were discussed at the newly launched AUA Innovation Nexus. The integration of strategics, venture capital, entrepreneurs, and urologists will provide the impetus to tremendous growth and opportunity. Buckle up—the ride is going to be amazing!