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AUA2023: REFLECTIONS Benign Prostatic Hyperplasia Semi-live Surgical Techniques

By: Michael Palese, MD, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City; Francisca Larenas, MD, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City | Posted on: 20 Jul 2023

The Benign Prostatic Hyperplasia (BPH) semi-live surgical techniques session at this year’s AUA meeting showcased 4 different procedures for the treatment of BPH: holmium laser enucleation of the prostate, iTind, Rezūm, and prostatic urethral lift (PUL). Renowned experts in the field presented these procedures, highlighting key steps, advantages, and patient selection criteria.

Dr Nicole Miller, from Vanderbilt University Medical Center, presented her technique for holmium laser enucleation of the prostate using a Moses laser. The case involved a 58-year-old male with a 100-g trilobar prostate and a prominent medium lobe.

En bloc technique was demonstrated, starting with an inverted V incision near the verumontanum. Blunt enucleation was performed, preserving the mucosa around the external sphincter, for early release. This step is done with a low-energy setting (2 J, 20 Hz). Moses pulse modulation technology is particularly beneficial for controlling small blood vessels and maintaining excellent visualization. Providing adequate countertraction during enucleation is essential. Attention was given to the transition point between the bladder neck and prostatic adenoma, releasing attachments to the median lobe. During this step, higher-energy laser settings were used (2 J, 40 Hz).

The advantages of using the Moses laser with the en bloc technique were emphasized, including superior hemostasis, enhanced visualization, shorter hospital stays, and the potential for same-day discharge.

Dr Bilal Chughtai, associate professor of urology at Weill Cornell Medical College, presented the Temporary Implantable Nitinol Prostate Stent for BPH (iTind). This Food and Drug Administration–approved procedure involves the temporary implantation of a stent for 5 to 7 days, creating deep, bloodless incisions.

The iTind is a single-use stent with 3 nitinol cutting struts which can be deployed with a rigid or flexible cystoscope. Correct positioning of the stent with the anchoring leaflet placed behind the bladder neck is crucial. Removal of the stent is done using a catheter and retrieval snare provided in the iTind kit. The entire procedure can be performed in an office setting under local anesthesia, and postoperative catheter is not required.

Patient selection criteria include prostate volumes of 25 to 75 g, absence of an obstructive medium lobe, and good bladder function. Patients with high bladder necks typically have excellent results. The procedure provides immediate symptom relief with improved urinary stream without compromising sexual function.

Dr Michael Palese, urology professor at the Icahn School of Medicine at Mount Sinai, detailed his step-by-step technique for Rezūm, a treatment designed for prostates ranging from 30 to 80 g, with potential to treat medium lobes.

Rezūm involves 9-second injections of water vapor at 103 °C into the prostate, effectively heating it to 70 °C, using conductive energy, which results in tissue necrosis. Approximately 1 treatment is required for every 10 g of tissue.

The procedure starts with a preliminary treatment performed outside the patient to clear condensation from the delivery device. The device is then atraumatically inserted into the urethra to minimize bleeding and maintain optimal visibility. Next, the treatment zone is determined by measuring the fields of view between the bladder neck and verumontanum, which is the distance from the device tip to where its arms extend (0.5 cm). Treatment is initiated on a lateral lobe, with a 90° angle, 2FOV away from the bladder neck, with subsequent injections spaced 1 cm apart. It is recommended to complete treatment on one entire lobe before proceeding to the contralateral side. For medium or central lobes, a 45° angle is utilized to prevent injury to the rectum. Throughout the procedure, maintaining stability in hand movements is vital to ensure optimal delivery of the energy. Observation of bubbles during vapor injection serves as an indicator of an inadequate seal, which may compromise treatment effectiveness. However, once the needle is deployed, repositioning should be avoided to prevent bleeding. It is crucial to thoroughly assess the treatment area for any gaps or the need for potential retreatment, which can be accomplished by identifying areas without tissue blanching. Finally, the cystoscope is removed, and a urethral catheter is placed for a period of 5 days, except in patients with prostates larger than 80 g, who require catheterization for 2 weeks.

Rezūm can be performed in an office setting under sedation and has exhibited excellent outcomes, with a low long-term surgical retreatment rate of 4.4%. Moreover, it generally preserves ejaculatory function. Patients typically experience noticeable results by the 12-week mark.

The final presentation was given by Dr Gregg Eure, from Urology of Virginia, on PUL. This procedure involves creating an anterior channel in the prostate by deploying implants to relieve urinary obstruction. Accurate placement is crucial for optimal results, starting at the bladder neck and pulling 2 cm back. Treatment of a medium lobe is possible by mobilizing it away from the neck and then extending it out toward the lateral lobe. Although the medium lobe is not obliterated, the goal is to create a pathway, relieving urinary obstruction.

The procedure effectively relieves urinary obstruction, allowing patients to go home without a catheter in most cases. It can be done in an office setting and does not impact ejaculation.

Recent advancements in PUL include the UL2 system and the Advanced Tissue Control device.

The UL2 system improves the delivery of PUL with an ergonomic design, fewer cystoscopic exchanges, and more consistent implant deployment. It also offers improved suture cutting and a smaller packaging footprint. The Advanced Tissue Control device enhances precision in PUL by featuring expandable wings with laser-etched marks for accurate implant placement. It helps in gripping tissue and ensures effective deployment of the implants. These advancements have made PUL more efficient and precise.

In summary, the session provided valuable insights into 4 different procedures for treating BPH. Urologists should carefully evaluate each patient’s case when selecting a treatment option and be aware of key aspects for each procedure to achieve optimal outcomes. These advancements in BPH treatment offer patients a range of options that can provide symptom relief, improved urinary flow, and minimal impact on sexual function.