Benign prostatic hyperplasia minimal invasive surgery

Minimal invasive surgery review article

1. MIS in BPH article rev iew A lqahtani abdullah M entored by professor kin jang hwan

2. Portrait Maximilian Stern N ew method to treat “ obstructions at the vesical orifice” 1926. Räto T. Strebel · Steven A. Kaplan : The state of TURP through a historical lens world J of urology 2021.

3. Theodore M Davis 1931 “cutting and coagulating current diathermy inventing a foot pedal ” Jonathan Charles Goddard history of urology : British AUS

4. Jonathan Charles Goddard history of urology : British AUS

5. M oving to MIS ( a -blockers and 5 a -reductase inhibitors) Long-term side effects. Mood disorders, depression and suicidal thoughts, cognitive dysfunction, dementia, sleeping disorders, and chronic fatigue. TURP requires the use of general or spinal anesthesia. Risk of bleeding, urinary incontinence, retrograde ejaculation, and ED. postoperative erections and ejaculatory function important to 95% and 92% of men, respectively, regardless of age. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

6. Aquablation ( AquaBeam )

7. Mode of action Stephan Madersbacher The role of novel minimally invasive treatments for lower urinary tract symptoms associated with benign prostatic hyperplasia BJU Int 2020.

8. Technique Yalçın and Tunc ̧. UroLift ® System, ( i )TIND®, Aquablation®, Rezūm ® System, and Prostatic Artery Embolization Turk J Urol 2020

9. Efficacy and Safety Water I Double-blind, multicenter, prospective RCT. Aquablation (116 men) and TURP (65 men). (IPSS < 12) . Prostate volume of 30 cm3 to 80 cm3. Mean prostate size was 53 cm3. Qmax <15 mL/s. 81% were sexually active. WATER II Prospective, single-arm, multicenter trial. recruited 101 patients. Larger prostate size (80 cm3 to 150 cm3) Mean prostate size was 107 cm3. Prior prostate surgery. Catheter use for less than 90 days. 76.2% of them were sexually active. Stephan Madersbacher The role of novel minimally invasive treatments for lower urinary tract symptoms associated with benign prostatic hyperplasia BJU Int 2020.

10. Efficacy and Safety Peter j gilling : five-year outcome for Aquablation therapy compared to TURP , Can. J of urology 2022

11. Efficacy and Safety WATER II. 2 years results. IPSS decreased by 75%. IPSS QoL decreased by 76%. Qmax increased by 52%. S urgical retreatment rate was 2%. M edical retreatment rate was 7.9%. M ean total operative time was 37 minutes. Mean resection time 8 minutes. Stephan Madersbacher The role of novel minimally invasive treatments for lower urinary tract symptoms associated with benign prostatic hyperplasia BJU Int 2020.

12. Efficacy and Safety Cochrane metanalysis 2019. A quablation is equally effective as TURP. IPSS, IPSS-QoL and Q max . (15 fewer adverse events/1000 participants) VS TURP. (10 more re-treatments/1000 participants) VS TURP. HWANG EC .Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2019

13. Efficacy and Safety Not an approved treatment of BPH for men on anticoagulation. Elterman and colleagues' analysis: 801 men had Aquablation. Transfusion rate was 3.9%, and larger prostates (>77 cm3) had the highest rates without cautery. Another analysis for FBNC after AQUABLATION. 2089 men who underwent Aquablation, as well as received FBNC . O verall transfusion rate of 0.8% FBNC : introduces a standard resectoscope to first remove the “fluffy” tissue remnants Cauterize the deeper bleeding vessels ( with no resection ). Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

14. Guidelines AUA Robotic waterjet treatment (RWT) may be offered as a treatment option to patients with LUTS/BPH provided prostate volume 30-80cc. (Conditional Recommendation; Evidence Level: Grade C) EAU Aquablation appears to be as effective as TURP both subjectively and objectively; however, there are still some concerns about the best methods of achieving post-treatment hemostasis. 1b Recommendations Strength rating Offer Aquablation* to patients with moderate-to-severe LUTS and a prostate volume of 30-80 mL as an alternative to transurethral resection of the prostate. Weak Inform patients about the risk of bleeding and the lack of long-term follow-up data. Strong

15. WATER VAPOR THERMAL THERAPY (REZUM)

16. Mode of Action A khil d das bph : an update on minimally invasive theray including aquablatiob Can. J of U 2020

17. Technique (RF) generator. Single-use transurethral delivery device with an integrated 30 cystoscopic lens for direct visualization, R etractable 18-gauge polyetheretherketone (PEEK) needle S aline flush (local block or sedation) N eedle is designed to circumferentially disperse steam 3 rows of 4 holes spaced at 120 intervals. 1.5 – 2.0 cm lesion B eginning 1 cm distal to the bladder neck. N eedle is repositioned in 1-cm distally from the previous point A khil d das bph : an update on minimally invasive theray including aquablatiob Can. J of U 2020

18. Efficacy and Safety US FDA approval in 2015 Rezum II R andomized controlled trial. F inal 5-year data published in 2021. 196 patients were enrolled 2:1. T reatment (135 patients) and sham control arms (61 patients). (IPSS < 13) . P rostate volume of 30 cm3 to 80 cm3 . N o restrictions on the presence of a middle lobe. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

19. Efficacy and Safety D ecrease in IPSS by 48% . D ecrease in IPSS QoL by 45% . I ncrease in Qmax by 49% . M edical retreatment rate of 11.1% . S urgical retreatment rate of 4.4% . NO ED neither retrograde ejaculation. D ysuria (16.9%). H ematuria (11.8%). F requency or urgency (5.9%) A cute urinary retention (3.7%). S uspected UTI (3.7%). All resolved in 30 days. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

20. Efficacy and Safety UK- based study was published in 2020 Multicenter prospective cohort study. 210 patients (25 of which were in urinary retention) Average prostate volume of 56.9 cm3 1 year showed 79% reduction in IPSS 72% reduction in IPSS QoL 50% increase in Qmax Zero cases of de novo ED . Two patients underwent retreatment within 1 year. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

21. Efficacy and Safety Italy-based prospective study consisting of 135 patients Average prostate volume of 60 cm3. published in 2021. 6-month results R eduction in IPSS scores (21.5–4.4) Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

22. Efficacy and Safety McVary and colleagues compared MTOPS VS REZUM studies on sexual function. Patients in the drug treatment groups showed worsening sexual desire and ejaculatory function. Rezum patients showed no worsening ejaculatory function and exhibited slight improvements in sexual desire Both studies have reported no de novo ED. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

23. guidlines AUA WVTT should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc. (Moderate Recommendation; Evidence Level: Grade C) WVTT may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C) EAU Have not yet provided a level of evidence or grade of recommendation, but recommended RCTs against a reference technique to evaluate mid- and long-term ef fi cacy, as well as safety results

24. UroLift (PROSTATIC URETHRAL LIFT)

25. MODE OF ACTION P ermanent implants consisting of two nitinol anchors C onnected with a non-absorbable polyethylene terephthalate (PETP) suture R etract the obstructed prostatic urethra to the prostatic capsule. Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

26. TECHNIQUE Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

27. Efficacy and Safety US FDA approval in 2013. LIFT study. M ulticenter, prospective, double- blinded RCT. P rostates less than 80 cm3. 140 men were assigned to the UroLift procedure. 66 men to sham rigid cystoscopy. Five-year out- comes published in 2017. 35% reduction in IPSS. 50% reduction in IPSS QoL . 50% increase in Qmax. Surgical retreatment rate of 13.6% for the treatment arm. M edical retreatment was 3.6% after 1 year and 10.7% at 5 years. N o de novo, sustained ejaculatory or ED.

28. Efficacy and Safety

29. BPH 6 STUDY 80 patients. RCT UROLIFT VS TURP. IPSS change with TURP was superior to that with PUL. TURP was superior regarding Qmax. Higher retreatment rate in PUL group (13.6%). QOR superior for PUL Ejaculatory function was superior for PUL (100%) vs 76% in TURP. ISI :TURP arm, patients experienced a significant worsening at both 2 weeks and 3 months. Sleep quality : PUL provided statistically significant improvement Christian Gratzke Prostatic urethral lift vs transurethral resection of the prostate: 2-year results of the BPH6 prospective, multicentre , randomized study BJU I nt 2017

30. Efficacy and Safety Larry E miller and colleague's systematic review and meta-analysis 2020 I nvolving 2016 patients from 11 studies. S uggests a higher retreatment rate at 6% per annum. 153 surgical reinterventions. T ransurethral resection of the prostate/laser (51.0%). R epeat prostatic urethral lift (32.7%). D evice explant (19.6%). Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

31. Guidelines AUA PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe. (Moderate Recommendation; Evidence Level: Grade C) PUL may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C) EUA Summary of evidence LE Prostatic urethral lift improves IPSS, Q max  and QoL; these improvements are inferior to TURP at 24- months. 1b Prostatic urethral lift has a low incidence of sexual side effects. 1b Patients should be informed that long-term effects, including the risk of retreatment, have not been evaluated. 4 Recommendation Strength rating Offer Prostatic urethral lift ( Urolift ® ) to men with LUTS interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe. Strong

32. iTind (TEMPORARILY IMPLANTED NITINOL DEVICE)

33. Mode of action Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

34. Technique LA. S tandard 19 to 22 Fr cystoscope. I nserts the enclosed device through the cystoscope sheath. A nchoring leaflet at the 6 o’clock position After a week, removed by using the retrieval suture. S pecial open-ended silicone catheter that allows the device to be collapsed and removed. No catheter needed. Yalçın and Tunc ̧. UroLift ® System, ( i )TIND®, Aquablation®, Rezūm ® System, and Prostatic Artery Embolization Turk J Urol 2020

35. Efficacy and Safety Dean Elterman :New Technologies for Treatment of Benign Prostatic Hyperplasia Urol Clin N Am 49 (2022)

36. conclusion

37. Thank you