|Year : 2023 | Volume
| Issue : 2 | Page : 55-63
Treatment of benign prostatic hyperplasia: Update and future
Tai-Hua Chiu1, Yi-Hsuan Wu2, Yung-Chin Lee3
1 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University; Kaohsiung Medical University, Kaohsiung, Taiwan
|Date of Submission||01-Dec-2022|
|Date of Decision||09-Feb-2023|
|Date of Acceptance||22-Feb-2023|
|Date of Web Publication||17-Jun-2023|
100, Shih-Chua 1st Road, Sanmin, Kaohsiung 807
Source of Support: None, Conflict of Interest: None
Benign prostatic hyperplasia (BPH) is one of the widespread diseases affecting aging males globally. As prostatic cell proliferation, it clinically influences a great degree of bladder outlet obstruction and is characterized by bothersome lower urinary tract symptoms. Assessments and treatments should not only be conducted based on the prostate volume or condition, related symptoms and quality of life should be considered also. The present analysis focuses on the update of management for BPH, including pharmacotherapy and slightly invasive surgical options. Despite alpha-1 adrenoceptor antagonists, many other factors and even combination therapy were extensively studied. Regarding slightly invasive surgical treatments, including Aquablation, water vapor thermal therapy, prostatic artery embolization, prostatic urethral lift, and nitinol butterfly-like stent, we analyzed the latest findings of studies, as well as safety issues. Finally, we highlighted current guidelines for clinical practice and future direction for further investigation.
Keywords: Benign prostatic hyperplasia, lower urinary tract symptoms, minimally invasive surgical treatments
|How to cite this article:|
Chiu TH, Wu YH, Lee YC. Treatment of benign prostatic hyperplasia: Update and future. Urol Sci 2023;34:55-63
| Introduction|| |
Benign prostatic hyperplasia (BPH), inducing prostatic enlargement and obstruction of the urethra, is a proliferation of glandular epithelial tissue, smooth muscle, and connective tissue at the transitional zone by histological research. There are several known risk factors such as race, genetics, alcohol, and metabolic syndrome, though aging is the most renowned.,,, The natural course initiated in the fifth decade of life, attaining 80% by the age of 80 years. The initial approach to BPH includes patient history, digital rectal exam, urinalysis, and prostate-specific antigen test. International prostate symptom score (IPSS), comprising 7 questions to break down the severity of lower urinary tract symptoms (LUTS), offers important information about micturition and guides treatment decisions. Furthermore, measurements of maximum urinary flow rate (Qmax) and postvoid residual (PVR) urine volume generally are presumed to be diagnostic tools.
As men age, mild-to-moderate LUTS resulting from BPH can be relieved by the first-line approach, behavioural, and lifestyle modification. Gradually, medication and surgical intervention may be implemented, or bothersome LUTS not only impact the quality of life (QoL) but causes adverse consequence when it advances, such as urinary tract infection (UTI), acute urine retention (AUR), and renal insufficiency. In recent years, innovative agents and combination treatments were studied thoroughly. For those who were fragile and unresponsive to medical treatments, minimally invasive surgical treatments became available and kept in advance. The current review sought to update the treatments for BPH and inform about the future direction.
| Behavioral and Lifestyle Modification|| |
The basic step of BPH management is behavioral and lifestyle change. At the outpatient clinic, the physician enlightened patients about lowering the consumption of caffeine and alcohol, reducing liquid consumption, using the toilet before sleep, performing exercises to strengthen the pelvic floor muscles, doing bladder training, and preventing constipation. Besides, a healthy diet comprising vegetables and fruit instead of high protein or polyunsaturated fatty acid help to decrease the risk of BPH., Regular and thorough Physical activity indicated an inverse association with BPH and LUTS (odds ratio was 0.74).
| Pharmacological Management|| |
Though conservative treatment can be a choice for those who did not have significant LUTS, about 19% of patients were clinically advanced after a mean follow-up of 17 months of monitored waiting. Alpha-1 adrenoceptor antagonists (α1-blockers) are the initial line of treatment for moderate-to-severe symptomatic BPH. They mitigated bladder outlet obstruction by inhibiting the effect of endogenous noradrenaline on smooth muscle cells in the prostate. The efficacy and coexistence of different α1-blockers have been analyzed through direct or indirect comparisons, and a recent study showed similar efficacy among different α1-blockers. Objectively, urodynamic studies also demonstrated a considerable improvement of Qmax (2.27 ml/s, P < 0.0001), and mitigated bladder outlet obstruction index (BOOI) (−14.19, P < 0.0001) and detrusor pressure at Qmax (PdetQmax) (−11. 39 cm H2O, P < 0.0001). Regarding well-documented adverse effects, such as vasodilatation-related dizziness and orthostatic hypotension, ejaculation disorder, or intra-operative floppy iris syndrome, counseling before treatments and adequate doses would help to maintain safety and medical compliance clinically.
Although α1-blockers were prevalently applied for LUTS, they cannot inhibit BPH advancement. Five-alpha-reductase inhibitors (5-ARIs), block the conversion of testosterone to dihydrotestosterone and lower the prostate volume., After long-term application, 5-ARIs enhanced IPSS clinically, lowered detQmax, and increase Qmax in urodynamic parameters., Furthermore, studies indicated that they mitigated the relative risk of AUR by 57%–68% and the requirement for surgery by 34%–55%.,,
Antimuscarinics inhibit the activation of acetylcholine to muscarinic receptors and mediate voiding contractions, so they have been mostly applied for overactive bladder (OAB) patients. Treating BPH with antimuscarinics solely has been tested and demonstrated efficacy, particularly for those who were presumed nonobstructive BPH and OAB.,, Kaplan et al. carried out a prospective study and revealed that treatment with antimuscarinics in men with BPH and refractory LUTS decreased urinary frequency and nocturia and greatly improved the American Urological Association (AUA) symptom scores and Qmax. Furthermore, antimuscarinics are a supplementary choice for those experiencing α1-blockers with residual storage symptoms. Randomized controlled trials (RCTs) indicated a combination of antimuscarinics and α1-blockers was the rational therapy for BPH concomitant OAB because of its efficacy in reducing the frequency, urgency, and urinary incontinence and improving IPSS.,,,, Although adverse effects of antimuscarinics and α1-blockers may be observed when receiving combination therapy, the AUR rate was low as 0.4%–1.1%.,
Novel beta-3 agonists function on the beta-3 adrenoceptor which is a major role in mediating human detrusor relaxation. The agent can also be beneficial for male patients with LUTS, particularly in storage symptoms. Monotherapy with Mirabegron 25 mg daily boosted the satisfactory rate and QoL for OAB male patients with or without BOO, though greatly decreased IPSS in patients without BOO. Treatment with a combination of beta-3 agonists and α1-blockers worth assessing after antimuscarinics is proposed for men with refractory storage symptoms and experiencing α1-blockers monotherapy. Ichihara et al. investigated the addition of beta-3 agonists to α1-blockers greatly relieved daytime frequency, urgency, and IPSS despite open-labeled and short-term study design. A recent MATCH trial discovered treatment with Tamsulosin 0.2 mg and mirabegron 50 mg was superior to a combination with tamsulosin and placebo in a stand of storage symptoms, voided volume each micturition, IPSS, and QoL in a high Asian population. Another PLUS trial statistically demonstrated improvement in mean volume voided per micturition and urgency episodes per day rather than IPSS for a standard dose of Tamsulosin 0.4 mg plus mirabegron 50 mg. In 2022, the European Association of Urology (EAU) guidelines for nonneurogenic male LUTS, patients with recurrent storage symptoms after treatment with α1-blockers monotherapy are suggested to use mirabegron. Although adverse effects of both drugs may be observed, drug-drug interactions did not induce clinically relevant changes in pulse rate and systolic blood pressure, remaining cardiovascular safety.
Both LUTS and erectile dysfunction are common in aging males and epidemiologic studies have determined a correlation. There are 4 theories indicating the link between LUTS and erectile dysfunction, the NOS/NO theory, the autonomic hyperactivity, and metabolic syndrome hypothesis, the Rho-kinase activation/endothelin pathway, and pelvic atherosclerosis. Though the connection between LUTS and erectile dysfunction remains unclear, phosphodiesterase-5 (PDE-5) inhibitors have presented promising outcomes in preclinical and clinical studies. Gacci et al. performed a meta-analysis with 3214 men and expressed that PDE-5 inhibitors alone substantially improved IPSS (−2.8; P < 0.0001) but not Qmax (−0.00; P = not significant) unlike placebo. Another recent systemic research and meta-analysis revealed a comparable result. However, an integrated analysis of tadalafil 5 mg statistically increased Qmax versus placebo (median 1.1 vs. 0.4 ml per s, P = 0.003). Guo et al. directly contrasted PDE-5 inhibitors to Tamsulosin and there was no statistical difference in terms of IPSS, voiding subscores, storage subscores, QoL, Qmax, and PVR, signifying a similar therapeutic impact as Tamsulosin for BPH-related LUTS. An updated systematic review and meta-analysis revealed the conforming results that the combination of alpha-blockers and PDE-5 inhibitors was superior to alpha-blockers solely in IPSS and Qmax.,,
| Minimally Invasive Surgical Treatment|| |
Minimally invasive surgical treatments are innovative options for those who were unresponsive to medication or transurethral resection of the prostate (TURP) [Table 1].
| Aquablation|| |
Aquablation, executed using the Aquabeam system (PROCEPT BioRobotics, Redwood City, CA, USA), is an innovative technology incorporating real-time image-based ultrasonic guidance and robotics with high-pressure (500–8000 pounds per square inch) saline jet for resection of prostate parenchymal tissue.
The procedure of Aquablation was originally characterized by Farber et al. in 2015, and the effectiveness was further evaluated by many other authors with medium-term follow-up data expressed.,,,, WATER I trial,, conducted by Gilling et al., was the first double-blind, multicenter (across 17 different centers), prospective RCT, which included 181 patients who underwent Aquablation (n = 116) or TURP (n = 65) with prostate volume 30 and 80 mL. The mean resection time was shorter irrespective of prostate size in the Aquablation arm than in the TURP arm (4 min and 27 min, P < 0.001), while the total operative time was comparable in the 2 arms. Safety data at 3 months following the procedure revealed Aquablation to be noninferior to TURP. The Clavien–Dindo one events linked to retrograde ejaculation were observed in 24.6% of TURP patients and 6.9% of aquablation patients. The efficacy data at 6 months also revealed noninferiority in the aquablation arm, with similar improvement in IPSS (6.0 for aquablation and 6.7 for TURP). Besides, additional assessment of QoL, Qmax, and PVR also indicated comparable results in both groups. Urinary incontinence assessment, using self-reported incontinence severity index, was found to be improved following aquablation, unlike baseline. Besides, male sexual health questionnaire-ejaculatory dysfunction (EjD) scores were considerably low after TURP but stable in Aquablation groups 6 months postprocedure. At 5 years of follow-up data available in 2022, IPSS advancements in the aquablation arm were 15.1 points and 13.2 points in the TURP. Improvements in Qmax were 125% and 89% than baseline in aquablation and TURP groups, respectively. Furthermore, the need for further BPH medication or surgery due to LUTS was 51% less in aquablation groups than in TURP groups.
The water II study sought to analyze the efficacy and safety of Aquablation in 101 patients with larger prostate (80–150 mL). WATER II was also a prospective multicenter study, and as a single-arm study, it contrasted efficacy and safety with an objective performance criterion to assess noninferiority. The resection time was 8 min with a total operation time of 35 min. The 3-year follow-up data for WATER II are currently accessible., IPSS dropped from 23.2 at baseline to 6.5 at 36 months, and Qmax elevated by 9.8 mL/s. At 3 years, 94% of Aquablation-treated patients were BPH medication free and 97% of treated patients were free from surgical intervention due to LUTS. For an even larger prostate size, Helfand et al. analyzed the effectiveness and safety data in 34 patients with an average prostate volume of 209 mL (range 151–362 mL). With a mean follow-up of 7 months, the IPSS declined from 19 to 7 points, and Qmax elevated from 7 to 19 mL/s.
As an athermal resection procedure, Aquablation lacks direct hemostasis for the resection bed after the intervention. A systematic analysis comparing different minimally invasive transurethral treatments for BPH indicated that hematuria or postoperative bleeding was 0.8%–26% in the studied literature and the need for reintervention or transfusion due to bleeding varied from 1.8% to 9%. Hematuria-related complication after Aquablation without any cautery was found to be 10%. The bleeding events had conformed to the concept of hemostasis with bladder neck cautery right after the procedure. Nonresective focal cautery at the bladder neck was an effective method for hemostasis after aquablation, with a transfusion rate of 0.8% and reintervention for a fulguration rate of 0.6% after the procedure. In another analysis, with selective hemostasis on the prostate resection bed and on the bladder neck using bipolar cauterization, the rate of perioperative bleeding complication after aquablation was shown to be similar to those discovered in holmium laser enucleation of the prostate (HoLEP) group. Some rare complications such as rectal perforation were observed and were thought to be linked to a decrease in the haptic feedback after the transrectal ultrasound scan (TRUS) probe was affixed to the mobile arm.
In 2022 EAU guidelines, aquablation seems to be as effective as TURP, but concerns about the best methods of achieving posttreatment hemostasis still exist (Oxford level of evidence 1b); Aquablation is being investigated and may be administered to patients with moderate-to-severe LUTS and a prostate volume of 30–80 mL as an alternative to TURP (weak recommendation). According to the current AUA guideline on the management of BPH, Aquablation/Robotic waterjet treatment can also serve as a treatment option for patients with LUTS/BPH provided prostate volume 30–80cc, but it has the lowest grade of recommendation (conditional, on a scale from strong to conditional). ATHLETE, a prospective, randomized, open-label, noninferiority trial comparing Aquablation with HoLEP, is being performed at a Swiss center of tertiary care. This trial revealed the efficacy of Aquablation in medium to large prostate, as HoLEP is a well-established approach in the management of prostate glands of 30 mL or larger and is considered the first-line therapy in prostate volume over 80 mL in EAU guidelines.
| Water Vapor Thermal Therapy (Rezum)|| |
Rezum System (Boston Scientific Company Inc., Marlborough, MA, USA) utilizes convective radiofrequency water vapor to ablate obstructive prostate tissue. The steam was infused into the transition zone of the prostate through a needle inserted into the prostate transurethrally. Once the steam had contact with prostate tissue, the stored thermal energy is released and induces damage to the prostatic cell, and let to tissue necrosis.
The eventual 5-year findings of the multicenter randomized sham-controlled trial assessing 197 patients (mean prostate volume of 45.9 mL in the treatment group) have been accessible lately. McVary et al. revealed that improvement of LUTS was noticed at <3 months after the therapy and the effect remained durable through year 5 of follow-up. IPSS decreased by 48% when compared to baseline, QoL elevated by 45%, and the maximum flow rate was boosted by 44%. In another analysis of 83 patients with large-volume prostates (≥80 mL), IPSS, QoL, and maximum flow rate improvement was shown to be 59%, 70%, and 29% at 12 months following the Rezum procedure, respectively. A retrospective study of 49 patients in urinary retention (with a median PVR of 900 ml) who had Rezum revealed that 6/49 (12.2%) patients stayed in catheter-dependent urinary retention after 6 months of the procedure, even after further surgical intervention for BPH. In a retrospective study of 461 patients undergoing Rezum, the retreatment rate following the procedure was found to be 4.6% and 11/461 (2.4%) cases were within the 1st year. Inadequately treated median lobe, an obstructing bladder neck, and asymmetry of the prostate cavity or recesses were the most prevalent outcomes at reoperation. In the data of 5-year outcomes of Rezum RCT by McVary et al., surgical and medication retreatment rate was found to be 4.4% and 11.1%, respectively. To contrast the efficacy of rezum in medical management for BPH, Gupta et al. employed data from rezum RCT and Medical Therapy of Prostatic Symptoms trial, revealing that LUTS improvement was greater than with either drug alone (doxazosin, finasteride) but comparable to that of combination drugs (P ≤ 0.02 and P = 0.73, respectively).
Concerning the preservation of sexual function, McVary et al. revealed the 5-year outcomes of 197 patients and discovered that rezum induced a modest impact on erectile or ejaculatory function. There were no de novo device or procedure-related erectile dysfunction reported during the study duration. However, the de novo erectile dysfunction rate was discovered to be 3.1% by Mollengarden et al. in a single surgeon retrospective analysis of 129 patients who had the rezum procedure. McVary et al. also discovered that water vapor thermal therapy (WVTT) does not have an overt negative influence on sexual function, unlike conventional medical therapy for BPH. Common adverse events (AEs) linked to the device or procedure after rezum were dysuria, gross hematuria, hematospermia, urinary frequency, AUR, and a decrease in ejaculatory volume in the RCT by McVary et al. Most of these AEs were mild-to-moderate and self-resolved, and no late-onset procedure-related complication was demonstrated in years 1–5.
In 2022 EAU guidelines on the management of male LUTS, no grade of recommendation was known yet. According to the current AUA guideline, rezum/WVTT still has the lowest level of proof and should be deemed a treatment option for patients LUTS/BPH provided prostate volume 30–80 mL (moderate recommendation), and may be recommended to eligible patients who desire the preservation of erectile and ejaculatory function (conditional recommendation). Only one manufacturer-funded double-blind RCT with a follow-up duration of 5 years has been performed currently. More RCTs for rezum against a reference technique (TURP and/or other minimally invasive procedure) are required.
| Prostate Artery Embolization|| |
Prostate artery embolization (PAE) employs several embolic agents to blockade prostatic arterial blood flow, facilitating local tissue infarction and necrosis, and further shrinkage of prostate size after necrotic tissue desquamation. Furthermore, the procedure may decrease the level of dihydrotestosterone in the prostate by hindering the entrance of free testosterone from plasma and thus inhibit prostatic tissue growth.
Several prior RCTs have compared the efficacy and safety of PAE to TURP, and one sham-controlled RCT has been published as well., The 2-year follow-up data of RCTs of 103 patients by Abt et al. indicated that the reduction of IPSS after 2 years was 9.21 points following PAE and 12.09 points following TURP. PAE was also shown to be less effective than TURP in the improvement of maximum urinary flow rate (3.9 vs. 10.23 ml/s, in PAE and TURP, respectively), reduction of PVR urine (62.1 vs. 204.0 ml), and reduction of prostate volume (10.66 vs. 30.20 ml). In the first randomized, sham-controlled RCT of 80 men (1:1 in PAE and sham arm) with LUTS/BPH, Pisco et al. indicated that patients in the PAE arm had a higher improvement in IPSS (difference = 13.2 compared to baseline), and a better QoL score at 6 months (difference = 2.13) than patients in the sham arm. Furthermore, the mean difference (MD) in Qmax was 4.2 mL/s. A recent meta-analysis included 6 RCTs and 2 nonrandomized studies contrasting PAE with TURP, and 1 RCT contrasting PAE with sham. The result discovered little to no difference between PAE and TURP in postoperative IPSS (MD 1.72) and QoL (MD 0.28), and that PAE may augment retreatment rates (risk ratio [RR] 3.20) in follow-up duration up to 12 months. In long-term (13–24 months) follow-up, PAE still yielded little to no difference in IPSS (MD 2.58) and IPSS QoL (MD 0.50), with an increased retreatment rate (RR 3.80).
Overall, PAE is linked to fewer complications and a relevant retreatment rate than TURP in RCT by Abt et al. A meta-analysis demonstrated PAE was not greatly correlated with major AEs (Clavien-Dindo Classification III-V), erectile and ejaculatory disorders, AUR, and other minor AEs (Clavien-Dindo Classification I–II). Nonetheless, severe complications had been documented such as penile glans necrosis. This rare condition was believed to be linked to reflux intravascular particles and nontarget embolization and can be managed with hyperbaric oxygen therapy with complete resolution. The retreatment rate of PAE was shown to be 21% after 2 years of procedure in a study by Ray et al., and 19.9% (5.1% in the 1st year and 14.8% thereafter) in an observational UK Register of Prostate Embolization study. The major risks of reoperation included unilateral embolization, median lobe enlargement, small prostate size, and high bladder neck. In a large retrospective study comprising 1072 patients, reintervention rates were 3.4% at 1 year, 21.1% at 5 years, and as high as 58.1% at 10 years.
Current EAU guidelines suggest PAE to men with moderate-to-severe LUTS who wish to consider minimally invasive treatment options and accept less optimal outcomes than TURP (weak recommendation), and only in the department where the workup and follow-up are conducted by urologists working collaboratively with trained interventional radiologists to determine PAE suitable patients (strong recommendation). PAE is not proposed outside the context of clinical trials by the current AUA guidelines on the management of BPH. The data assessing the effectiveness and safety of PAE was restricted, with only 2-year follow-up data available currently. Furthermore, comparative studies are required to determine the benefits and risks of different embolic agents, as innovative embolic agents continue to be employed.
| Prostatic Urethral Lift|| |
The prostatic urethral lift (PUL, UroLift System; NeoTract-Teleflex, Pleasanton, CA, USA) employs permanent implants, comprising 2 nitinol anchors linked to nonabsorbable polyethylene terephthalate suture, to displace the prostatic tissue. The procedure is a tissue-sparing method, with one nitinol anchor on the surface of the urethra mucosa and the other found on the outside of the prostate capsule, resulting in retraction of obstructing prostatic lateral or median lobe and further dilatation of prostatic urethra lumen.
Two significant trials assessed the efficacy and safety of PUL when compared to the sham group and TURP. The L.I.F.T analysis was the longest-term multicenter randomized blinded trial of UroLift to date, which included 206 participants with age >50 years, IPPS ≥13, Qmax ≤12 mL/s, and prostate volume of 30–80 mL, and randomized patient to 2:1 (PUL [n = 140], sham treatment [n = 66]). Patients with obstructive median lobe and active UTI were exempted. The AUA-Symptom Score reduction in the PUL arm was 88% higher than that of sham at 3 months (11.1 in PUL and 5.9 in sham), and Qmax increased by 4.3 mL/s (PUL) versus 2.0 mL/s (sham). Advancements in IPSS, QoL, BPH Impact Index (BPH II), and Qmax were sustained through 5 years with improvements of 36%, 50%, 52%, and 44%, respectively. There were no de novo erectile or EjD during the 5-year follow-up. BPH 6 analysis, a prospective RCT involving 80 men, was performed to compare LUTS improvement, recovery, worsening of erectile and ejaculatory functions, continence, and safety in patients that underwent PUL to those of TURP, and 2-year follow-up results have been published. Significant improvements in IPSS, IPSS QoL, BPHII, and Qmax were observed in both treatment groups during the follow-up period. The improvement of IPSS and Qmax were superior in the TURP group, while the PUL group had a superior quality of recovery, ejaculatory function preservation, and performance. The change in IPSS QoL and BPHII was not statistically distinct between the 2 arms. While the obstructive median lobe was deemed exclusion criteria in the L.I.F.T study, the MedLift study, a 2018 nonrandomized prospective study by Rukstalis et al. assessed the utility of PUL in a patient with an obstructive median lobe. The procedure modifies the original method, retracting the intravesically protruding portion of the prostate into the prostatic fossa and fixing prostate tissues laterally to either side of the urethra. Forty-five patients were enrolled and followed for 12 months, and the data was evaluated to previous L.I.F.T lateral lobe enlargement findings. After 12 months of follow-up, mean IPSS enhanced by at least 13.5 from baseline, and QoL and BPHII improved by over 60% and 70%, respectively. The alleviation of symptoms was at least as much comparing the obstructive median lobe group and lateral lobe enlargement group. After combining obstructive median lobe and lateral lobe enlargement data, over 70% of patients indicated ≥8 points improvement in IPSS through 12 months. A meta-analysis of 322 patients with a follow-up period of 24 months was published in 2020, reporting an improvement of IPSS was 9.1 in randomized studies and 10.4 in nonrandomized studies, and that meaningful improvement in Qmax was 3.7 in randomized studies and 3.0 in nonrandomized studies.
AEs following the PUL procedure were mild, including dysuria, gross hematuria, and pelvic pain, which usually resolved in 2–3 weeks. Nonetheless, some pelvic hematoma was self-limiting, and some needed surgical intervention and resulted in renal failure., Another study characterized implant clipping the vesicoureteric junction, leading to groin pain, ureteric obstruction, and hydronephrosis. PUL outperformed TURP in sexual function preservation, and no de novo retrograde ejaculation was discovered. The retreatment rate was relatively high after PUL. The surgical retreatment rate after 2 years in the BPH 6 trial was 5.7% for TURP and 13.6% for PUL and was 13.6% over 5 years in the L.I.F.T trial.
According to the current EAU guidelines, PUL can be given to men interested in preserving ejaculatory function, with prostates <70 mL and no middle lobe (strong recommendation). According to the AUA Guidelines on BPH, PUL should be considered in a patient with LUTS/BPH provided prostate volume 30–80 mL and the confirmed absence of an obstructive middle lobe (moderate recommendation; evidence level: Grade C), and can be given to eligible patients who desire preservation of erectile and ejaculatory function (conditional recommendation; evidence level: Grade C).
The safe and efficacy of PUL in a patient with large prostate or median lobe obstruction had only been assessed in limited studies. Besides, metallic content in implants generates artifacts in magnetic resonance imaging images of the prostate, and the influence of this artifact on prostate cancer imaging evaluation is not extensively studied yet.
| Nitinol Butterfly-Like Stent|| |
The nitinol butterfly-like stent (i-TIND) (Medi-Tate, Hadera, Israel/Olympus Corporation, Tokyo, Japan) is the second generation of the temporary implantable nitinol device. The device comprises 3 intertwined nitinol struts connected at the distal end and an antimigration anchoring leaflet. After deployment, the struts expand in the urethra, promoting local ischemic necrosis of the prostate at 5, 7, and 12 o'clock positions, influencing the decrease of bladder outlet obstruction.,
The MT02 is a prospective, multicenter, single-arm trial, including 81 patients (IPSS ≥10, prostate volume <75 ml, and without obstructing median lobe) at first, with 50 men available for 3 years of follow-up data. Amparore et al. indicated that i-TIND implantation efficacy was durable through 36 months, with averages IPSS, QoL, and Qmax as (20.7–8.55), (3.9–1.76), and (7.71 mL/s to 15.2 mL/s) (baseline to follow-up), improved from baseline by −58.2, −55.6, and + 114.7%. Sexual function was also consistent through 36 months, with no reports of sexual or EjDs. Chughtai et al. reviewed the first comparative data in an RCT (MT03 study), comparing i-TIND to a sham procedure for the treatment of LUTS secondary to BPH. 175 men were included (118 i-TIND and 57 sham). The i-TIND group had a 9.25 decrease in IPSS, a 3.52 ml/s increase in Qmax, and a 1.9 reduction in QoL at 12 months. Most AEs including dysuria and hematuria were mild and only occurred before device removal. In the MT02 study, the surgical retreatment rate was 8.6%, and 6.2% participant-required medication therapy up to 3 years follow-up. In the MT03 study, the surgical reintervention rate and medication usage rate following i-TIND were both 4.7%.
The current EAU guideline considers i-TIND as a technique under investigation and had no recommendation on the usage i-TIND. The AUA guidelines on BPH have not outlined i-TIND yet. Additional studies comparing i-TIND with TURP and other minimally invasive techniques are required. MT-08 trial comparing the effectiveness of i-TIND to UroLift is ongoing and data are presently unavailable.
| Future Direction|| |
Initial studies had assessed the effectiveness of several minimally invasive therapies for BPH-related LUTS, while the study design of these trials still had some restrictions, including anatomical consideration (prostate size, obstructive median lobe), reference procedure (TURP or sham), and follow-up duration. Further studies targeting different patient groups (e.g. patients with larger prostate and median lobe, anticoagulant agent usage), with more reference therapies, and an extensive follow-up are required for these minimally invasive therapies. Many minimally invasive therapies are based on the comparable mechanism as i-TIND. The optilume BPH catheter system (Urotronic Inc., Plymouth, Minnesota, USA) is a drug-coated balloon catheter system that delivered an antiproliferative agent to the prostate after dilatation of prostatic urethra with a balloon, and the 1-year outcome had been published. XFLO Expander System (Medeon Biodesign, Inc., Taiwan), Zenflow Spring System (Zenflow, South San Francisco, CA, USA), and Butterfly Prostatic Retraction device (Butterfly, Medical Ltd, Yokneam, Yilit, Israel) adverse are different kinds of nitinol implant for temporary or permanent placement in the urethra and can be deployed with a flexible cystoscope.
| Conclusion|| |
Combination medical treatments and minimally invasive therapies are prevalently evaluated for treating BPH in recent years. However, minimally invasive therapies have not been developed to totally replace standard BPH surgery but offer an alternative for men unable to undergo standard surgery or those who cannot withstand side-effect of TURP. Many innovative minimally invasive devices for treating BPH are being analyzed.
Data availability statement
All data generated or analyzed during this study are included in this published article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol 2017;4:148-51.
Guess HA, Arrighi HM, Metter EJ, Fozard JL. Cumulative prevalence of prostatism matches the autopsy prevalence of benign prostatic hyperplasia. Prostate 1990;17:241-6.
Kok ET, Schouten BW, Bohnen AM, Groeneveld FP, Thomas S, Bosch JL. Risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in a community based population of healthy aging men: The Krimpen Study. J Urol 2009;181:710-6.
Taylor BC, Wilt TJ, Fink HA, Lambert LC, Marshall LM, Hoffman AR, et al.
Prevalence, severity, and health correlates of lower urinary tract symptoms among older men: The MrOS study. Urology 2006;68:804-9.
Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms: Prevalence and incident rates. Urol Clin North Am 2016;43:289-97.
Bravi F, Bosetti C, Dal Maso L, Talamini R, Montella M, Negri E, et al.
Food groups and risk of benign prostatic hyperplasia. Urology 2006;67:73-9.
Rohrmann S, Giovannucci E, Willett WC, Platz EA. Fruit and vegetable consumption, intake of micronutrients, and benign prostatic hyperplasia in US men. Am J Clin Nutr 2007;85:523-9.
Parsons JK, Kashefi C. Physical activity, benign prostatic hyperplasia, and lower urinary tract symptoms. Eur Urol 2008;53:1228-35.
Netto NR Jr., de Lima ML, Netto MR, D'Ancona CA. Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting. Urology 1999;53:314-6.
Michel MC, Vrydag W. Alpha1-, alpha2- and beta-adrenoceptors in the urinary bladder, urethra and prostate. Br J Pharmacol 2006;147 Suppl 2:S88-119.
Djavan B, Chapple C, Milani S, Marberger M. State of the art on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2004;64:1081-8.
Manjunatha R, Pundarikaksha HP, Madhusudhana HR, Amarkumar J, Hanumantharaju BK. A randomized, comparative, open-label study of efficacy and tolerability of alfuzosin, tamsulosin and silodosin in benign prostatic hyperplasia. Indian J Pharmacol 2016;48:134-40.
] [Full text]
Fusco F, Palmieri A, Ficarra V, Giannarini G, Novara G, Longo N, et al.
α1-blockers improve benign prostatic obstruction in men with lower urinary tract symptoms: A systematic review and meta-analysis of urodynamic studies. Eur Urol 2016;69:1091-101.
Traish AM. 5α-reductases in human physiology: An unfolding story. Endocr Pract 2012;18:965-75.
Busetto GM, Del Giudice F, D'Agostino D, Romagnoli D, Minervini A, Rocco B, et al.
Efficacy and safety of Finasteride (5 alpha-reductase inhibitor) monotherapy in patients with benign prostatic hyperplasia: A critical review of the literature. Arch Ital Urol Androl 2020;91:205-10.
Roehrborn CG, Siami P, Barkin J, Damião R, Major-Walker K, Morrill B, et al.
The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. J Urol 2008;179:616-21.
Tammela TL, Kontturi MJ. Long-term effects of finasteride on invasive urodynamics and symptoms in the treatment of patients with bladder outflow obstruction due to benign prostatic hyperplasia. J Urol 1995;154:1466-9.
McConnell JD, Roehrborn CG, Bautista OM, Andriole GL Jr., Dixon CM, Kusek JW, et al.
The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003;349:2387-98.
McConnell JD, Bruskewitz R, Walsh P, Andriole G, Lieber M, Holtgrewe HL, et al.
The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med 1998;338:557-63.
Andersen JT, Nickel JC, Marshall VR, Schulman CC, Boyle P. Finasteride significantly reduces acute urinary retention and need for surgery in patients with symptomatic benign prostatic hyperplasia. Urology 1997;49:839-45.
Höfner K, Burkart M, Jacob G, Jonas U. Safety and efficacy of tolterodine extended release in men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia. World J Urol 2007;25:627-33.
Roehrborn CG, Abrams P, Rovner ES, Kaplan SA, Herschorn S, Guan Z. Efficacy and tolerability of tolterodine extended-release in men with overactive bladder and urgency urinary incontinence. BJU Int 2006;97:1003-6.
Kaplan SA, Roehrborn CG, Rovner ES, Carlsson M, Bavendam T, Guan Z. Tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder: A randomized controlled trial. JAMA 2006;296:2319-28.
Kaplan SA, Walmsley K, Te AE. Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2005;174:2273-5.
Yokoyama T, Uematsu K, Watanabe T, Sasaki K, Kumon H, Nagai A, et al.
Naftopidil and propiverine hydrochloride for treatment of male lower urinary tract symptoms suggestive of benign prostatic hyperplasia and concomitant overactive bladder: A prospective randomized controlled study. Scand J Urol Nephrol 2009;43:307-14.
van Kerrebroeck P, Chapple C, Drogendijk T, Klaver M, Sokol R, Speakman M, et al.
Combination therapy with solifenacin and tamsulosin oral controlled absorption system in a single tablet for lower urinary tract symptoms in men: Efficacy and safety results from the randomised controlled NEPTUNE trial. Eur Urol 2013;64:1003-12.
Kaplan SA, Roehrborn CG, Gong J, Sun F, Guan Z. Add-on fesoterodine for residual storage symptoms suggestive of overactive bladder in men receiving α-blocker treatment for lower urinary tract symptoms. BJU Int 2012;109:1831-40.
Kim TH, Jung W, Suh YS, Yook S, Sung HH, Lee KS. Comparison of the efficacy and safety of tolterodine 2 mg and 4 mg combined with an α-blocker in men with lower urinary tract symptoms (LUTS) and overactive bladder: A randomized controlled trial. BJU Int 2016;117:307-15.
Drake MJ, Oelke M, Snijder R, Klaver M, Traudtner K, van Charldorp K, et al.
Incidence of urinary retention during treatment with single tablet combinations of solifenacin+tamsulosin OCAS™ for up to 1 year in adult men with both storage and voiding LUTS: A subanalysis of the NEPTUNE/NEPTUNE II randomized controlled studies. PLoS One 2017;12:e0170726.
Sebastianelli A, Russo GI, Kaplan SA, McVary KT, Moncada I, Gravas S, et al.
Systematic review and meta-analysis on the efficacy and tolerability of mirabegron for the treatment of storage lower urinary tract symptoms/overactive bladder: Comparison with placebo and tolterodine. Int J Urol 2018;25:196-205.
Liao CH, Kuo HC. Mirabegron 25mg monotherapy is safe but less effective in male patients with overactive bladder and bladder outlet obstruction. Urology 2018;117:115-9.
Ichihara K, Masumori N, Fukuta F, Tsukamoto T, Iwasawa A, Tanaka Y. A randomized controlled study of the efficacy of tamsulosin monotherapy and its combination with mirabegron for overactive bladder induced by benign prostatic obstruction. J Urol 2015;193:921-6.
Kakizaki H, Lee KS, Yamamoto O, Jong JJ, Katou D, Sumarsono B, et al.
Mirabegron add-on therapy to tamsulosin for the treatment of overactive bladder in men with lower urinary tract symptoms: A Randomized, Placebo-controlled Study (MATCH). Eur Urol Focus 2020;6:729-37.
Kaplan SA, Herschorn S, McVary KT, Staskin D, Chapple C, Foley S, et al.
Efficacy and safety of mirabegron versus placebo add-on therapy in men with overactive bladder symptoms receiving tamsulosin for underlying benign prostatic hyperplasia: A randomized, phase 4 study (PLUS). J Urol 2020;203:1163-71.
van Gelderen M, Tretter R, Meijer J, Dorrepaal C, Gangaram-Panday S, Brooks A, et al.
Absence of clinically relevant cardiovascular interaction upon add-on of mirabegron or tamsulosin to an established tamsulosin or mirabegron treatment in healthy middle-aged to elderly men. Int J Clin Pharmacol Ther 2014;52:693-701.
Wang C. Phosphodiesterase-5 inhibitors and benign prostatic hyperplasia. Curr Opin Urol 2010;20:49-54.
McVary K. Lower urinary tract symptoms and sexual dysfunction: Epidemiology and pathophysiology. BJU Int 2006;97 Suppl 2:23-8.
Gacci M, Corona G, Salvi M, Vignozzi L, McVary KT, Kaplan SA, et al
. A systematic review and meta-analysis on the use of phosphodiesterase 5 inhibitors alone or in combination with α-blockers for lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2012;61:994-1003.
Wang Y, Bao Y, Liu J, Duan L, Cui Y. Tadalafil 5 mg once daily improves lower urinary tract symptoms and erectile dysfunction: A systematic review and meta-analysis. Low Urin Tract Symptoms 2018;10:84-92.
Roehrborn CG, Chapple C, Oelke M, Cox D, Esler A, Viktrup L. Effects of tadalafil once daily on maximum urinary flow rate in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. J Urol 2014;191:1045-50.
Guo B, Chen X, Wang M, Hou H, Zhang Z, Liu M. Comparative effectiveness of tadalafil versus tamsulosin in treating lower urinary tract symptoms suggestive of benign prostate hyperplasia: A meta-analysis of randomized controlled trials. Med Sci Monit 2020;26:e923179.
Zhang J, Li X, Yang B, Wu C, Fan Y, Li H. Alpha-blockers with or without phosphodiesterase type 5 inhibitor for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: A systematic review and meta-analysis. World J Urol 2019;37:143-53.
Nagasubramanian S, John NT, Antonisamy B, Mukha RP, Jeyachandra Berry CS, Kumar S, et al.
Tamsulosin and placebo vs. tamsulosin and tadalafil in male lower urinary tract symptoms: A double-blinded, randomised controlled trial. BJU Int 2020;125:718-24.
Chen PC, Wang CC, Tu YK. Combination alpha blocker and phosphodiesterase 5 inhibitor versus alpha-blocker monotherapy for lower urinary tract symptoms associated with benign prostate hyperplasia: A systematic review and meta-analysis. Urol Sci 2020;31:99-107. [Full text]
Gilling P, Reuther R, Kahokehr A, Fraundorfer M. Aquablation - image-guided robot-assisted waterjet ablation of the prostate: initial clinical experience. BJU Int 2016;117:923-9.
Gilling P, Barber N, Bidair M, Anderson P, Sutton M, Aho T, et al
. WATER: A double-blind, randomized, controlled trial of aquablation ((r)) vs transurethral resection of the prostate in benign prostatic hyperplasia. J Urol 2018;199:1252-61.
Desai M, Bidair M, Zorn KC, Trainer A, Arther A, Kramolowsky E, et al
. Aquablation for benign prostatic hyperplasia in large prostates (80-150 mL): 6-month results from the WATER II trial. BJU Int 2019;124:321-8.
Assad A, Nguyen DD, Barber N, Bidair M, Gilling P, Anderson P, et al
. WATER vs WATER II 3-Year Update: Comparing aquablation therapy for benign prostatic hyperplasia in 30-80 cc and 80-150 cc prostates. Urology 2022;165:268-74.
Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Aho T, et al
. Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol 2022;29:10960-8.
Zorn KC, Bidair M, Trainer A, Arther A, Kramolowsky E, Desai M, et al
. Aquablation therapy in large prostates (80-150 cc) for lower urinary tract symptoms due to benign prostatic hyperplasia: WATER II 3-year trial results. BJUI Compass 2022;3:130-8.
Helfand BT, Glaser AP, Kasraeian A, Sterious S, Talaty P, Alcantara M et al
. Men with lower urinary tract symptoms secondary to BPH undergoing Aquablation with very large prostates (> 150 mL). Can J Urol 2021;28:10884-8.
Manfredi C, Arcaniolo D, Spatafora P, Crocerossa F, Fusco F, Verze P et al
. Emerging minimally invasive transurethral treatments for benign prostatic hyperplasia: a systematic review with meta-analysis of functional outcomes and description of complications. Minerva Urol Nephrol 2022;74:389-99.
Desai M, Bidair M, Bhojani N, Trainer A, Arther A, Kramolowsky E et al
. WATER II (80-150 mL) procedural outcomes. BJU Int 2019;123:106-12.
Elterman DS, Foller S, Ubrig B, Kugler A, Misrai V, Porreca A, et al
. Focal bladder neck cautery associated with low rate of post-Aquablation bleeding. Can J Urol 2021;28:10610-3.
Gloger S, Schueller L, Paulics L, Bach T, Ubrig B. Aquablation with subsequent selective bipolar cauterization versus holmium laser enucleation of the prostate (HoLEP) with regard to perioperative bleeding. Can J Urol 2021;28:10685-90.
Gross AJ, Lipp MJ, Baumbach R, Becker B, Vogt K, Rosenbaum C, et al
. Rectal perforation after aquablation of the prostate: lessons learned the hard way. World J Urol 2021;39:3441-6.
Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al
. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. J Urol 2021;206:818-26.
Mullhaupt G, Gusewell S, Schmid HP, Zumstein V, Betschart P, Engeler DS, et al
. Aquablation versus holmium laser enucleation of the prostate in the treatment of benign prostatic hyperplasia in medium-to-large-sized prostates (ATHLETE): protocol of a prospective randomised trial. BMJ Open 2021;11:e046973.
McVary KT, Gittelman MC, Goldberg KA, Patel K, Shore ND, Levin RM, et al
. Final 5-Year outcomes of the multicenter randomized sham-controlled trial of a water vapor thermal therapy for treatment of moderate to severe lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol 2021;206:715-24.
Elterman D, Bhojani N, Vannabouathong C, Chughtai B, Zorn KC. Rezum therapy for >/=80-mL benign prostatic enlargement: a large, multicentre cohort study. BJU Int 2022;130:522-7.
Bassily D, Wong V, Phillips JL, Fraiman M, Bauer R, Dixon CM, et al
. Rezum for retention-retrospective review of water vaporization therapy in the management of urinary retention in men with benign prostatic hyperplasia. Prostate 2021;81:1049-54.
Whiting D, Noureldin M, Abdelmotagly Y, Johnston MJ, Brittain J, Rajkumar G, et al
. Real-world early outcomes and retreatment rates following water vapour ablative therapy for symptomatic benign prostatic hyperplasia. Eur Urol Open Sci 2022;39:72-8.
Gupta N, Rogers T, Holland B, Helo S, Dynda D, McVary KT. Three-year treatment outcomes of water vapor thermal therapy compared to doxazosin, finasteride and combination drug therapy in men with benign prostatic hyperplasia: Cohort data from the MTOPS trial. J Urol 2018;200:405-13.
McVary KT, El-Arabi A, Roehrborn C. Preservation of sexual function 5 years after water vapor thermal therapy for benign prostatic hyperplasia. Sex Med 2021;9:100454.
Mollengarden D, Goldberg K, Wong D, Roehrborn C. Convective radiofrequency water vapor thermal therapy for benign prostatic hyperplasia: a single office experience. Prostate Cancer Prostatic Dis 2018;21:379-85.
McVary KT, Rogers T, Mahon J, Gupta NK. Is sexual function better preserved after water vapor thermal therapy or medical therapy for lower urinary tract symptoms due to benign prostatic hyperplasia? J Sex Med 2018;15:1728-38.
Jung JH, McCutcheon KA, Borofsky M, Young S, Golzarian J, Kim MH, et al
. Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2022;3:CD012867.
Abt D, Mullhaupt G, Hechelhammer L, Markart S, Gusewell S, Schmid HP, et al
. Prostatic artery embolisation versus transurethral resection of the prostate for benign prostatic hyperplasia: 2-yr outcomes of a randomised, open-label, single-centre trial. Eur Urol 2021;80:34-42.
Pisco JM, Bilhim T, Costa NV, Torres D, Pisco J, Pinheiro LC, et al
. Randomised clinical trial of prostatic artery embolisation versus a sham procedure for benign prostatic hyperplasia. Eur Urol 2020;77:354-62.
Chung E. Penile glans necrosis following prostatic artery embolization for the treatment of benign prostatic hyperplasia: A rare but serious complication. Case Rep Urol 2021;2021:6662899.
Ray AF, Powell J, Speakman MJ, Longford NT, DasGupta R, Bryant T, et al
. Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study). BJU Int 2018;122:270-82.
Bilhim T, Costa NV, Torres D, Pinheiro LC, Spaepen E. Long-term outcome of prostatic artery embolization for patients with benign prostatic hyperplasia: Single-centre retrospective study in 1072 patients over a 10-year period. Cardiovasc Intervent Radiol 2022;45:1324-36.
Insausti I, Galbete A, Lucas-Cava V, de Ocariz AS, Solchaga S, Monreal R, et al
. Prostatic artery embolization (PAE) using polyethylene glycol microspheres: Safety and efficacy in 81 patients. Cardiovasc Intervent Radiol 2022;45:1339-48.
Roehrborn CG, Barkin J, Gange SN, Shore ND, Giddens JL, Bolton DM, et al
. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol 2017;24:8802-13.
Gratzke C, Barber N, Speakman MJ, Berges R, Wetterauer U, Greene D, et al
. Prostatic urethral lift vs transurethral resection of the prostate: 2-year results of the BPH6 prospective, multicentre, randomized study. BJU Int 2017;119:767-75.
Rukstalis D, Grier D, Stroup SP, Tutrone R, deSouza E, Freedman S, et al
. Prostatic urethral lift (PUL) for obstructive median lobes: 12 month results of the medlift study. Prostate Cancer Prostatic Dis 2019;22:411-9.
Tanneru K, Gautam S, Norez D, Kumar J, Alam MU, Koocheckpour S, et al
. Meta-analysis and systematic review of intermediate-term follow-up of prostatic urethral lift for benign prostatic hyperplasia. Int Urol Nephrol 2020;52:999-1008.
Cai PY, Gaffney C, Vanden Berg RW, Shoag JE, Lee RK. Pelvic hematoma following urolift procedure for BPH. Urology 2020;137:208.
Ewing B, Alavi-Dunn N, Hamann H, Danforth T. Large pelvic hematoma following UroLift procedure causing renal failure requiring dialysis. Urol Case Rep 2021;34:101514.
Colemeadow J, Malde S. Vesico-ureteric junction obstruction and calyceal rupture secondary to a urolift implant. Urology 2020;141:e26.
Diaz TA, Benson B, Clinkenbeard A, Long JR, Kawashima A, Yano M. MRI Evaluation of patients before and after interventions for benign prostatic hyperplasia: An update. AJR Am J Roentgenol 2022;218:88-99.
De Nunzio C, Cantiello F, Fiori C, Crocerossa F, Tognoni P, Amparore D, et al
. Urinary and sexual function after treatment with temporary implantable nitinol device (iTind) in men with LUTS: 6-month interim results of the MT-06-study. World J Urol 2021;39:2037-42.
Elterman D, Gao B, Zorn KC, Bhojani N, Chughtai B. How I Do It: Temporarily implanted nitinol device (iTind). Can J Urol 2021;28:10788-93.
Amparore D, Fiori C, Valerio M, Schulman C, Giannakis I, De Cillis S, et al
. 3-Year results following treatment with the second generation of the temporary implantable nitinol device in men with LUTS secondary to benign prostatic obstruction. Prostate Cancer Prostatic Dis 2021;24:349-57.
Chughtai B, Elterman D, Shore N, Gittleman M, Motola J, Pike S, et al
. The iTind temporarily implanted nitinol device for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: A multicenter, randomized, controlled trial. Urology 2021;153:270-6.
Barber M, Chalifour DS, Anderson MR. Uterine perforation and migration of an intrauterine contraceptive device in a 24-year-old patient seeking care for abdominal pain. J Chiropr Med 2011;10:126-9.
Kaplan SA, Pichardo M, Rijo E, Espino G, Lay RR, Estrella R. One-year outcomes after treatment with a drug-coated balloon catheter system for lower urinary tract symptoms related to benign prostatic hyperplasia. Prostate Cancer Prostatic Dis 2021;24:1073-9.
Sountoulides P, Karatzas A, Gravas S. Current and emerging mechanical minimally invasive therapies for benign prostatic obstruction. Ther Adv Urol 2019;11:1756287219828971.