Evalua&ng  New  Op&ons  for  BPH:  UroLi:  and  Rezum  

Clif  Vestal  MD  USMD  /  UANT  Arlington,  TX  

2010  AUA  BPH  

Guidelines  MIST,  Surgery  may  be  elected:  1)  instead  of  Rx;  or    2)  a2er  failure  of  Rx  

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Today’s  Treatment  Op&ons  for  BPH  

•   Watchful  wai&ng  

•   Pharmacologic  therapy  –   1-­‐adrenergic  blockers  –   5-­‐ARIs  

•   Surgery  –   Open  surgery  (large  prostate)  –   TURP  (mono  or  bipolar)  

•   Thermal  Abla&on  –   TUMT  –   TUNA  –   Steam  (Rezum)  

•   Prosta&c  Urethral  Li:  (UroLi:)  

–   Combina&on  therapy  –   PDE-­‐5  inhibitor  (tadalafil)  

–   TUIP  (small  prostate)  –   Laser  Vaporiza&on  &  Enuclea&on  

Tolerability 1 AUA Guidelines 2003, 2010, 2014 2 Varkarakis et al, The Prostate 58: 248-251 (2004) 3 Rubenstin J, Transurethral  Microwave Thermotherapy of the Prostate (TUMT), eMedicine article, July 2004 4 Muruve, N, Transuretheral Needle Ablation of the Prostate (TUNA), eMedicine article, June 2005 5 AUA: Urologyhealth.org 6. No new, sustained ejaculatory or erectile dysfunction reported. Roehrborn 2013 LIFT Study 7. Cialis Safety Information 8. Flowmax Prescribing Information 9. Clarke JL. Pop  Health  Mgt  2013;  16(2);  S1-­‐S13.

Trade-­‐Offs  Must  Be  Weighed  Ef

fect

iven

ess

Cialis Headache, vision

hearing7

Cost

Alpha Blocker Fatigue, dizziness,

congestion, headache EjD, ED1,5

Floppy iris8

5ARI Decreased libido

ED, EjD Ineffective first 2-3 months1,5

Thermal Ablation TUMT, TUNA, ILC,

Steam Catheter 1-2 wks3

4-6 wks before improvement4

30-70% irritative symptoms1

4%-16% EjD1 0%-3% ED1

High retreatment

Laser PVP TURP-like

with reduced bleeding1,2

Fewer inpatient 42% EjD1

7% ED

TURP/HoLEP Surgical Standard

60%inpatient (1-3 days)9

4-6 weeks recovery5

2%-3% incontinence1 5%-7% stricture1

65% EjD1

10% ED1 Prostatic Urethral Lift Mild/Mod irritative 2-4 wks 20% overnight catheter6

Return to pre-op 5.1 days6 No EjD or ED6

Low retreatment rate

The  Rezūm  System  

Generator  and  Hand-­‐held  Delivery  Device   Water  Vapor  Delivery  into  Transi&on  Zone  

Avoiding  Sexual  Dysfunc&on  

•   UroLi:  appears  unique  in  having  no  associated  sexual  dysfunc&on  

•   Rezum  and  other  thermal  abla&ons  do  have  lower  rates  than  surgical  op&ons  

ED   EjD  

Surgery:  

TURP1   10%   65%  

PVP1   7%   42%  

HoLEP1   3%   59%  

Minimally  Invasive:  

TUNA1   3%   4%  

TUMT1   3%   5%-­‐16%  

Steam2   0%   6%  

UroLi23   0%   0%  

1  AUA  BPH  Guidelines  2  McVary  et  al.  J  Sex  Med  2016;13:924-­‐933  3.McVary  et  al.  J  Sex  Med  2014;  11:  279-­‐287  

Summary  

•   UroLi:  and  Rezum  have  similar  efficacy  –   10-­‐11  IPSS  at  1  year  

•   Both  can  be  done  in  office  selng.  –   UroLi:  appears  more  tolerable  under  local.  

•   UroLi:  has  much  lower  need  for  catheter.  –   20%-­‐30%  (1  day)    vs.  90%  (3.4  days)  

•   Both  appear  to  preserve  ejaculatory  func&on,  though  more  reliable  with  UroLi:.    –   0%  vs.  6%  

•   Reasonable  durability  established  for  UroLi:  at  5  years  and  for  Rezum  at  2  years.  –   7.5%  UroLi:  vs.  4.4%  Rezum  at  2  years  –   13.6%  UroLi:  at  5  years.