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Introduction: Benign prostatic hyperplasia (BPH) is a prevalent condition affecting a significant portion of the male population, leading to secondary lower urinary tract symptoms (LUTS). Alternative therapies such as phytotherapy using Lipidosterolic extract of Serenoa repens (LSESR USPlus) are commonly used. However, the efficacy of LSESr remains controversial due to conflicting data. We sought to determine the effect of a standardized USP-verified Saw Palmetto extract on male LUTS secondary to BPH., Materials and Methods: In this prospective single-arm trial, we investigated the efficacy of a standardized USP-verified Saw Palmetto extract in treating male LUTS secondary to BPH. We utilized the ProudP mobile application for home uroflowmetry and symptom assessment., Results: Results from 46 patients using 320 mg daily of USP-verified Saw Palmetto extract revealed significant improvements in IPSS and QoL scores at 12 weeks compared to baseline, particularly in patients with moderate symptoms. Uroflowmetry parameters also improved with increased flow rates, primarily in patients with mild symptoms., Conclusion: Our findings support the efficacy of USP-verified Saw Palmetto extract in alleviating LUTS in men with BPH. Further studies are warranted in larger, diverse cohorts over longer follow up periods.

Introduction: Benign prostatic hyperplasia (BPH) is a condition that affects over 50% of men as they enter their fifth decade of life, often leading to lower urinary tract symptoms (LUTS). Primary treatment options include alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 inhibitors. However, these medications can have some side effects, and there is a noticeable dearth of information addressing the long-term use of these medications. Thus, the exploration of all treatment modalities helps ensure patients receive personalized and effective care. Consequently, the primary objective of this review is to identify potential emerging medications for the treatment of BPH., Areas Covered: We conducted an extensive review of articles discussing pharmacotherapy for BPH spanning the last 15 years. Our information gathering process involved Scopus, PubMed-MEDLINE, Cochrane, Wiley Online Library Google Scholar, ClinicalTrials.gov, and the PharmaProjects database. This approach ensures that readers gain an in-depth knowledge of the existing therapeutic agents as well as promising avenues for managing BPH., Expert Opinion: BPH treatment targets a patient's specific constellation of symptoms. Therefore, a broad knowledge base encompassing various treatment options is paramount in ensuring optimal treatment. Looking forward, the emphasis on personalization promises to reshape the landscape of BPH treatment and improve patient outcomes.

Introduction: Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function., Methods: In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies., Results: Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function., Conclusions: Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH)., Methods: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4., Results: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term., Conclusion: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options., (© 2024. The Author(s).)

Objective: We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥70 years of age., Methods: A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: "BPH", "elderly", "surgical", "ablation", "resection", "embolization", and "aging"., Results: We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population., Conclusion: There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population., Competing Interests: Bilal Chughtai is a consultant for Olympus, Boston Scientific, Ferring Pharmaceuticals, and Allergan. Dean Elterman reports grants, personal fees from Boston Scientific, grants from Olympus, grants from Urotronic, grants from Procept Biorobotics, grants from Zenflow, outside the submitted work. Kevin C. Zorn is a consultant and proctor for Boston Scientific, Procept BioRobotics, and investigator for Zenflow. Naeem Bhojani is a consultant for Olympus, Boston Scientific, and Procept BioRobotics. Lori Lerner reports Uncompensated - Chair of the Clinical Events Committee (CEC) from Proverum, outside the submitted work. The authors declare that they have no other known competing interests., (© 2023 Codelia-Anjum et al.)

Introduction: To report the 5-year efficacy and safety of Aquablation compared with transurethral resection of the prostate for the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with prostate volumes 50-80 mL., Materials and Methods: In a large double-blinded, multicenter, and prospective randomized controlled trial, 96 randomized men with 50-80 mL prostates who underwent Aquablation or transurethral prostate resection were prospectively identified for subgroup analysis. Follow up was performed for up to 5 years. The primary efficacy endpoint was the reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo (CD) postoperative complications grade 1 persistent and grade 2 or higher at 3 months., Results: Both groups had comparable baseline characteristics. Reduction in IPSS score was significantly higher in the Aquablation group across 5 years of follow up (-14.1 vs. -10.8, p = 0.02). The Aquablation group achieved a significantly lower rate of CD1P and CD2 or higher events at 3 months follow up (risk difference of -23.1%). Among recorded adverse events, de novo postoperative ejaculatory dysfunction was notably lower in Aquablation (risk difference of -21.9%), while the risk of bleeding remained similar after 6 months. The surgical and medical retreatment rate at 6 months was also lower in Aquablation (risk difference of -14.4%)., Conclusions: In the 50-80 mL prostate volume subgroup, Aquablation yields superior long-term symptom relief and lower complication rates than standard transurethral resection, with notably lower rates of ejaculatory dysfunction. This further supports the adoption of Aquablation for men with medium-sized prostates.

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction and Hypothesis: Data from a large US population-based, cross-sectional, epidemiological study (the EpiNP Study) were used to assess the symptoms and bother experienced by women with nocturnal polyuria (NP)., Methods: Consenting participants recruited from an online panel completed the baseline EpiNP survey online (Lower Urinary Tract Symptoms Tool and urological comorbidities). All reporting ≥2 voids/night and a random sample of 100 respondents, each reporting 0 or 1 void/night were asked to complete a 3-day web-based bladder diary recording time, volume, and urgency rating of each void. NP was calculated by the proportion of urine production that occurred during nocturnal hours using a Nocturnal Polyuria Index (NPI33) threshold of >0.33 or nocturnal urine production of >90 ml/h (NUP90). The frequency of participants reporting LUTS and bother was determined by age and NP: idiopathic NP, NP associated with overactive bladder (NPOAB), NP associated with comorbidities (NPCom), and no NP (did not meet NP criteria)., Results: A total of 5,290 women completed the baseline survey. Mean age (range) was 54.9 (30-95) years; 1,841 (34.8%) reported ≥2 nocturnal voids. The prevalence of LUTS increased across the lifespan; however, bother associated with each LUTS decreased with increasing age. The percentage of women rating bother by nocturia episodes ≥2 "> somewhat" ranged from 40.3% to 68.3%, with bother ratings highest in the NPOAB and No NP groups., Conclusions: NP is prevalent in women with considerable bother and is often associated with other urinary symptoms. Multifactorial causes and potential treatments of NP should be considered, particularly at a later age., (© 2023. The International Urogynecological Association.)

Objective: To evaluate the change in prostate volume (PV) and relationship to improvement in urinary symptom scores following Rezūm therapy., Methods: Quality of life outcomes and PV were assessed at baseline and 12months postprocedure. Percent change from baseline in outcomes and PV were calculated, as was the number of Rezum injection to baseline PV ratio. Association between total number of injections and changes in outcomes and PV were evaluated using linear regression models., Results: A total of 49 men (mean age=67.8; standard deviation=9.4) underwent the procedure between April 2019 and September 2020, with a median baseline PV of 71.5 cc (range 24-150) and median number of vapor injections of 11.0 (range 4-21). At 12months, the median percent change in PV was - 34.0% (interquartile range: -49.2%, -16.7%), with 45/49 (91.8%) patients having reduced volume. Among the 45 patients with reduced volume at 12months, every 10% increase in volume reduction was associated with a 7.5% (95% confidence interval, 1.4%-13.6%; P = .02) improvement in the International Prostate Symptom Score. There was no significant association between total number of injections or injection to baseline volume ratio and change in PV., Conclusion: In this cohort of men treated with Rezūm therapy for benign prostatic hyperplasia, it was demonstrated that there is a correlation between greater PV reduction and greater symptomatic improvement. This study showed no association between more injections or the ratio of injections to PV changes, refuting the claim that more injections are better., Competing Interests: DECLARATION OF COMPETING INTEREST Drs. Elterman, Bhojani, Chughtai, Zorn are consultants for Boston Scientific., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Context: Minimally invasive surgical therapies for male lower urinary tract symptoms secondary to benign prostatic obstruction were developed to be safer and more tolerable than standard ablative techniques. These treatments have not been compared with each other in a randomised fashion, and for some treatments, there are no trials against a reference technique., Objective: To compare the efficacy, safety, and tolerability of water vapour thermal therapy (WVTT), prostatic urethral lift (PUL), prostatic arterial embolisation (PAE), temporary implantable nitinol device (iTIND), transurethral microwave thermotherapy (TUMT), and transurethral resection of the prostate (TURP)., Evidence Acquisition: A systematic search of MEDLINE/PubMed, Embase, Cochrane Library, and grey literature for randomised controlled trials was performed. Trials meeting the selection criteria were assessed for the risk of bias using the Cochrane RoB2 tool. Treatments were compared, using a network meta-analysis, in terms of outcomes including symptom score, quality of life, maximum urinary flow rate, postvoid residual urine, International Index of Erectile Function (IIEF-5), and scales from the Male Sexual Health Questionnaire., Evidence Synthesis: The search identified 63 trials. Symptoms and quality of life for PAE, PUL, and WVTT appeared similar to those for TURP, whereas TURP was found to have the most clinically significant improvement in flow rate. TUMT was less efficacious than TURP but provided similar results on quality of life. Comparisons of ejaculatory function favoured WVTT and PUL compared with TURP. The relative efficacy of iTIND was less clear because of the risk of bias in the respective trial., Conclusions: PAE, PUL, and WVTT appear favourable from a risk-benefit perspective despite probably having less efficacy than TURP for objective outcomes. These findings warrant confirmation through long-term randomised controlled trials., Patient Summary: This paper has summarised the evidence from 63 clinical trials on minimally invasive surgical therapies for men with symptoms of an enlarged prostate, including water vapour thermal therapy (WVTT), prostatic urethral lift (PUL), prostatic arterial embolisation (PAE), temporary implantable nitinol device, and transurethral microwave thermotherapy (TUMT). Improvement in symptoms for each of PAE, PUL, TUMT, and WVTT in short-term follow-up was similar to that for the standard surgical treatment, although standard surgery appeared to provide the greatest increase in urine flow. Men who had WVTT or PUL were less likely to have problems with sexual function than those who had standard surgery., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To understand which attributes men with benign prostatic hyperplasia (BPH) undergoing water vapor thermal therapy (WVTT) find important while considering treatment options for the condition. Methods: Men ( n  = 170) with lower urinary tract symptoms due to BPH who underwent WVTT between April 2019 and November 2020 in a Toronto urologic clinic were invited to participate in an online survey. The survey included eight attributes of BPH surgical procedures and five attributes of WVTT. Patients were asked how important each attribute was to them before they selected a BPH procedure and decided to undergo WVTT. Results: In total, 128 respondents (75%) completed the survey. A majority of the respondents were White (88%), married (83%), and aged 60-69 years old (45%). Approximately 97% of respondents rated the ability to avoid further BPH treatments as "very important" or "extremely important," followed by duration to return to normal activities (79%), and wait times to receive the procedure (57%). Only 47% of patients reported that postprocedural catheterization was important. For WVTT, 98% of the respondents rated avoiding more invasive surgical treatments and 88% rated a quick recovery as important attributes. Conclusions: Among men with moderate-to-severe BPH undergoing WVTT, the most important attributes for selecting a BPH surgical procedure were avoiding further BPH treatments, returning quickly to normal activities, and reducing treatment wait times. Most men chose WVTT to avoid more invasive procedures and have a quick recovery.

Purpose: The Butterfly Prostatic Retraction Device ("Butterfly") is a permanent nitinol implant for benign prostatic hyperplasia. This study examines the chronic response of prostate tissue to the Butterfly in histological specimens from patients in the Butterfly pilot clinical study., Methods: Retrospective qualitative and semi-quantitative review of histological specimens of seven (7) patients who participated in the Butterfly pilot clinical study. Patients had at least 1-month implantation with the Butterfly prior to implant removal and TURP. Tissue samples were graded by two pathologists., Results: Four out of six patients had IPSS decreased from baseline. All seven patients' samples had signs of chronic inflammation; one demonstrated acute inflammation and one demonstrated fibrosis. In three cases, intraglandular calcification was identified. There was no ischemic necrosis induced by the implant, and no encrustation, urethral edema, or cellular atypia was noted., Conclusion: The Butterfly demonstrated an overall favorable safety profile in terms of tissue response. This study demonstrates that there is no significant tissue reaction in the prostatic urethra due to presence of Butterfly device., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objectives: To explore the impact of nocturnal polyuria (NP) on health-related quality of life (HRQoL), work productivity, mental health, fatigue, bother, and daytime sleepiness., Materials and Methods: This large-scale, US population-representative epidemiologic study was conducted in two parts: a web-based survey and 3-day bladder diary. Consenting participants completed the baseline Epidemiology of NP (EpiNP) survey online (Lower Urinary Tract Symptoms [LUTS] Tool, comorbidities, burden, and multiple HRQoL measures). Participants who reported ≥2 voids/night, and a random sample of 100 respondents each reporting 0 or 1 void/night, were sent urine measurement containers and asked to complete the 3-day bladder diary. NP was defined as Nocturnal Polyuria Index >0.33 (NPI33) or nocturnal urine production >90 ml/h (NUP90). Five subgroups were created: Idiopathic NP (NP with no underlying cause), NP associated with symptoms of overactive bladder (NPOAB) or bladder outlet obstruction (NPBOO; men only), NP associated with other comorbidities (NPCOM; e.g., diabetes, hypertension, heart disease, sleep apnea), and no NP (did not meet NP criteria)., Results: A total of 4893 men and 5297 women completed the EpiNP survey; mean age was 54.4 (SD = 14.7). Significantly greater patient burden (p < 0.0001) was evidenced in the nocturia group (≥2 voids/night) versus no nocturia group (0-1 void/night) on daily impact of nocturia, LUTS Bother, prostate symptoms (men only), work productivity, physical and mental health component scores, depression, fatigue, and daytime sleepiness. NP subgroup analyses showed men in the NPBOO group and women in the NPOAB group reported the greatest impact on LUTS bother, fatigue, physical health, work productivity impairment, daytime sleepiness, and depression (women only)., Conclusion: This was the first large-scale, epidemiologic study to explore the impact of different forms of NP on patients' HRQoL. Findings demonstrate that NP associated with other urologic or comorbid conditions appears to have greater patient burden than idiopathic NP, in particular for women., (© 2023 Wiley Periodicals LLC.)

Purpose: To document the effect of the temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Israel) on sexual function from a multicenter, randomized, single-blinded, sham-controlled trial. Materials and Methods: Men were randomized 2:1 between iTind and sham procedure arms. The iTind was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 3, and 12 months postoperatively using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF). Unblinding occurred at 3 months. Results: We studied 185 men with a mean age of 61.1 ± 6.5 years. There was no difference in SHIM or total IIEF between iTind and sham at 3 months or in the iTind arm at 12 months compared with baseline. Men in the iTind arm without erectile dysfunction at baseline showed an improvement in total IIEF score of +6.07 ± 21.17 points ( p  = 0.034) at 12 months, in addition to an improvement in ejaculatory function. SHIM scores remained unchanged in all groups, regardless of age, prostate volume, or baseline erectile function. Conclusion: No changes were observed in sexual and ejaculatory function of patients with iTind regardless of a man's age, prostate volume, and baseline sexual function. Clinicaltrials.gov: NCT02506465.

Background: There are growing interests for minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic hyperplasia (BPH)-associated lower urinary tract symptoms (LUTS). Prostatic artery embolization (PAE) uses selective angioembolization of prostatic arteries, thereby reducing size to improve LUTS/BPH. However, real-world data comparing surgical outcomes between MISTs and tissue resective techniques are lacking. We assessed the differences in surgical outcomes between PAE, transurethral resection of the prostate (TURP), and prostatic urethral lift (PUL) in a real-world population for LUTS/BPH., Methods: We present an observational population-based study of 12,902 men with BPH in New York State who received PAE, TURP, and PUL in outpatient and ambulatory surgery settings from 2014 to 2018. For short-term outcomes, we report 30-day and 90-day risks of readmission to inpatient and emergency room (ER) with/without complications and compared them across groups using χ 2 tests and mixed-effect logistic regressions. For long-term outcomes, we report surgical retreatment and stricture rates using Kaplan-Meier failure curves and compared them using Log rank tests and Cox regression models., Results: Of 12 902 men, 335 had PAE, 11,205 had TURP, and 1362 had PUL. PAE patients had the highest 30-day (19.9%) and 90-day (35.6%) risks of readmission to inpatient or ER (p < 0.01). Non-specific abdominal pain was the main diagnosis associated with 30-day and 90-day readmissions to inpatient or ER after PAE (14.3% and 26.8%, respectively). After 2 years of follow-up, PAE patients had the highest retreatment rate of 28.5% (95%CI 23.7-34.2%) compared to TURP (3.4% (95%CI 3.1-3.8%)) and PUL (8.5% (95%CI 5.6-12.9%)) (p < 0.001)., Conclusion: In a real-world population, PAE was associated with the most frequent 30-day and 90-day readmission to inpatient or ER and the highest retreatment rate among all surgical techniques even when controlled for individual patient comorbidities and surgical volume., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To create a prospective, multicenter coordinated registry network (CRN) of robust "real world" data for benign prostatic hyperplasia (BPH) that links surgical practices to objective and subjective outcomes of patients who undergo surgery for the improvement in lower urinary tract symptoms (LUTS) secondary to BPH., Methods: We gathered a group of BPH experts from various institutions to identify the minimum core data elements needed to assess BPH procedures. To achieve consensus on the data elements, we used a Delphi method adaptation, in which a series of surveys were answered by the expert panel individually and anonymously. Survey results were collected and analyzed. Questions for the following round were based on response analysis from the prior survey. This process was repeated until consensus was achieved., Results: Participation rates in the first and second rounds were 100% and 90%, respectively. The expert panel reached consensus on 148 data elements out of the 182 proposed, capturing patient medical and surgical history, procedure, discharge, short- and long-term follow-up, device factors, surgery, and surgeon factors., Conclusion: We have successfully developed a set of core data elements to support the study of BPH surgical therapies by gathering an expert panel on BPH and using the Delphi method. These data elements influence provider decisions about treatment and include important outcomes related to efficacy and safety., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To determine whether existing data support the use of multiple passes in Aquablation for LUTS due to BPH., Methods: Data were obtained from 2sources. The WATER trial (NCT02505919) is a prospective, multicenter, double-blind, randomized controlled trial of Aquablation vs TURP in prostate volumes of 30 - 80 ml. The WATER II trial (NCT03123250) is a prospective single-arm multicenter trial of Aquablation in prostate volumes of 80-150ml. The number of passes was determined by the procedural data collected and the video recordings of all study cases., Results: In total, 127 Aquablation subjects underwent a single pass, 90 underwent multiple passes (80 had 2passes and 10 underwent 3passes), and 65 underwent TURP (in WATER only). Men undergoing 2or more passes with Aquablation had larger prostates but few differences in other baseline parameters, including prostate size range. Compared to a single pass, the use of 2or more passes during Aquablation resulted in lower IPSS scores (by ∼4 points, P = .0002) and lower IPSS QoL scores (by ∼0.7 points, P = .0096) at the later timepoints of 24 and 36 months. Similarly, 36-month Qmax values were higher (by ∼5 ml/sec, P = .0220) in those with 2or more passes than in those with 1pass. There was no statistically significant difference in ejaculatory dysfunction between groups., Conclusion: Independent of prostate volume, a multiple treatment pass protocol led to improved voiding outcomes and IPSS improvement., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: As benign prostatic hyperplasia (BPH) is an age-related process, growing interest in surgical management for elderly men has emerged. Recently, Aquablation was approved for treatment of BPH associated lower urinary tract symptoms (LUTS) and utilizes robotic ultrasound guided surgeon-controlled waterjet ablation. We assessed the differences in functional and surgical outcomes between elderly and young men undergoing Aquablation for BPH/LUTS., Materials and Methods: We retrospectively assessed prospectively collected data from the WATER I (NCT02505919) and WATER II (NCT03123250) clinical trials reporting safety and efficacy of Aquablation in the treatment of LUTS/BPH in men 45-80 years with a prostate between 30 and 80 cc, and 80 cc and 150 cc, respectively. Men ≥ 65 years were defined as elderly and men < 65 years as young., Results: Of 217 patients included, 83 (38.2%) were young and 134 (61.8%) were elderly. Mean age (SD) was 59.3 (± 3.4) years and 71.2 (± 4.2) years for young and elderly men, respectively. At 3 years of follow-up compared to baseline, elderly men showed similar reductions in total IPSS (7.68 points vs 7.12 points, p > 0.05) and similar increases in Qmax (20.6 mL/s vs 19.3 mL/s, p > 0.05) compared to young men. The ejaculatory dysfunction rate was similar for both cohorts (12.0% vs 9.7%, p > 0.05). Elderly men experienced similar annual retreatment rates compared to young men (1.5% vs 0.8% p > 0.05)., Conclusions: Elderly men undergoing Aquablation have similar functional and surgical outcomes as young men. Elderly patient BPH surgical counseling should, therefore, consider Aquablation as a treatment option for LUTS/BPH., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate the efficacy and safety of Rezūm therapy in benign prostatic hyperplasia (BPH) patients with prostates ≥80 mL., Methods: A prospective registry was established at two high-volume Canadian centres. Patients had baseline medical history documented, and uroflowmetry and questionnaire results were recorded over 12 months., Results: Eighty-three patients (median [interquartile range {IQR}] age 69.2 [63.2, 74.8] years) with a prostate size ≥80 mL were included. The median (IQR) prostate volume was 100.0 (88.5, 115.0) mL and 65% had a median lobe. Twenty-one patients had prior urinary retention. The median (IQR) number of injections was 13 (11, 15) and catheterization duration was 9 (7, 14) days. International Prostate Symptom Scores (IPSSs) improved by 24%, 57% and 59% at 1, 3 and 12 months, respectively (P < 0.001). IPSS Quality of Life (QoL) scores improved by 27%, 56% and 70% at these same timepoints (P < 0.001). Maximum urinary flow rate improved by 55% at 3 months (P = 0.002) and 59% at 12 months, and post-void residual urine volume improved by 58% at 3 months (P = 0.006). BPH Impact Index scores improved by 57% at 3 months and 71% at 12 months. International Index of Erectile Function-15 scores improved by 15% at 6 months, and Male Sexual Health Questionnaire for Ejaculatory Dysfunction scores improved by 22.4% at 1 month. Three patients (3.6%) noted reduced/anejaculation. No events of Clavien-Dindo grade III or higher occurred., Conclusion: This study demonstrates, for the first time, the safety and efficacy of Rezūm therapy in large glands >80 mL. IPSS improved by 59% and IPSS QoL score improved by 70% at 12 months. Objective maximum urinary flow measures improved at 12 months by 59%, while erectile and ejaculatory function remained preserved., (© 2022 BJU International.)

We aim to report the short-term outcomes of patients undergoing Rezum as a re-treatment intervention for recurrent lower urinary tract symptoms after prior surgical treatment for benign prostate enlargement. Data from two institutions for baseline International Prostatic Symptom Score with Quality of life item, prostate size, and maximum flow-rate was acquired. Patients were assessed 3-month post-treatment. Outcomes were compared with unpaired t-tests and Fisher's exact tests. Nineteen patients were included. Prior surgical interventions included transurethral resection of the prostate (31.6%, n = 6), Urolift (26.3%, n = 5), transurethral bladder neck incision (15.8%, n = 3), prostate artery embolization (10.5%, n = 2), transurethral needle ablation, greenlight photovaporization of prostate and Rezum (5.3%, n = 1 each). Median age was 69.0 years (IQR 14; range 59-87 years) with a median prostate volume of 65.0 ml (IQR 63; range 22-160 ml). The median time to Rezum treatment was 48 months (IQR 78; range 9-240 months). 63.1% (n = 12) were re-started on benign prostatic enlargement medication and 36.8% (n = 7) had recurrent bothersome symptoms before re-treatment with Rezum. At 3-month follow up, median International Prostatic Symptom Score decreased from 23 to 9 (p < 0.001) and Quality of life from 4 to 2 (p < 0.001). Median maximum flow-rate improved after treatment from 8.6 to 14.8 ml/s (p < 0.001). None of the patients were required to restart medication for benign prostate enlargement., (© 2022 Wiley-VCH GmbH.)

The following video Atlas summary reviews all technical elements of the standardized setup, robotic execution, aquablation procedure, and hemostasis for efficient rapid benign prostate hyperplasia treatment.

Background: The prevalence of nocturnal polyuria (NP), which is passing large volumes of urine during the main sleep period, has been investigated primarily in middle-aged to older men. There is thus a gap in the NP evidence base for women and for younger individuals., Objective: To estimate the prevalence of nocturia due to NP in the USA., Design, Setting, and Participants: This large epidemiologic study used a US population-representative sample of men and women aged ≥30 yr to assess the prevalence of NP (NCT04125186)., Outcome Measurements and Statistical Analysis: Consenting participants completed an online survey (Lower Urinary Tract Symptoms Tool and comorbidities). All who reported two or more voids per night and 100 random respondents each reporting no or one void per night were asked to complete a 3-d bladder diary. Two NP definitions were used: nocturnal urine production >90 ml/h (NUP90) and Nocturnal Polyuria Index >0.33 (NPI33). Crude and population-adjusted prevalence results were calculated from completed diaries for the following subgroups by sex and age: idiopathic NP; NP with overactive bladder (NP-OAB) or bladder outlet obstruction (NP-BOO; men only); NP associated with other comorbidities; and no NP (did not meet the NPI33 or NUP90 definition)., Results and Limitations: Among the 10,190 respondents who completed the survey, the mean age was 54.4 yr (range 30-95); 3,339 reported two or more nocturnal voids and 1,763 completed the 3-d diary (response rate 49.3%). The adjusted overall NP prevalence was 31.5% among men and 38.5% among women using the NPI33 definition, and 23.8% among men and 18.1% among women using NUP90. The adjusted idiopathic NP prevalence was lower among men (NPI33: 5.2%; NUP90: 1.4%) than among women (NPI33: 9.8%; NUP90: 4.0%). The prevalence of idiopathic NP decreased with age as NP associated with other possible causes increased with age in men (most common, BOO) and women (most common, OAB)., Conclusions: This is the first population-based study of NP prevalence to include men, women, and young adults. NP is common; a multifactorial etiology should be considered, particularly as age increases., Patient Summary: In this population-based US study, we examined the frequency of nighttime urination among men and women aged ≥30 y and older. We found that nighttime urination is common among men and women. Many conditions can lead to increased nighttime urination as people age., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To compare the outcomes of Aquablation for small-to-moderate (30-80cc) prostates with the outcomes for large (80-150 cc) prostates at 3-year follow up., Methods: WATER is a prospective, double-blind, multicenter, international clinical trial comparing the safety and efficacy of Aquablation and TURP in the treatment of LUTS/BPH in men 45-80 year with a prostate of 30cc-80cc. WATER II is a prospective, multicenter, single-arm international clinical trial of Aquablation in men with a prostate of 80cc-150cc. We compare 36-mo outcomes amongst 116 WATER and 101 WATER II study subjects undergoing Aquablation., Results: International Prostate Symptom Score (IPSS) scores improved from 22.9 and 23.2 at baseline in WATER and WATER II, respectively, to 8.0 and 6.5 at 36-month, with 36-mo reductions of 14.4 and 16.3 points, respectively (P = .247). At baseline, urinary flow rate (Qmax) was 9.4 and 8.7 cc/sec in WATER and WATER II, improving to 20.6 and 18.5 cc/sec, respectively (P = .552) at 36-mo. Improvements in both IPSS and Qmax were immediate and sustained throughout follow-up. At 3 year, 98% and 94% of treated patients were BPH medication-free in WATER and WATER II, respectively (P = .038). At 3yr, 96% and 97% of treated patients were free from surgical retreatment in WATER and WATER II, respectively (P = .613)., Conclusions: Three-year follow-up demonstrates that Aquablation therapy leads to sustained outcomes, few irreversible complications, and low retreatment rates for the treatment of LUTS/BPH independently of prostate volume., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To illustrate the role of Rezūm convective water vapor ablation for treatment of lower urinary tract symptoms secondary to Benign prostatic hyperplasia., Methods: A prospective registry was established for Rezūm therapy in Canada at two high-volume centers. All patients had baseline medical and Benign prostatic hyperplasia history documented, along with uroflowmetry and validated questionnaires up to 12 months post-surgery., Results: 229 patients (mean age 67.3 years), including 83 with prostate volumes ≥80 mL, were treated from April 2019 to December 2020. The mean prostate volume was 71.5 mL (range 20-160 mL) and 55% had a median lobe. The mean number of injections was 11 (range: 4-28) and mean procedural length was 4.8 minutes (range: 1.5-14). The mean duration of postprocedure catheterization was 9.8 days. International Prostate Symptom Scores improved from baseline by 29%, 53%, and 59% at 1, 3, and 12 months, respectively. International Prostate Symptom Scores quality of life improved from baseline by 30%, 50%, and 67% at 1, 3, and 12 months, respectively. Qmax improved by 60% at 3 months and 74% at 12 months. Post-void residual volume improved by 51% and 61% at 3 and 12 months, respectively. No statistically significant changes were seen in International Index of Erectile Function-15 or Male Sexual Health Questionnaire for Ejaculatory Dysfunction scores. No Clavien-Dindo events ≥Grade III occurred., Conclusion: Rezūm therapy is a safe, effective, and quick outpatient procedure for prostate glands over a wide range of volumes. Clinically significant improvements are seen in all validated questionnaires. Objective maximum flow measures improved, while erectile and ejaculatory function remains preserved., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To assess the outcomes of a "less is more" treatment approach consisting of a single water vapor treatment per prostate lobe for benign prostatic hyperplasia (BPH)., Methods: Retrospective cohort study in a single urologic clinic of men with moderate to severe symptomatic BPH with and without median lobes undergoing thermal water vapor therapy. Single injection of thermal water vapor was given in each prostate lobe. The primary endpoint compared maximum urine flow rate (Qmax), post-void residual (PVR), International Prostatism Symptom Score (IPSS), and the IPSS Quality of Life scale (IPSS QoL) at baseline and at 1, 3, 6, and 12 months., Results: The study included 52 men with mean prostate volume and IPSS of 52.8cc and 20.3cc, respectively. IPSS was reduced by -3.95 ± 7.5 at 3 months (P = .02875), -8.5 ± 9.3 at 6 months (P = .01767), and -11.63 ± 8.4 at 12 months (P = .005908). IPSS QoL improved by -1.75 ± 1.2 t 12 months (P = .003799) and QMax by 5.36 ± 3.7 mL/s at 12 months (P = .008445). Time to post-operative catheter removal was 3.5 ± 1.3 days. One patient reported ejaculatory dysfunction. All other adverse events were mild to moderate in severity and resolved quickly., Conclusion: Thermal water vapor therapy with single injection per lobe is both an effective and safe treatment for BPH that provides comparable improvements in lower urinary tract symptoms and quality of life to the traditional approach that employed variable number of injections by prostate volume., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Stereotactic body radiation therapy (SBRT) is increasingly used for prostate cancer, but has morbidity as both the bladder and rectum are radiated during treatment. Our goal was to document and compare lower urinary tract symptoms (LUTS) among men who underwent SBRT with and without SpaceOAR hydrogel (Augmenix, Inc., Bedford, MA)., Methods: We performed a retrospective analysis of 87 men (50 SpaceOAR and 37 non-SpaceOAR) who underwent SBRT. Primary outcomes were patient reported symptoms during radiation therapy, pharmacotherapy usage, and urologic and bowel survey scores up to 6-months post-SBRT., Results: 78% of men were on α-inhibitors at the end of SBRT, an increase from 27.6% baseline usage (p < 0.001). Post-SBRT urinary frequency was more common in the non-SpaceOAR group versus the SpaceOAR group (68% versus 38%, p = 0.006), as was nocturia (35% vs. 8%, p = 0.002). Acute gastrointestinal symptoms did not differ. 58.8% of men were on α-inhibitors at 6-months of follow-up post-SBRT, an increase from 27.6% baseline usage (p < 0.001). Importantly, there was a difference of α-inhibitor use between non-SpaceOAR and SpaceOAR groups at the end of SBRT and at 1.5-, 3-, and 6-months follow up (86% vs. 53% [p = 0.002], 83% vs. 53% [p = 0.005], 72% vs. 49% [p = 0.038], respectively)., Conclusion: LUTS after SBRT remains a significant problem for men undergoing treatment for prostate cancer. LUTS affects men during and up to 6-months following SBRT. Owing to these increased LUTS, preemptive minimally invasive solutions and their mechanisms of protection, including the SpaceOAR, should be further investigated., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Effective clinical management of benign prostatic obstruction is determined by the ability to address lower urinary tract symptoms as measured via patient-reported outcomes (PROs). Minimally invasive surgical therapies (MISTs) offer better erectile or ejaculatory side effects and potentially faster recovery time in comparison to transurethral resection of the prostate (TURP). Premature excitement for MISTs derives from prospective sham-controlled trials with several years of follow-up data. Currently there is a lack of randomized controlled trials that directly compare MISTs to TURP and of a clearer definition of treatment failure. These types of studies are important in comparing efficacy between treatments. In head-to-head comparison, TURP yields the most robust improvement in PROs when compared to MISTs. At best, MISTs may achieve equivalent urological symptom-relief profiles to TURP; however, noninferiority assessments are needed. MISTs are potentially advantageous for their side-effect profiles and lower complication rates, but consistency in reporting these data is needed. PATIENT SUMMARY: We looked at the current data on patient-reported outcomes after each type of treatment for lower urinary tract symptoms. We found that the efficacy of these procedures is difficult to compare given the lack of direct studies comparing new options to the standard procedure. We can only conclude that the standard procedure, transurethral resection of the prostate, will provide the best relief of voiding symptoms as reported by patients., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Importance: Voiding diaries can be onerous, we sought to investigate if some women can predict their voided volumes., Objectives: The objective of this study is to determine the accuracy of estimated voided volumes and characteristics most predictive of accuracy., Study Design: We prospectively collected data on 101 women undergoing urodynamics for lower urinary tract symptoms and/or prolapse at a tertiary care facility. Data collection included postvoid residual volume, urodynamic diagnosis, flow time and rate, and a 1-time measurement of voided volume into a blinded uroflow. Linear and logistic regression analyses were performed to examine predictors of estimated voided volume (mL)., Results: Mean age was 58.2 years (standard deviation, 12.8 years). The median estimated voided volume and actual voided volume were 240 and 215 mL, respectively. The average percent error was 15% (63% of patients being within a 30% margin of error and 32.7% being within a 20% margin of error). On linear regression analysis, smaller voids of 101 to 200 mL were associated with greater accuracy (R2 = 0.37 P = 0.001) and diagnosis of anxiety was associated with a higher voided volume percent error (P = 0.028). Logistic regression analysis revealed that for every 1 year increase in age, there was a 3% decrease in odds of predicting voiding volume within 30% (odds ratios, 0.97; P = 0.041)., Conclusions: Nearly two-thirds of women estimated their voided volume within 30% of the actual void and one-third of women could predict within 20%. This should be taken into consideration when obtaining patient history, particularly with age and diagnosis of anxiety, and may substantiate use of voiding diaries for accurate measurement in specific populations., Competing Interests: B.C. is a consultant for Medi-Tate Ltd, Olympus, Boston Scientific, and Medeon Bio. The remaining authors have declared they have no conflicts of interest., (Copyright © 2022 American Urogynecologic Society. All rights reserved.)

Objective: To evaluate the safety, feasibility, and tissue response of a novel device for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia, using the first-generation Urocross Expander System (Mercury Expander System)., Methods: The implant was deployed and retrieved using flexible cystoscope in 8 adult male canines, separated into three study arms by retrieval date (1-, 6-, and 12- months post-deployment). Cystoscopy and urethrograms verified implant position/diameter; bladder neck and external sphincter function/changes; prostatic tissue response; and implant condition. One-month post-retrieval, the prostate and surrounding tissue was sectioned and evaluated by a veterinary pathologist., Results: All implants were successfully deployed in the prostatic urethra. Urethral width was increased (6.9 ± 1.8 mm to 10.2 ± 0.6 mm, P = .012) and preserved through the dwell period. Urethral length and sphincter diameters didn't significantly change. All subjects (n = 8) remained continent without obstruction or retention. Adverse events included incisional site bleeding (n = 2) and transient hematuria (n = 3). One implant migrated into the bladder and spontaneously repositioned into the prostatic urethra. Post-retrieval, explant surfaces demonstrated no tissue growth, encrustation or stone formation. Imaging revealed contact site erythema and indentation, but no stones, strictures, perforations, erosions, nor ulcerations. Histopathology revealed glandular acinar changes, inflammation, and fibrosis., Conclusion: The first generation of the Urocross Expander System demonstrated a favorable safety profile in the canine model. Changes in the prostatic urethra shape were noted with an increase in urethral width during the dwell period with minimal tissue changes. Further, the implant didn't demonstrate any encrustation, tissue growth or stone formation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose of Review: Benign prostatic hyperplasia (BPH) is a common disease in men. A rapidly rising demand for safe and effective therapy for BPH has generated novel minimally invasive surgical treatments (MISTs). With multiple procedural options in the urology armamentarium for BPH therapy, we describe the current therapies and outcomes for office-based procedures for BPH including quality of life, voiding symptoms, and sexual function., Recent Findings: There are three FDA-approved MISTs (Rezūm, Urolift, and iTind) and three emerging MISTs for BPH. Preliminary data suggest improvement in voiding symptoms and quality of life while minimizing unwanted sexual side effects. Long term data is required on the durability and safety of MISTs for BPH. MISTs mark a paradigm shift in BPH management. Sandwiched between conservative medical management and conventional transurethral surgery, these novel technologies promise to combine efficacy approaching that of TURP while sparing the negative side effects. We envision a future where BPH can be diagnosed and treated in an office-based setting with a standard cystoscope in one procedure., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Half of men aged > 60 years will develop benign prostatic hyperplasia (BPH) with 40% of these men having moderate-to-severe lower urinary tract symptoms (LUTS). There is limited knowledge on a head-to-head comparison of prostatic urethral lift (UroLift) and convective water vapor ablation (Rezum) for the treatment of LUTS secondary to BPH. We sought to compare randomized controlled trials with 3-year clinical outcome data., Materials and Methods: After a thorough literature search, two multicenter sham-controlled double-blind randomized trials for UroLift and Rezum were identified and compared. Both studies had similar designs, baseline characteristics, reported outcomes, and low risks of bias., Results: Rezum and UroLift resulted in significant improvement of International Prostate Symptom Score (IPSS) at 3 months (51.4% and 49.9%, respectively) and 50% reduction of IPSS Quality of Life that was durable across all time points. At 24 and 36 months, there was a statistically significant difference in IPSS between groups, favoring Rezum (-11.2 ± 7.3 versus -9.13 ± 7.62, p = 0.04, and -11.0 ± 7.1 versus -8.83 ± 7.41, p = 0.04, respectively). While Rezum had greater improvement in Qmax at 3 months (6.4 ± 7.2 versus 4.29 ± 5.16, p < 0.01), there was no difference in improvement from 12-36 months between treatments. Only UroLift experienced improvements of Men's Sexual Health Questionnaire- Ejaculatory Dysfunction (MSHQ-EjD) function from baseline and was better than Rezum at all time points (p < 0.01). Rezum failed to significantly reduce the MSHQ-EjD bother at 3 months, while UroLift demonstrated a significant reduction of 27.56% (p < 0.01). Both systems offered equal improvements in the bother score by 12-36 months. Surgical re-treatment rates favored Rezum over Urolift (4.4% vs. 10.7%, respectively)., Conclusions: Rezum achieved a greater improvement in symptom relief compared to UroLift. Improvement in ejaculatory dysfunction in patients treated with UroLift was greater than Rezum.

Benign prostatic hyperplasia is a common and progressive disease affecting aging men which has a significant impact on quality of life. The second-generation Temporarily Implanted Nitinol Device (iTind) is an FDA approved temporary prostatic urethral device which can be deployed using standard flexible cystoscopy without sedation or general anesthesia. The device is left in-situ for 5 to 7 days and is then entirely removed in the office, using an open-ended silicone catheter. Prospective, randomized data indicate that iTind has favorable functional and sexual patient outcomes. Readers will familiarize themselves with iTind, significant historical studies and the technique for deploying iTind using a flexible cystoscope in the office setting.

Objective: To report the results of a multicenter, randomized, controlled trial with a temporarily implanted nitinol device (iTind; Medi-Tate Ltd, Hadera, Israel) compared to sham for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia., Materials and Methods: Men 50 years or older were randomized 2:1 between iTind and sham procedure arms. A self-expanding, temporary nitinol device was placed for 5-7 days and an 18F Foley catheter was inserted and removed for the iTind and sham group, respectively. Patients were assessed at baseline, 1.5, 3, and 12 months postoperatively using the IPSS, peak urinary flow rate, residual urine, quality of life, and the International Index of Erectile Function. Unblinding occurred at 3 months., Results: A total of 175 men (mean age 61.1 ± 6.5) participated (118 iTind vs 57 sham). A total of 78.6% of patients in the iTind arm showed a reduction of ≥3 points in IPSS, vs 60% of patients in the control arm at 3 months. At 12 months, the iTind group reported a 9.25 decrease in IPSS (P< .0001), a 3.52ml/s increase in peak urinary flow rate (P < .0001) and a 1.9-point reduction in quality of life (P < .0001). Adverse events were typically mild and transient, most Clavien-Dindo grade I or II, in 38.1% of patients in the iTind arm and 17.5% in the control arm. No de novo ejaculatory or erectile dysfunction occurred., Conclusion: Treatment with the second-generation iTind provided rapid and sustained improvement in lower urinary tract symptoms for the study period while preserving sexual function., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To compare pain, quality of life (QoL), sexual function and lower urinary tract symptoms (LUTS) between rigid (RC) and flexible cystoscopy (FC)., Methods: Forty-one patients who were planned control cystoscopies were enrolled the study. At the first cystoscopy, 20 patients (Group 1) and other 21 patients (Group 2) were performed by flexible (15.5 Fr) and rigid cystoscope (15.5 Fr), respectively. At the second cystoscopies, the patients in group 1 and group 2 were performed by rigid and flexible cystosacope, respectively. In all the patients, pain was measured with visual pain scale (VPS) shortly after cystoscopy. Also, SF, QoL and LUTS were assessed by IIEF, SF-36 and MLUTS forms, respectively., Results: While 22 of the patients preferred FC, the other 19 preferred RC (P > 0.05). There were no statistical differences between VPS, IIEF, SF-36 and MLUTS scores of the two groups. In multivariate analysis regarding the quality of life, although sexual function, pain and cystoscopy type did not affect QoL, voiding symptoms affected independently QoL. After both cystoscopy type, IIEF, SF-36 and MLUTS scores did not change statistically., Conclusion: The results showed that the effects on pain, sexual function, QoL and LUTS of RC and FC were similar. In general, cystoscopy did not affect negatively on QoL, sexual function and LUTS of the patients., (© 2020 John Wiley & Sons Ltd.)

Introduction: Traditional benign prostatic hyperplasia treatment options, such as transurethral resection of the prostate and laser, have focused on addressing urinary symptoms for men; however, these options are associated with a high risk of sexual dysfunction., Objective: The objective of this study was to assess newer technologies (Aquablation therapy, UroLift, and Rezum) for the treatment of benign prostatic hyperplasia and the impact of preserving sexual function compared with transurethral resection of the prostate., Methods: A comprehensive review of Food and Drug Administration randomized studies from each of the technologies was carried out. A comparison of 3-year outcomes for International Index of Erectile Function-5 and Male Sexual Health Questionnaire Ejaculatory Function domain short form was analyzed., Results: Aquablation and prostatic urethral lift were the only therapies to show permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment., Conclusion: For prostates less than 80 cc, Aquablation and prostatic urethral lift were able to demonstrate permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment. Bhojani N, Yafi FA, Misrai V, et al. Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials. Sex Med Rev 2021;9:169-173., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: Lower urinary tract symptoms (LUTS) are a common urological referral, which sometimes can have a neurological basis in a patient with no formally diagnosed neurological disease ("occult neurology"). Early identification and specialist input is needed to avoid bad LUTS outcomes, and to initiate suitable neurological management., Methods: The International Continence Society established a neurological working group to consider: Which neurological conditions may include LUTS as an early feature? What diagnostic evaluations should be undertaken in the LUTS clinic? A shortlist of conditions was drawn up by expert consensus and discussed at the annual congress of the International Neurourology Society. A multidisciplinary working group then generated recommendations for identifying clinical features and management., Results: The relevant conditions are multiple sclerosis, multiple system atrophy, normal pressure hydrocephalus, early dementia, Parkinsonian syndromes (including early Parkinson's Disease and Multiple System Atrophy) and spinal cord disorders (including spina bifida occulta with tethered cord, and spinal stenosis). In LUTS clinics, the need is to identify additional atypical features; new onset severe LUTS (excluding infection), unusual aspects (eg, enuresis without chronic retention) or "suspicious" symptoms (eg, numbness, weakness, speech disturbance, gait disturbance, memory loss/cognitive impairment, and autonomic symptoms). Where occult neurology is suspected, healthcare professionals need to undertake early appropriate referral; central nervous system imaging booked from LUTS clinic is not recommended., Conclusions: Occult neurology is an uncommon underlying cause of LUTS, but it is essential to intervene promptly if suspected, and to establish suitable management pathways., (© 2020 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Background: Water vapor thermal therapy (WVTT) is a minimally invasive procedure for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH). There are no known systematic reviews reporting the effectiveness and safety of this increasingly common BPH therapy., Methods: We performed a systematic review and meta-analysis of studies utilizing WVTT for symptomatic BPH. The international prostate symptom score (IPSS), IPSS-quality of life (IPSS-QOL), BPH impact index (BPHII), and maximum flow rate (Qmax) were calculated as the weighted mean difference relative to baseline and reported in minimal clinically important difference (MCID) units. MCID thresholds were -3 for IPSS, -0.5 for IPSS-QOL, -0.5 for BPHII, and 2 mL/s for Qmax. The surgical retreatment rate was calculated using life-table methods., Results: We identified 5 cohorts treated with WVTT from 4 studies (514 patients; 40% with median lobe obstruction) with 2 years median follow-up (range: 6 months to 4 years). The IPSS, IPSS-QOL, BPHII, and Qmax significantly improved at all intervals between 3 months and 4 years; this benefit ranged from 3.3 to 3.8 MCID units for IPSS, 3.9 to 4.6 MCID units for IPSS-QOL, 6.8 to 8.2 MCID units for BPHII, and 1.5 to 3.0 MCID units for Qmax. The surgical retreatment rate was 7.0% at 4 years of follow-up data. Most adverse events were nonserious and transient; dysuria, urinary retention, and urinary tract infection were most common. No cases of de novo erectile dysfunction occurred., Conclusions: WVTT provided improvement in BPH symptoms that exceeded established MCID thresholds, preserved sexual function, and was associated with low surgical retreatment rates over 4 years.

Purpose: To determine if patients can accurately estimate volumes voided in a bladder diary, and to determine the patient characteristics that are most predictive of accuracy in volume estimation in the workup of lower urinary tract symptoms (LUTs)., Methods: We prospectively collected data on 180 consecutive patients undergoing a workup for LUTs at a tertiary care facility. Data collected include American Urological Association Symptom Scores (AUASS), flow time and rate, and one time measurement of voided volume into a blinded uroflow. Baseline characteristics and demographics were recorded. Descriptive statistics and linear regression analysis were performed to examine predictors of estimated voiding volume (mL) in SAS Version 9.4 (SAS Institute, Inc., Cary, NC, USA)., Results: Median age and BMI were 64 years (SD = 15.4) and 26.9 kg/m 2 (SD = 4.6), respectively. The median estimated voided volume and actual voided volume were 120 mL (range 1-480) and 101.5 mL (range 6.5-622.0), respectively. On linear regression analysis, 47.1% of patients estimated volume voided with a 20% margin of error, and 63.2% of patients estimated with a 30% margin of error. Each 1-year increase in age correlated with a 2% decrease in the odds of estimating voided volume within 20% of actual volume (p < 0.05). For each 1 unit increase in flow rate, there was an 8% (p < 0.005) increase in the odds of estimating voided volume within 20% of actual volume., Conclusions: Just under half of patients can accurately estimate volume voided with a margin of error of 20%.

Benign prostatic hyperplasia (BPH) affects over 50% of men above the age of 50 yr. With half of these men having bothersome lower urinary tract symptoms, this area represents a hot bed of novel treatments. Many BPH therapies have favorable short-term outcomes but lack durability or well-defined adverse events (AEs). Clinical trials are a gold standard for comparing treatments. We characterized all BPH clinical trials registered worldwide from inception to 2017. A total of 251 clinical trials were included. Of the studies, 30.1% used patient-reported outcomes such as the American Urological Association Symptom Score. Approximately 70% of clinical trials studied medical interventions, while the remaining trials investigated surgical approaches. Seventy-nine percent of trials were industry sponsored, while a minority were funded without commercial interest. Only 42% of trials had 12-mo follow-up, with the majority with <3 mo of follow-up. No trials evaluated prevention, diet, behavior, or alternative methods Overall, only 23% of trials reported results. Management options for BPH need unified benchmarks of success, AEs, durability, and standard reporting for all clinical trials, regardless of outcomes. PATIENT SUMMARY: We found that the majority of clinical trials were medical intervention, with very few trials evaluating prevention, diet, behavior, or alternative methods Furthermore, a few trials reported results in peer-reviewed journals. All clinical trials need to report results regardless of outcome, and in conclusion, standardized methods are needed in order to document the successes, adverse events, and durability for all clinical trials., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Benign prostatic hyperplasia (BPH) and erectile dysfunction (ED) are common conditions that increase in the aging population. Several environmental factors have been linked to the development and progression of BPH and ED. Several studies have shown potential direct and indirect influences of several micronutrients and macronutrients on the risk of developing these conditions. We reviewed the available published literature of the effect of diet on BPH and ED., Methods: A comprehensive search was performed to identify studies that evaluated how diet affected males with BPH and ED. Searches were run on July 5th, 2018 in the following databases: Ovid MEDLINE ® ; Ovid EMBASE; and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL). There were no language restrictions, publication date restrictions, or article type restrictions on the search strategy., Results: We retrieved a total of 1670 results across all databases. After removing any duplicated results, 2 independent reviewers screened a total of 1325 citations. A total of 35 articles were selected for inclusion in this review. Diet is an important factor affecting the risk of development of BPH and ED. Several studies have shown the effect of dietary interventions for BPH and ED., Discussion: A better understanding diet and its relative effects on the development, treatment and prevention of these diseases are an important area of further research for the given aging male population.

Purpose of Review: Transurethral resection of the prostate (TURP) is the standard surgical therapy for lower urinary tract symptoms (LUTS) due to prostatic enlargement. Following TURP, LUTS may persist in a proportion of patients. Persistent LUTS necessitates proper evaluation and management. In this review, we sought to describe the prevalence, pathophysiology, and predictors of LUTS following TURP, as well as the recommended evaluation and management., Recent Findings: Among the different techniques utilized for TURP, the prevalence of postoperative LUTS is similar. The chronically obstructed bladder has been shown to vary in its expression of collagen, tissue factors, and receptors when compared to the normal bladder which could contribute to the pathophysiology of LUTS after TURP. Although androgen receptors exist in the urinary epithelium, the role of sex hormones in LUTS remains obscure. GreenLight laser can lead to postoperative irritative voiding symptoms as a result of tissue necrosis. A large proportion of patients have persistent LUTS following TURP, with similar incidences between different techniques that can be used to perform TURP. LUTS after TURP should be evaluated with a thorough history and physical, including International Prostate Symptom Score, and urine culture to rule out infection. Noninvasive uroflow, post-void residuals, and subsequent urodynamic study or cystoscopy can be utilized as needed. Further research is necessary to be able to more precisely predict the patients who will experience no improvement in or worsening of LUTS following TURP.

Introduction: To present short-term safety and efficacy data of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) treated with Aquablation., Methods: Men with LUTs secondary to BPH (60-150 cc) underwent Aquablation treatment from February 2016 to December 2017 across 17 investigational sites in the USA from two contemporary investigational device exemption (IDE) studies called WATER (NCT02505919) and WATER II (NCT03123250)., Results: One hundred seven males with mean age of 67.3 ± 6.5 years were treated with Aquablation; mean prostate volume was 99.4 ± 24.1 cc. The pooled results show that large prostates have an average procedure time of less than 36 min and discharge on average 1.6 ± 1 days. The IPSS decreased by 16.7 ± 8.1 points at 3 months and Q max increased by 11.2 ± 12.4 ml/s. The Clavien-Dindo (CD) grade 2 or higher event rate at 3 months was 29%. A non-hierarchical breakdown for CD events yielded 18% grade 2 and 19% grade 3 or higher., Conclusion: Men with LUTS secondary to BPH (60-150 cc) in a pooled analysis were treated safely and effectively with Aquablation up to 3 months postoperatively., Trial Registration: ClinicalTrials.gov identifiers, NCT02505919 and NCT03123250., Funding: PROCEPT BioRobotics.

Objective: We assessed the effectiveness and durability of 532 nm laser photovaporization with GreenLight XPS in men with and without preoperative urinary retention., Materials and Methods: From 2010 to 2017 we prospectively studied men who underwent photovaporization of the prostate (PVP) for obstructive lower urinary tract symptoms (LUTS) secondary to BPH. The cohort was retrospectively divided into those with catheter dependent retention and those with elective PVP. Primary endpoints were catheter-free rate and improvement in quality of life (QoL) scores, international prostate symptom score (IPSS), maximum urinary flow rate (Qmax), and postvoid residual (PVR). The secondary endpoints of the study were complication outcomes as defined by the standardized Clavien-Dindo grading system., Results: One hundred thirty-seven men with preoperative retention and 195 men without preoperative retention underwent PVP. Men with preoperative retention were older (70 years vs 66 years; p < 0.001), had a higher American Society of Anesthesiology (ASA) score, and had a higher prevalence of neurologic disease (8% vs 2.6%; p = 0.04). These men also had a larger prostate volume (76 cc vs 69 cc; p < 0.001) and higher prostate specific antigen (5 ng/mL vs 2.7 ng/mL; p < 0.001) than those without retention. Patients with preoperative retention also had higher preoperative baseline IPSS and QoL score. After PVP they improved to values similar to those without retention, with durability up to 24 months. After PVP, men in preoperative retention had similar rates to fail their first void trial (18.2% vs 10.3%, p = 0.053). There was a 96% catheter-free rate in the men with preoperative retention. The rate of complication was higher in the nonretention group, specifically at 90 days (35.4% vs 21.2%; p = 0.009), with almost all the complications being Clavien-Dindo grade 2., Conclusion: PVP is an effective, safe, and durable treatment for men in acute urinary retention (AUR) with a catheter-free rate of 96%. The improvement is similar to those who did not present in AUR.

Introduction: The GreenLight™ XPS Laser System (GL-XPS) is a safe and efficacious treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH), but there is limited evidence on its use in prostates over 150 mL. We demonstrate the safety and efficacy of the GL-XPS system using a vapoenucleation technique in prostate glands measuring over 150 mL., Methods: We prospectively collected data on all consecutive patients with prostates measuring over 150 mL on transrectal ultrasound treated with the GL-XPS (AMS, Inc., Minnetonka, MN) at a tertiary referral center from September 2011 to October 2015. Data collected include prostate volume, International Prostate Symptom Score (IPSS) and quality of life (QoL) scores, maximum urinary flow rate (Qmax), postvoid residual (PVR), prostate-specific antigen, complications, and reintervention rates., Results: Seventy male patients with a median prostate size of 202 mL (range 152-376 mL) were included. There were 41 patients (59%) in preoperative urinary retention with an indwelling catheter preoperatively. Thirty-seven (53%) patients were American Society of Anesthesiologists (ASA) class 2 and 33 (47%) were class 3. Median operative time was 180 minutes, laser time 97 minutes, energy utilization 674 kJ, and energy density 3.3 kJ/mL, with median 3 fibers used per case. Median length of stay and length of catheterization were 1 day. IPSS and QoL scores demonstrated significant improvements from baseline at all endpoints, improving from 16 to 3.5 and from 4 to 1 at 24 months, respectively (p = 0.001). At 12 months, Qmax and PVR improved from 10.1 to 22.4 mL/s (p = 0.043) and from 84 to 31.4 mL (p = 0.015), respectively. Retreatment was required in two patients (2.9%)., Conclusion: GL-XPS vapoenucleation provided durable subjective and objective improvements in symptoms and voiding parameters, with no serious adverse events in men with prostates >150 mL.

Many monotherapies are currently available to clinically treat and alleviate symptoms of lower urinary tract symptoms secondary to benign prostatic hyperplasia: α-blockers, 5ARIs, PDE5Is, β-3-andrenoceptor agonists, and anticholinergic agents. Current studies have evaluated the effective of these treatments in comparison to other groups or in combination therapies. The current review evaluates the effectiveness of class formulations. Based on the findings, α-blockers, specifically doxazosin and terazosin, were most effective in reducing IPSS scores and peak urinary flow rate, while being most cost-effective. However, further clinical investigations are required to evaluate the clinical implications of different formulations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Lower urinary tract symptoms (LUTS) in young women is becoming a more recognized urologic issue that can arise from many causes, each with their own management strategy. The purpose of this study was to determine the rates of various etiologies for LUTS in women under 40 years of age., Materials and Methods: Video urodynamic studies (VUDS) were performed in 70 women age 40 years or less with LUTS for greater than 6 months between March 2005 and June 2012 at Weill Cornell Medical College. Patients with culture-proven bacterial urinary tract infections, pelvic organ prolapse greater than grade I, symptoms for less than 6 months, a history of neurologic disease, or previous urological surgery affecting voiding function, were excluded from the analysis., Results: The mean age of the patients was 31.95 ± 5.57. There were 48 patients that presented with more than one urinary symptom (68.57%). The most frequent complaints included: urinary frequency (n = 42, 34.15%), incontinence (n = 26, 21.14%), and urinary urgency (n = 22, 17.89%). The most common urodynamic abnormality was dysfunctional voiding (n = 25, 28.74%), detrusor overactivity (n = 15, 20.00%), bladder outlet obstruction (n = 8, 11.43%). There were no significant differences seen in complaints or AUA symptom and quality of life scores across diagnosis groups., Conclusions: Persistent LUTS can present in younger women with an unclear etiology, which may be characterized using VUDS. The most common etiology found is dysfunctional voiding followed by detrusor overactivity. This study shows that the etiology can be more accurately determined using VUDs, which can assist in management.

Transurethral resection of the prostate (TURP) continues to be the most common treatment in the operative management of benign prostatic hypertrophy (BPH). Several other modalities have shown equivalence to TURP. However, even after surgical treatment, up to one third of patients have bothersome lower urinary tract symptoms (LUTS). This review discusses the pathophysiology, evaluation, and management options for patients with LUTS after TURP.

Purpose: Lower urinary tract symptoms (LUTS) in young men are becoming a more recognized urologic issue that can arise from many causes, each with their own management strategy. The purpose of this study was to determine the rates and types of voiding dysfunction causing LUTS in men under 40 years., Methods: Videourodynamic studies (VUDS) of 87 men 40 years of age or less with LUTS for greater than 6 months, performed between July 2004 and June 2012 at Weill Cornell Medical College, were retrospectively analyzed. Patients with culture-proven bacterial prostatitis, symptoms for less than 6 months, a history of neurologic disease, or previous urological surgery affecting voiding function were excluded from the analysis., Results: The mean age of the patients was 31.84 ± 5.78. There were 37 patients that presented with more than one urinary symptom (42.5 %). The most frequent complaints included: urinary frequency (N = 42, 48.28 %), difficulty with urination (N = 41, 47.13 %), and urinary urgency (N = 21, 24.14 %). The most common urodynamic abnormality was bladder outlet obstruction (BOO) (N = 37, 42.53 %), dysfunctional voiding (N = 25, 28.74 %), detrusor underactivity (N = 10, 11.49 %), and detrusor overactivity (N = 7, 8.05 %). There were no differences seen in AUA symptom and quality of life scores across diagnosis groups., Conclusions: Lower urinary tract symptoms can present in younger men with a variety of types of voiding dysfunction. This study uses VUDS to show that the most common types of voiding dysfunction in this population with chronic LUTS are BOO followed by dysfunctional voiding.