Controversies Modern BPH Treatment

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Matthew Lee, MD, a former fellow of Northwestern Urology’s Endourology Fellowship Program and currently a Clinical Assistant Professor of Urology at Ohio State University, delivered an electrifying presentation on the Controversies in BPH Management. Dr. Lee explored key topics, including surgical management options for men with LUTS/BPH, the debates surrounding bladder contractility and its impact on surgical intervention, and the controversial topic of ejaculation preservation in relation to HoLEP.

Advancements and Controversies in BPH Treatment: Understanding the "Window of Curability"​

In a recent Endo Urology CM session, Dr. Matt Lee, Clinical Assistant Professor of Urology at Ohio State University, shared his insights on the modern treatment landscape for benign prostatic hyperplasia (BPH), a common urological condition in aging men. With over 500 holmium laser enucleation procedures (HoLEP) under his belt and extensive research in BPH surgical outcomes, Dr. Lee provided a nuanced view of both established and emerging BPH treatments, addressing surgical options, minimally invasive techniques, and the long-term effects of delayed treatment on bladder health.

Overview: BPH and Surgical Treatment Evolution​

BPH is associated with urinary symptoms due to prostate enlargement, leading to bladder outlet obstruction. Traditionally, transurethral resection of the prostate (TURP) was the most common surgical treatment, but the past decade has seen the rise of minimally invasive surgical therapies (MIST), including UroLift, Rezum, and HoLEP, all offering symptom relief while attempting to balance invasiveness, durability, and preservation of function.

Trends in BPH Surgery​

Studies of BPH surgery trends reveal significant shifts in practice over the last decade:

1. Turp Decline: TURP was the most common procedure up until recent years but has gradually decreased in frequency, representing about 25% of surgeries by 2021.
2. Growth of Minimally Invasive Options: UroLift procedures, a tissue-sparing implant technique, grew from 7% to 30% from 2014 to 2021, becoming the most common BPH surgery in recent years.
3. Economic and Clinical Implications: While newer options like UroLift and Rezum offer effective symptom relief, they often come at a higher cost when considering initial and follow-up expenses, compared to more traditional options like TURP.

These shifting patterns reflect a movement toward procedures that minimize recovery time and preserve ejaculation, yet also raise questions about long-term durability and cost-effectiveness in BPH care.

Minimally Invasive Surgical Therapies (MIST) and Emerging "True-MIST" Techniques​

MIST options aim to bridge the gap between medical management and full surgical procedures, addressing moderate symptoms with fewer complications and quicker recovery times. Dr. Lee highlighted key features and limitations of current MISTs as well as “True-MIST” techniques that allow for office-based deployment and can be used as interim options for patients who may not yet require surgery.

UroLift and Rezum​

• UroLift: The UroLift device retracts prostate tissue to improve urinary flow without removing or ablating it. Approved by the FDA for prostates up to 80cc, the procedure avoids ejaculatory dysfunction, with durable outcomes shown in five-year studies, although re-treatment rates can reach 13.6% over this period.
• Rezum: Using steam injections to induce necrosis and shrink prostate tissue, Rezum is another effective, tissue-sparing method. It is associated with durable symptom relief up to five years post-treatment, with relatively low re-treatment rates.

True-MIST: iTind and Optilume​

True-MIST techniques are new, simpler options with office-based deployment designed to provide short-term relief without a long-term commitment to surgery.

• iTind: This temporary implant reshapes the bladder neck and prostate to relieve symptoms. After five to seven days, the device is removed, offering quick symptom relief without disrupting ejaculation. While symptom improvements were seen in clinical studies, durability beyond one year requires further investigation.
• Optilume: Initially developed for urethral strictures, Optilume uses a balloon to open the bladder neck and prostate urethra. It shows promise for short-term symptom relief, but long-term data is still emerging.

The "Window of Curability" in BPH Treatment​

A key concept presented by Dr. Lee is the "window of curability"—a theoretical timeframe in which intervention may prevent irreversible bladder damage due to prolonged bladder outlet obstruction. Current symptom-based approaches to BPH treatment, which wait for symptoms to become bothersome before intervention, might delay treatment too long, allowing for progressive bladder decompensation.

Bladder Changes Due to Chronic Obstruction​

As BPH progresses, the bladder undergoes compensatory changes to maintain function, including muscle hypertrophy and changes in collagen structure. Over time, however, these adaptations may lead to decompensation, characterized by decreased contractility, altered sensation, and in severe cases, loss of bladder function. Dr. Lee discussed several animal and clinical studies showing structural and functional changes in the bladder muscle tissue as BPH progresses untreated.

Clinical Implications of Delayed Intervention​

The landmark study by Abrams and colleagues provides insight into BPH's natural progression, highlighting that not all men with bladder outlet obstruction develop decompensation. However, delayed intervention has been associated with reduced treatment efficacy and worsening bladder function in some cases. Data suggest that early intervention, particularly TURP, yields superior symptom relief and may prevent irreversible changes.

Dr. Lee pointed to the limitations of current diagnostic criteria, as symptom-based management may miss underlying structural damage to the bladder.

Limitations of MIST for Preventing Bladder Decompensation​

Dr. Lee highlighted concerns that while MIST and True-MIST options relieve symptoms, they may not adequately address bladder outlet obstruction, thus risking long-term bladder decompensation in some patients. Studies have shown that, although MISTs like UroLift and Rezum provide symptom improvement, only some techniques achieve complete bladder outlet obstruction relief as measured by objective parameters such as bladder outlet obstruction index.

Future Directions: Biomarkers and Genomic Testing for Bladder Health​

The need for biomarkers to assess bladder health and predict decompensation before significant damage occurs is a promising frontier. Dr. Lee discussed a recent study that identified potential genomic markers associated with bladder remodeling due to BPH. Proteins such as thrombospondin, detectable in urine, show potential as biomarkers to guide optimal intervention timing.

Conclusion: Balancing Early Intervention and Conservative Management​

The “window of curability” concept challenges the symptom-based paradigm in BPH treatment, suggesting that earlier intervention might protect against irreversible bladder damage. While MISTs offer less invasive options, the question of whether they prevent long-term bladder deterioration remains.

In the absence of reliable biomarkers or advanced imaging techniques for bladder decompensation, symptom-based management remains a reasonable approach. However, the evolution of diagnostics in BPH, including the development of non-invasive biomarkers, may one day allow for more targeted and individualized treatment plans that prevent bladder decompensation while minimizing unnecessary interventions.

Dr. Lee’s insights underscore the importance of ongoing research to refine the timing and methods of BPH intervention, paving the way for a future where BPH treatment not only alleviates symptoms but also preserves bladder health over the long term.

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References​

• Dr. Matt Lee – Clinical Assistant Professor, Ohio State University, Presentation on BPH Treatment, "Controversies in Modern BPH Treatment: The Window of Curability," Endo Urology CM Session at Northwestern.