Current Urology Reports (2020) 21:32

https://doi.org/10.1007/s11934-020-00985-0

BENIGN PROSTATIC HYPERPLASIA (K MCVARY, SECTION EDITOR)

The New American Urological Association Benign Prostatic

Hyperplasia Clinical Guidelines: 2019 Update
Ryan Dornbier 1 & Gaurav Pahouja 1 & Jeffrey Branch 1 & Kevin T. McVary 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review The goal of this paper was to analyze the efficacy of the current modalities available to surgically treat lower
urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).
Recent Findings There have been significant surgical advancements for the treatment of BPH, including an increasing develop-
ment and utilization of minimally invasive surgical techniques (MISTs). These procedures have varying outcomes that are critical
to understand. In addition, MISTs have important adverse effects, though have minimized effects on sexual function when
compared to more invasive surgical techniques.
Summary It is important for all urologists to be familiar with the surgical techniques available to treat BPH and the updated
American Urological Association (AUA) Guidelines. Further studies evaluating efficacy, safety, and sexual functioning will help
guide care in the future and evolve practice.

Keywords Benign prostatic hyperplasia . Lower urinary tract symptoms . Minimally invasive surgical techniques . UroLift .
Rezum . Transurethral resection of the prostate . Aquablation . Prostatic artery embolization . Laser enucleation

Introduction sensation of incomplete bladder emptying). Clinically signif-

icant LUTS in men are presumed to be due to BPH in the
Benign prostatic hyperplasia (BPH) represents a histologic absence of other relevant diagnoses. Such symptoms can have
diagnosis defined as the proliferation in the total number of a negative impact on quality of life, and when severe in the
stromal and glandular epithelial cells within the transition setting of BPH can lead to urinary retention [3]. As therapies
zone of the prostate gland [1, 2]. In some men, BPH can result are being considered specifically for BPE/BPO, the impor-
in benign prostatic enlargement (BPE), which may lead to tance of a definitive diagnosis increases.
benign prostatic obstruction (BPO) and subsequently lower The prevalence of BPH increases with age [3]. Histologic
urinary tract symptoms (LUTS). BPH is therefore often asso- prevalence reaches 60% at age 60 and 80% at age 80 [4].
ciated with LUTS, which may require treatment. LUTS refer Moderate to severe LUTS, defined as an International
to a group of clinical symptoms related to voiding. Although Prostate Symptom Score (I-PSS) greater than 7, have been
nonspecific and secondary to numerous etiologies, including used to refine the prevalence and incidence of BPH. Studies
BPE/BPO, LUTS are further subdivided to symptoms of uri- have shown the prevalence of moderate to severe LUTS to be
nary storage (frequency, urgency, nocturia) and urinary 26%, 33%, 41%, and 46% in men in the fifth, sixth, seventh,
voiding (urinary intermittency, hesitancy, weak stream, and eighth decades of life, respectively [5]. Urinary retention
is considered to represent a final symptomatic stage of BPH,
and has been shown to increase in incidence with age [5, 6].
This article is part of the Topical Collection on Benign Prostatic
Hyperplasia
BPH represents one the largest segments of urologic practice
and encompasses approximately 23% of all office visits
* Ryan Dornbier [7].The economic burden of BPH consists of direct costs
[email protected] (medications, diagnostics, office visits, procedures), lost earn-
ings, and intangible costs. In the USA, it is estimated that BPH
1
Center for Male Health, Department of Urology, Stritch School of
costs approximately US$4 billion annually [8].
Medicine, Loyola University Medical Center, 2160 S. First Ave., The treatment of BPH is often multimodal. Patients should
Maywood, IL 60153, USA be counseled on lifestyle changes including fluid restriction
 32 Page 2 of 10 Curr Urol Rep (2020) 21:32

and avoidance of substances with diuretic properties. A vari- between mTURP and bTURP. In the aforementioned
ety of pharmacologic agents are also utilized to treat LUTS Cochrane review, IIEF scores were similar between the two
attributed to BPH. These include alpha-adrenergic antago- groups. In a more in-depth look a sexual function, El-Assmy
nists, beta-adrenergic agonists, 5-alpha-reductase inhibitors, et al. found no difference in erectile function, orgasmic func-
anticholinergics, vasopressin analogs, phosphodiesterase-5 in- tion, sexual desire, intercourse satisfaction, or overall satisfac-
hibitors, and phytotherapeutics which can be used indepen- tion [16].
dently or in combination. Despite these efforts, lifestyle It is evident that bTURP is equivalent in terms of efficacy and
changes and pharmacological management may be inade- far superior than mTURP in terms of safety. For the purpose of
quate or undesired by the patient. In these instances, manage- The Guideline, comparisons to mTURP were justified given that
ment warrants consideration of invasive procedures available most comparisons were related to efficacy standards. This most
to treat BPH. Furthermore, some patients desire to avoid tak- appropriately relates to TUR syndrome, which is unique to
ing daily medications or have conditions (acute or chronic mTURP. However, as MIST technology advances, and urolo-
renal insufficiency, refractory urinary retention, recurrent uri- gists lean more heavily on outpatient- and office-based proce-
nary tract infections, bladder stones, or gross hematuria dures for the management of smaller gland sizes (< 80 g), TURP
thought to be secondary to BPH) requiring more aggressive will likely become a procedure utilized for larger glands.
management. Inherently, this will lead to longer resection times and place
The AUA conducted a thorough review of literature patients at increased risk of adverse events, further validating that
pertaining to BPH and released an updated BPH Guideline a surgical transition to bTURP is justified.
in 2018. This guideline was then amended in 2019 to include
all relevant literature through January of 2019, hereto referred Simple Prostatectomy
to as The Guideline [9••]. These efforts comprised the first
comprehensive evaluation of BPH since 2011. The An alternative management option for BPH includes simple
Guideline highlights the evolution of surgical therapies and prostatectomy. Comparison to TURP demonstrates similar ef-
advancements in various minimally invasive surgical tech- ficacy and safety profile as pointed out by The Guideline
niques (MISTs) utilized for the treatment of BPH. We sought analysis of four RCTs, though data suggests lower re-
to thoroughly review the surgical treatment of BPH and high- operative rate for those undergoing simple prostatectomy
light important changes in practice within The Guideline. In [17–20]. Since the last rendition of The Guideline in 2010, a
addition, we sought to evaluate surgical therapy and analyze major development has been the evolution of technique for
outcomes pertaining to efficacy and sexual function. simple prostatectomy, with more widespread utilization of
robotic assistance.
Gold Standard and Proven Surgical Therapies Overall, minimally invasive simple prostatectomy (laparo-
scopic and robotic technique) shows no difference in I-PSS,
Transurethral Resection of the Prostate max flow rates, and post void residual volume with less blood
loss, risk of transfusion, shorter hospital stay, and lower com-
Historically and in The Guideline, TURP remains the bench- plication rate compared to open simple prostatectomy.
mark by which all other surgical advancements are compared. Minimally invasive simple prostatectomy was associated with
As such, The Guidelines recommend offering patients TURP a longer operative time [21]. Direct comparison between ro-
due to its continued efficacy and safety. In breaking down the botic and open simple prostatectomy afford similar efficacy
role of TURP in the management of LUTS/BPH, The with improved safety considerations showing that robotic sim-
Guideline does not distinguish between the utilization of ple prostatectomy has a shorter length of hospital stay and
monopolar (mTURP) or bipolar (bTURP) technology, leaving reduced blood loss, though a longer operative time [22, 23].
the decision to the urologist. The bTURP platform has certain- Comparison of minimally invasive approaches have not
ly become more refined and more widely available from mul- shown a difference between laparoscopic and robotic tech-
tiple manufacturers in the endoscopic manufacturing sector. In nique, as it pertains to efficacy or safety, suggesting that utili-
five systematic reviews and meta-analyses of mTURP versus zation of either approach should be based on surgeon prefer-
bTURP, there was no difference in efficacy [10–14]; however, ence or availability of equipment [24, 25].
when comparing safety parameters, bTURP is superior. This As far as sexual outcomes are concerned, none of the RCTs
includes shorter hospital stay, lower risk of blood transfusion, from The Guideline reported sexual function outcomes for
clot retention, and lower rates of TUR syndrome. A recent simple prostatectomy compared to TURP. One trial compar-
Cochrane review analyzing 59 randomized control trials of ing laparoscopic simple prostatectomy to TURP describes 36
mTURP versus bTURP with 8924 participants, supported cases of retrograde ejaculation following the procedures [20].
these conclusions [15]. With regard to sexual function and It is likely that sexual outcomes of open prostatectomy are
satisfaction, there is no clinically demonstrable difference similar to that of enucleation and TURP with resultant
Curr Urol Rep (2020) 21:32 Page 3 of 10 32

ejaculatory dysfunction [26]. Moreover, there is a renewed Guideline highlights the utilization of holmium (HoLEP)
effort to alter simple prostatectomy techniques that might pre- and thulium (ThuLEP) laser enucleation of the prostate, in
serve ejaculatory function [27]. which prostatic lobes are removed en bloc and morcellated
for removal. Both of these laser technologies have shallow
Photovaporization of the Prostate tissue penetration resulting in rapid tissue vaporization and
improved coagulation [36]. In comparison of HoLEP and
The 532 nm Greenlight laser imparts a unique combination of ThuLEP with TURP, enucleation has similar efficacy
prostatic tissue and water absorption properties with the goal of pertaining to I-PSS reduction, IPS-QoL scores, flow rate, re-
ablating or enucleating tissue to create a TURP-like cavity. The operation, and complications with long-term follow-up
recent evolution of this variable-wattage technology has facilitat- [37–39]. There is also a significantly lower rate of blood trans-
ed more powerful wattage settings to remove fibrous tissue while fusion with laser enucleation. Direct comparison of ThuLEP
maintaining a fixed depth of energy transfer. The Guideline spe- and HoLEP offers similar efficacy and safety profile, without
cifically references the utilization of the higher power 120 W and distinct advantages for either laser [40–42]. Outside of HoLEP
180 W platforms with avoidance of the 80 W platform due to and ThuLEP, many different laser technologies are being uti-
inferior outcomes and higher retreatment rates. lized for enucleation procedures [43]. Recently, many groups
The advancement of the 180 W GreenLight laser platform have reported on the use of the GreenLight laser for prostate
into a mature BPH management technology stems from pub- enucleation (GreenLEP) [44–46]. There are no randomized
lication of the 2-year outcomes from the GOLIATH trial [28]. trials comparing GreenLEP to TURP, though data suggests
This trial demonstrated the non-inferiority of the 180 W XPS efficacy similar to open prostatectomy [47].
platform in comparison to TURP pertaining to I-PSS, max Similar to patients undergoing GreenLight PVP, utilization
flow rate, complication free rate, prostate volume, post void of laser enucleation has improved outcomes in patients on
residual volume, PSA, and I-PSS QoL score. There was also AC/AT therapy. Data is limited and mainly retrospective;
no difference in retreatment rates. Separate studies have dem- however, there does not appear to be a difference in transfu-
onstrated the decreased need for blood transfusion compared sion rates or post-operative complications related to bleeding
to TURP [29, 30]. Moreover, saline irrigation is utilized which between patients undergoing HoLEP on AC/AT therapy [48].
eliminates the concern for TUR syndrome. The same series noted a longer hospital stay and duration of
A notable advantage of PVP is the ability to safely perform continuous bladder irrigation in patients on AC/AT [48]. Two
prostatic vaporization in patients on oral anti-thrombotic (AT) recent reviews and meta-analyses on patients undergoing
and anti-coagulative (AC) agents, specifically with the 180 W HoLEP suggested similar efficacy between patients on AC/
system [31, 32]. The safety profile of PVP in this special AT compared to those not on AC/AT therapy [49, 50]. Both
population centers around the wavelength and penetration of reported slightly increased bleeding events, while Zheng et al.
the laser energy. The 532-nm wavelength at a tissue penetra- showed an increased risk of acute urinary retention in men on
tion of 0.8 mm is absorbed by hemoglobin leading to better AC/AT therapy compared to those without [50]. Similar stud-
hemostasis. Though the risk of blood transfusion in this pop- ies have been performed in patients undergoing ThuLEP with
ulation was low, there is an increased risk of higher grade similar results [51, 52].
complications for patients on anticoagulants [32]. Sexual function following enucleation is most often asso-
Comparisons of sexual function between PVP and TURP ciated with retrograde ejaculation. Erectile function is un-
suggest similarity. In the GOLIATH trial, IIEF scores were main- changed for both ThuLEP and HoLEP, even with long-term
tained pre-treatment and at 2-year follow-up with no difference follow-up [53–55]. However, enucleation leads to a signifi-
between the groups. Ejaculatory function was not reported [28]. cantly higher rate of retrograde ejaculation and decrease of
Most studies support the notion that erectile function is not sig- orgasm perception. Sexual satisfaction and desire remain un-
nificantly affected by PVP [33, 34], though some studies suggest changed when compared to control [56]. Similar outcomes are
that patients with better pre-operative erectile function (IIEF > seen with GreenLEP patients when directly compared to PVP.
19) may experience a significant decline in erectile quality post- Huet et al. found that nearly all patients undergoing GreenLEP
operatively. In a look at multiple sexual parameters, Terrasa et al. (98.8%) developed retrograde ejaculation, while fewer pa-
found that ejaculatory function deteriorated following PVP with tients undergoing PVP (73.1%) developed retrograde ejacula-
a maintenance of erectile function. Interestingly, global sexual tion. Surprisingly, erectile function appeared improved in the
satisfaction was significantly improved [35]. GreenLEP cohort [57]. Overall, post-operatively sexual dys-
function following enucleation is related to ejaculatory dys-
Laser Enucleation function as opposed to erectile dysfunction.
A major drawback to the use of enucleation appears to be the
The properties of laser therapy to the prostate allows for steep learning curve necessary for new adopters prior to profi-
unique advantages when treating BPH endoscopically. The ciency. Most articles reference a large case volume prior to
 32 Page 4 of 10 Curr Urol Rep (2020) 21:32

apparent proficiency ranging from 14 to 60 cases [58–63]. This is advantages, while remembering the lessons learned from the
compared to a more modest learning curve for alternative ap- older MISTs.
proaches to large glands, such as robotic simple prostatectomy
[64]. It is believed that this learning curve has resulted in less Water Vapor Thermal Therapy
widespread adoption of enucleation among established and prac-
ticing urologists, despite proven efficacy [63]. However, with The initial pilot study using the REZŪM System was pub-
more widespread use among training programs and innovative lished in 2015 showing a 38% reduction in transition zone
techniques to teaching, we may see an increased adoption of volume at 6 months following thermal ablation [70]. A single
these technologies in the future [65, 66]. randomized controlled trial reporting data from men undergo-
ing WVTT showed a 50% reduction in I-PSS (20% in sham
Transurethral Incision of the Prostate arm) with 74% of actively treated men having a ≥ 8 point
reduction (31% in sham arm) at 12 months [71•]. Four-year
TUIP has been used to treat prostates < 30 g in size. Historically, outcomes from this RCT were recently reported showing du-
TUIP has been offered to patients to improve symptoms while rability with sustained improvement in I-PSS and flow rate.
minimizing the effects on ejaculation. Studies previously re- Surgical retreatment after 4 years was 4.4% [72]. There have
vealed lower rates of retrograde ejaculation (RE) (18.2% versus been no direct comparisons between WVTT and TURP.
65.4%) and need for blood transfusion (0.4% versus 8.6%) when During the course of the RCT, there were no procedure-
TUIP was compared to TURP [67]. Newer data has brought the related adverse events. Patients did report procedural side ef-
efficacy of TUIP into question. A randomized controlled trial fects including dysuria, hematuria, urgency, frequency, uri-
comparing TUIP to TURP in men with prostates < 30 g in size nary retention, and suspected UTI. These were overall antici-
showed similar changes from baseline in I-PSS between the pated and highlight the safety profile of WVTT [72].
TUIP and TURP groups [68]. With regard to sexual side effects, An important advantage of WVTT comes through with the
there was no significant difference in ED. TUIP did, however, lack of impact on sexual function from both erectile function
have a significantly lower rate of retrograde ejaculation (22.5% and ejaculatory function. This is specifically stated in The
for TUIP vs. 52.5% for TURP) [68]. Given these results, the role Guideline. In the previously mentioned RCT, there was no
of TUIP seems to be limited to the patient with a small prostate change in erectile function at 2-year follow-up. Importantly,
gland (< 30 g in size). Moreover, with the emergence of multiple ejaculatory function and bother scores improved [72, 73].
MISTs with improved maintenance of ejaculatory function (see WVTT shows better libido, erectile, and ejaculatory function
below), the continued utilization of TUIP may be further limited. when compared to medical therapy with finasteride or combi-
nation therapy [74]. Most of these benefits likely stem from a
Renewed Focus on Minimally Invasive Surgical lesser degree of retrograde ejaculation.
Techniques Currently, The Guideline only recommends the use of
WVTT in prostate glands < 80 g in size. This primarily stems
In the 2010 guideline, minimally invasive procedures for BPH from the exclusion of glands larger than 80 g from the single
were limited to transurethral microwave therapy (TUMT) and RCT demonstrating WVTT efficacy. Multiple retrospective
transurethral needle ablation (TUNA) of the prostate [69]. reviews utilizing WVTT have been performed with wide
Since that time, these technologies have largely fallen out of ranges of prostate size. These retrospective studies demon-
favor, with recommendation against the use of TUNA in The strated similar efficacy across their cohorts, though no sub-
Guideline. However, there has been a renewed interest in group analyses were performed specific to larger prostatic size
minimally invasive surgical techniques (MIST) for the man- [75, 76]. Despite these size limitations, a distinct advantage of
agement of BPH. Two new MIST technologies have shown WVTT in the MIST environment is its use in patients with
significant interest, water vapor thermal therapy (WVTT) with enlarged median prostatic lobe. These patients were not ex-
the REZŪM System (Boston Scientific) and prostatic urethral cluded from the initial RCT. In fact, 30.9% of patients in the
lift (PUL) with UroLift. WVTT uses radiofrequency to create trial had therapy to a median lobe [72]. In this regard, WVTT
thermal energy in the form of water vapor. This energy is can be used across the spectrum of prostate morphology.
dispersed through the prostatic transitional zone disrupting
cell membranes effectively causing cell death and tissue ne- Prostatic Urethral Lift
crosis. PUL uses permanent transprostatic sutures implanted
through the prostatic capsule to mechanically compress the Initial safety and feasibility of the UroLift procedure was pub-
prostate parenchyma and modify the prostatic urethral lumen. lished in 2011 following a study of 19 men in which there
These technologies have allowed for a new shift of BPH man- were no adverse procedural events. Additionally, histopatho-
agement to an outpatient and office-based setting. As the focus logical evaluation of subsequently resected tissue showed a
on MIST rejuvenates, it is important to highlight their benign response to the implant [77]. Subsequently, the LIFT
Curr Urol Rep (2020) 21:32 Page 5 of 10 32

trial compared PUL to sham procedure showing improvement but results have been inconsistent. A group of trials compared
in I-PSS, I-PSS QoL, and peak urinary flow rates [78•]. These symptom response between TUMT and TURP [85–89].
improvements were sustained through 5-year follow-up with a Response was defined as an I-PSS score decrease by 7 or more
13.6% retreatment rate [79]. Major adverse events were rare, points, or a > 50% improvement in I-PSS from baseline. Mean
while procedural side effects of dysuria, pain, hematuria, and prostate volumes in these trails were 56 mL and ranged from
urgency were transient, lasting roughly 2 weeks [78•]. The 50 to 69 mL. The trials found similar response rates in I-PSS
BPH6 study made direct comparison between TURP and symptom scores from baseline when TUMT was compared to
PUL. At 24-month follow-up, TURP was superior to PUL in TURP over a follow-up period ranging from 6 months to
terms of I-PSS reduction and flow rate. There was no differ- 5 years. Data also revealed that reoperation rates were signif-
ence in quality of life changes. PUL was favored for recovery icantly higher with TUMT as compared to TURP, approxi-
and ejaculatory function [80]. mately 9.9% vs. 2.3%. One trial evaluated the efficacy of 30 or
Similar to WVTT, PUL is associated with preservation of 60 min TUMT vs. sham treatment and found no difference in
sexual and ejaculatory function following treatment [81]. In symptom scores between the treatment and placebo arms after
the LIFT trial, there was no change in erectile quality based on 4 months [89]. Previous iterations of The Guideline have
SHIM score. Additionally, all patients had preserved ejacula- called into question the durability of TUMT based on these
tion with no reports of anejaculation or retrograde ejaculation studies [69]. Over the last 10 years, few, if any, trials have
[80]. When men from the LIFT trial were stratified by pre- been performed to refute these findings. In as such, The
procedure erectile quality, those with severe erectile dysfunc- Guideline has a qualified recommendation for the use of
tion saw some improvement from baseline following PUL. TUMT, emphasizing the retreatment rates reported. More
Moreover, early follow-up showed improvement in ejaculato- practically, this lack of research into TUMT efficacy suggests
ry bother and volume [82]. As The Guideline states, these the technology has fallen out of favor, likely secondary to the
findings support the notion that new MISTs are suitable alter- adoption of newer MIST technologies. Unless new studies are
natives for patients concerned about sexual and ejaculatory performed to reinvigorate enthusiasm for TUMT, utilization
preservation when considering BPH treatment. of this techology is predicted to continue to decline.
PUL is limited to by prostatic size (< 80 g) and to patients
without an obstructive median lobe. Both previously Transurethral Needle Ablation
discussed trials, BPH6 and LIFT, excluded patients with larg-
er glands and median lobe morphology. Utilization of PUL on TUNA is not currently recommended for the treatment of
larger glands is limited to case series reports, though it does LUTS attributed to BPH in The Guideline. TUNA was initial-
appear to achieve some benefit in men with glands larger than ly thought to reduce prostatic volume after its release.
80 g [83]. For median lobe morphology, a single non- However, volume reduction is likely modest given scar for-
randomized case series reports on a modification to the PUL mation as a result of TUNA and no known mechanism of
procedure for patients with median lobes. The modification action of TUNA. There has been little new information re-
requires pulling the intravesically protruding prostatic tissue garding efficacy and safety of TUNA since 2003, and limited
into the prostatic fossa and affixing the tissue to either side of low-quality data has shown that TUNA is not as efficacious in
the urethra [84]. Using this modification, the authors demon- achieving symptomatic improvement of LUTS as compared
strated an improvement in I-PSS, quality of life, and flow rate. to TURP [90]. The Guideline reports that rigorous literature
This study was excluded from The Guideline due to its non- reviews yield both a lack of high-quality studies and inconsis-
randomized nature. tent findings. This should effectively end the utilization of
In addition to the size and morphology restrictions, PUL TUNA in the surgical management of BPH.
was associated with a high retreatment rate. A 13.6% of pa-
tients in the LIFT trial required repeat PUL or TURP. Several Developing Technology
others required removal of encrusted clips or were restarted on
medical therapy. Similarly, in the BPH6 trial, 13.6% of pa- Aquablation
tients required additional procedures at 2-year follow-up. This
was compared to 5.7% in the TURP arm [78•]. Prospective Aquablation is a procedure requiring general anesthesia;
patients should be made aware of this retreatment rate as a therefore, it is not considered a MIST. During the procedure,
possible limitation to PUL. a transrectal ultrasound maps the prostate, a robotic handpiece
is placed transurethral, and the mapped area of the prostate is
Transurethral Microwave Therapy resected with a high velocity water jet. After water jet resec-
tion, electrocautery is often required to achieve hemostasis.
TUMT was introduced in 1994 as an alternative to TURP. There has been a single RCT comparing aquablation to
Since that time, TUMT has been evaluated in multiple trials TURP. This involved 181 (65, TURP; 116, aquablation)
 32 Page 6 of 10 Curr Urol Rep (2020) 21:32

patients in a double-blinded study, in which the patient and demonstrate significant conclusions. A recently performed
analysis team were blinded to the intervention, but the surgeon meta-analysis reviewed data from 5 trials comparing TURP
was not. Inclusion criteria were similar to WVTT and PUL to PAE. This included two additional prospective, non-
trials with prostatic size from 30 to 80 g. Overall, there was no randomized trials propensity-matched trials [103, 104] along
difference in operative time, I-PSS improvement, quality of with the three RCTs discussed in The Guideline. In meta-
life, maximum flow rate, and need for reoperation at analyses, TURP was favored for I-PSS reduction, maximum
12 months [91, 92]. A subgroup analysis of patients with flow rate, post void residual, and prostate volume. There was
urodynamics pre- and post-aquablation or TURP showed a no difference in I-PSS-QoL and PSA reduction. PAE was
similar decrease in bladder outlet obstruction parameters favored for IIEF-5 [105].
[93]. In terms of safety, aquablation was associated with fewer Minimal information is available in regard to sexual function
persistent Clavien 1 complications (2% vs. 26%), while rate of following PAE. Of the trials analyzed, one trial with short-term
Clavien 2 or higher trended towards aquablation superiority follow-up demonstrated lower ejaculatory dysfunction in PAE
(19% vs. 29%) [91]. compared to TURP [101]. In longer term analysis of this same
The RCT for aquablation had an exclusion criteria for glands trial, authors reported diminished ejaculate in 40% of PAE par-
> 80 cc. Several case series have been published regarding the ticipants at 3 months with higher MSHQ-EjD scores at mean 31-
efficacy of aquablation in larger glands which have demonstrated month follow-up [106]. In a prospective analysis of patients un-
mixed results in terms of safety [94–96]. Larger gland procedures dergoing PAE, antegrade ejaculation was preserved in 88% of
have had longer hospital stays (1.6–3.1 days), reinforcing the patients at 12 months [107]. Though due to limitations of the
notion that aquablation is not an outpatient procedure, and thus, available literature, ejaculatory preservation for PAE remains
not a MIST [95, 96]. As of yet, there are not clinical trials com- theoretical given preservation of the bladder neck.
paring aquablation to other BPH procedures for larger glands. A significant concern for these procedures includes proce-
Changes in sexual function following aquablation remains dure duration and length of radiation exposure. In one trial,
unclear. In the single RCT, there was an overall decrease in mean operative time was 122.2 min compared to 69.5 min for
MSHQ-EjD and IIEF-5 scores in 33% of aquablation patients, TURP. Mean time of fluoroscopy was 50.8 min [101]. These
which was better than 56% percent of TURP patients at the 6- procedure lengths are significantly longer than other MISTs
month time period only. Prior and following that time frame, [108]. Overall, more robust and well-designed clinical trials
there was no difference in sexual function when compared to need to be performed before conclusions regarding PAE can
TURP. Subgroup analysis of sexually active men showed sta- be drawn, preferably comparing PAE to sham procedures.
bility of erectile and ejaculatory function [91]. Moreover, ejac-
ulatory dysfunction may be less pronounced in men undergo- Future Directions
ing aquablation with larger prostates [97]. However, a recent
Cochrane review expressed concern about the certainty of The Guideline offers several areas of interest in terms of future
these results due to possible bias within the study [98]. Case research and knowledge gaps. These areas include interest in
series have shown variable rates of retrograde ejaculation from etiology, genetic environmental factors driving BPH growth,
19 to 27% [95, 99]. management of nocturia, advancements in imaging, develop-
Overall, trials have shown that aquablation is equivalent and ment of newer MIST technologies, and modeling of treatment
non-inferior to TURP with regard to safety and efficacy. comparisons specifically tailored to cost savings. An additional
Ejaculatory rates for aquablation appear improved. Additional area of importance is to focus more closely on retreatment and
trials will need to be performed with a more robust comparison initiation of BPH medications following surgical therapy as treat-
of sexual function parameters to draw stronger conclusions. ment failures. This will allow for better comparison across devel-
oping technologies and permit better comparisons between
Prostatic Artery Embolization RCTs. Lastly, there remains an unmet need in the realm of acute
urinary retention outcomes following intervention and outcomes
PAE is considered a MIST as patients do not require general based on prostate morphology (median lobe) for which minimal
anesthesia. These procedures are often performed by interven- to no data was available to The Guideline panel. These areas
tional radiologists under mild sedation. It is the conclusion of require more vigorous funding and research to further expand
The Guideline that PAE remains investigational and should our knowledge of BPH pathology and management.
not be used in the routine management of BPH. These recom-
mendations are based on several low-quality RCTs comparing
PAE to TURP [100–102]. Among all trials, there was signif- Conclusions
icant variability in the patient populations reflective of poor
randomization with heterogeneity in results across trials. The Since the previous version of American Urological
trials reviewed in The Guideline were not strong enough to Association Guidelines on the management of BPH, there
Curr Urol Rep (2020) 21:32 Page 7 of 10 32

have been significant surgical and technological advance- 8. Taub DA, Wei JT. The economics of benign prostatic hyperplasia
and lower urinary tract symptoms in the United States. Curr Urol
ments. TURP remains the Gold Standard for BPH therapy;
Rep. 2006;7:272–81.
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renewed focus on MISTs, patients now have multiple options et al. Surgical management of lower urinary tract symptoms at-
when considering efficacy, safety, and sexual outcomes. As tributed to benign prostatic hyperplasia: AUA Guideline
Amendment 2019. J Urol. 2019;202:592–8 AUA Guideline
these therapies evolve, a larger transition from hospital-based
statements for which this manuscript serves as a review.
procedures to outpatient and office-based procedures will like- 10. Cornu J-N, Ahyai S, Bachmann A, de la Rosette J, Gilling P,
ly be seen. As the future unfolds, the urologist should not only Gratzke C, et al. A systematic review and meta-analysis of func-
consider efficacy but also focus on retreatment as a valid qual- tional outcomes and complications following transurethral proce-
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gies develop, these refined metrics should be evaluated in urethral resection versus monopolar transurethral resection for be-
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quality-of-life standards for our patients.
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Compliance with Ethical Standards clinical effectiveness of bipolar compared with monopolar trans-
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Conflict of Interest J Branch reports a former consultanting relationship 35.
with Boston Scientific as a training proctor for GreenLight Technologies. 13. Burke N, Whelan JP, Goeree L, Hopkins RB, Campbell K, Goeree
K McVary discloses professional relationships with Olympus, Boston R, et al. Systematic review and meta-analysis of transurethral re-
Scientific, SRS Medical, Merck, and MedeonBio, and has participated section of the prostate versus minimally invasive procedures for
as a study site in clinical trials with Astellas, NIDDK, NxThera, and SRS. the treatment of benign prostatic obstruction. Urology. 2010;75:
He is the Co-chair of the American Urological Association Guidelines for 1015–22.
which this article serves as a review. R Dornbier reports no conflicts of 14. Mamoulakis C, Ubbink DT, de la Rosette JJMCH. Bipolar versus
interest. G Pahouja reports no conflicts of interest. monopolar transurethral resection of the prostate: a systematic
review and meta-analysis of randomized controlled trials. Eur
Urol. 2009;56:798–809.
Human and Animal Rights and Informed Consent This article does not
15. Alexander CE, Scullion MM, Omar MI, Yuan Y, Mamoulakis C,
contain any studies with human or animal subjects performed by any of
N’Dow JM, et al. Bipolar versus monopolar transurethral resec-
the authors.
tion of the prostate for lower urinary tract symptoms secondary to
benign prostatic obstruction. Cochrane Database Syst Rev.
2019;12:CD009629.
16. El-Assmy A, ElShal AM, Mekkawy R, El-Kappany H, Ibrahiem
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