key: cord-1046799-5g9g3r18
authors: Checcucci, Enrico; Veccia, Alessandro; De Cillis, Sabrina; Piramide, Federico; Volpi, Gabriele; Amparore, Daniele; Pecoraro, Angela; Piana, Alberto; Granato, Stefano; Verri, Paolo; Sica, Michele; Meziere, Juliette; Carbonaro, Beatrice; Piscitello, Stefano; Zamengo, Davide; Cacciamani, Giovanni; Okhunov, Zhamshid; Puliatti, Stefano; Taratkin, Mark; Marenco, Josè; Gomez Rivas, Juan; Veneziano, Domenico; Carbonara, Umberto; Russo, Giorgio Ivan; De Luca, Stefano; Manfredi, Matteo; Fiori, Cristian; Autorino, Riccardo; Porpiglia, Francesco
title: New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes
date: 2021-09-22
journal: Eur Urol Open Sci
DOI: 10.1016/j.euros.2021.08.009
sha: d1fec2efea0a4261281bcc4f65a86edbf8609932
doc_id: 1046799
cord_uid: 5g9g3r18

CONTEXT: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr. OBJECTIVE: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection. EVIDENCE ACQUISITION: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses. EVIDENCE SYNTHESIS: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; −9.81 points, 95% confidence interval [CI] −11.37 to −8.25 at 1 mo; −13.13 points, 95% CI −14.98 to −11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8–4.5 to +4.14 ml/s, 95% CI 0.72–7.56 at 12 mo), and postvoid residual volume (−10.10 ml, 95% CI −27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34–2.42 at the start of follow-up; and 1.04, 95% CI 0.28–1.8 after 1 yr), or the IPSS-Quality of Life questionnaire. CONCLUSIONS: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients’ sexual function with respect to baseline, especially regarding preservation of ejaculation. PATIENT SUMMARY: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function. TAKE HOME MESSAGE: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient’s quality of life.

Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) is the most diagnosed urologic condition among men aged 45-74 yr, with a prevalence ranging from 8% to 80% between the fourth and ninth decades of life [1] . Medical therapy is usually the first treatment choice. However, medication-related side effects and insufficient symptom control resulting in BPH-related adverse events (such as hematuria, recurrent infection, and bladder stones) often lead to pharmacological discontinuation in favor of operative treatment options [2] . Most of these patients are offered surgical treatments, such as the traditional gold-standard transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP) [3] , water ablation [4] , and simple prostatectomy (either open or minimally invasive [5] ). Nevertheless, these techniques carry a non-negligible risk of complications and significantly impact a patient's sexual function.

In this scenario, several new minimally invasive techniques have been introduced with the aim of providing better symptom relief compared to pharmacological therapy while minimizing the impact on sexual function [6] . Translating the concept from gynecology [7] and orthopedics [8] , these new approaches can be broadly defined as ultra-minimally invasive treatments (uMISTs).

Associate Editor: Guillaume Ploussard Keywords: Benign prostatic hyperplasia Lower urinary tract symptoms Ultra-minimally invasive Ejaculation Micturition Abstract Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr. Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezum, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection. Evidence acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses. Evidence synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; À9.81 points, 95% confidence interval [CI] À11.37 to À8.25 at 1 mo; À13.13 points, 95% CI À14.98 to À11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (À10.10 ml, 95% CI À27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire. Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezum, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation. Patient summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Among them, steam injection (Rezum), prostate artery embolization (PAE), intraprostatic injection of fexapotide triflutate (NX-1207) and PRX302, implantation of a prostatic urethral lift (PUL), and the temporary implantable nitinol device (TIND) were introduced in the 2020 European Association of Urology (EAU) guidelines, although their role in the management of BPH remains controversial.

The aim of this review was to summarize and evaluate the perioperative and functional outcomes of these new uMISTs.

Evidence 

The record selection process was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [10] . The study protocol was registered with PROSPERO (registry number CRD42021225014). Two of the authors (E.C. and S.D.C.) independently reviewed the literature according to the inclusion and exclusion criteria. Disagreements about eligibility were resolved in conjunction with a third reviewer (C.F.) until consensus was reached. We included only prospective studies referring to one of the five uMISTs mentioned in the EAU guidelines [6] and reporting outcomes of interest. Articles not in English, not original investigations (such as editorials, commentaries, abstracts, reviews, and book chapters), studies reporting experimental studies on animals or cadavers, and non-BPH-related surgeries were excluded. As the EAU guidelines do not recommend the use of botulinum toxin A for this indication, this treatment option was not considered and related articles were not eligible. The titles and abstracts were reviewed in accordance with the inclusion criteria. After screening, full-text analysis was performed to confirm whether the selected articles should be included. References from the pooled articles were manually reviewed to identify additional studies of interest. In the case of multiple studies from the same institution and with overlapping study periods, we only included the latest published study. However, studies from the same institution considering different study populations were included in the analysis.

Risk-of-bias assessment

The risk of bias and the quality of the studies were independently assessed using the standard Cochrane Collaboration risk-of-bias tool for single-arm studies [11] , the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for comparative studies [12] , and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for randomized controlled trials (RCTs) [13] .

For nonrandomized controlled trials, study quality was assessed using the Newcastle-Ottawa scale (total score: 5 = low quality; 6-7 = intermediate quality; 8-9 = high quality) [14] . RCTs were evaluated using the Jadad scale (0 = very poor quality, 5 = rigorous quality) [15] . The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine [16] .

A dedicated data extraction form was used to collect the data of interest. For continuous variables reported as the median (range), results were converted to the mean AE standard deviation (SD) using a dedicated formula [18] . Data reported as the median and interquartile range (IQR) were excluded because no information regarding the parametric distribution was available. After obtaining the mean AE SD, data were further converted to the mean with 95% confidence interval (CI). The grand mean was used to calculate the overall mean for data for the same variable but split into two groups. For continuous variables, a pooled analysis of the mean (95% CI) was performed using the metan command, whereas for dichotomous values a cumulative analysis of percentages was conducted using the metaprop command. A randomeffects model using the DerSimonian and Laird method was used to evaluate the I 2 value for heterogeneity. A heterogeneity level above 75% was considered to be high.

Funnel plot analysis was conducted for bias assessment using the metafunnel command.

Stata version 15.0 software (StataCorp LLC, College Station, TX, USA) was used for all statistical analyses.

The initial electronic search identified a total of 3978 papers. Of these, 1575 were identified for detailed review, and ultimately 48 studies met the inclusion criteria and were included in the analysis [25, 36, 45, 48, 49, 52, 55, 56, [62] [63] [64] [65] , and one was a comparative study [32] .

Four studies described Rezum [53] [54] [55] [56] , 32 PAE (including one perfected PAE [PPAE]) , two intraprostatic injections [51, 52] , seven PUL [60] [61] [62] [63] [64] [65] [66] , and three TIND [57] [58] [59] . Only seven studies reported a comparison with TURP, of which five were on PAE [25, 32, 36, 45, 49] and two were on PUL [64, 65] .

A total of 2689 patients were evaluated.

The quality of non-RCT studies evaluated with the Newcastle-Ottawa scale ranged from poor to good [19] [20] [21] [22] [23] [24] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [37] [38] [39] [40] [41] [42] [43] [44] 46, 47, 50, 51, 53, 54, [57] [58] [59] [60] [61] 66] . All the RCTs were found to be of acceptable quality (!3 points) [25, 36, 45, 48, 49, 52, 55, 56, [62] [63] [64] [65] ]. The quality assessment and level of evidence are summarized in Table 1 . 

At the start of follow-up, there was a decrease in the pooled IPSS median score with respect to baseline (À9.81 points, 95% CI À11.37 to À8.25) and a further decline by 12 mo (À13.13 points, 95% CI À14.98 to À11.64; Fig. 3A ). Pooled analysis showed that PAE led to the lowest 1-mo (À6.53 points, 95% CI À7.62 to À5.54) and the highest 12-mo postintervention changes in IPSS (À18.21 points, 95% CI À21.25 to À15.17; Fig. 3A ). IPSS data for every time point for all the uMISTs are reported in Supplementary Figure 3 .

For Qmax, an overall pooled improvement of 3.66 ml/s (95% CI 2.8-4.5) was recorded at 1 mo of follow-up and remained relatively stable during the study period (4.14 ml/ s, 95% CI 0.72-7.56 at 12 mo). The highest postintervention change in Qmax was observed for UroLift at 1 mo (7.80 ml/s, 95% CI 5.78-9.82) and for TIND at 12 mo (7.30 ml/s, 95% CI 6.10-8.50; Fig. 3B and Supplementary Fig. 3) .

A significant improvement in PVR was observed at 1 mo (À28.72 ml, 95% CI À52.23 to À5.21) and 6 mo (À23.45 ml, 95% CI À33.48 to À13.45), followed by a slight decrease up to 12 mo (À10.10 ml, 95% CI À27.90 to 7.71; Fig. 3C and Supplementary Fig. 3 ). The highest postintervention change was found at 12 mo for the TIND technique (À39.51 ml, 95% CI À47.86 to À31.16; Fig. 3C ).

Data for IIEF-5 were available for PAE and PPAE only. The 12mo IIEF-5 score was higher for the PPAE group than for the PAE group (18.70 vs 15.71; Supplementary Fig. 3 ). No analysis of postintervention changes in IIEF-5 was possible. No significant difference in postintervention changes in MSHQ-EjD bother among the treatments was found at 1, 3, 6, and 12 mo ( Fig. 4A and Supplementary Fig. 3 ).

MSHQ-EjD function was not affected by the treatments either at the beginning of follow-up (change in overall pooled median score of 1.88 points, 95% CI 1.34-2.42) or after 1 yr (1.04 points, 95% CI 0.28-1.8). At 12 mo the change in MSHQ-EjD function was lower in the Rezum group (À0.30 points, 95% CI À1.08 to 0.48; Fig. 4B ). Data regarding SHIM scores were only available for UroLift studies (Supplementary Fig. 3 ).

QoL outcomes At 1 mo the pooled change in IPSS-QoL was lowest in the TIND group (À2.74 points, 95% CI À3.17 to À2.32), whereas there was no difference at 3, 6, and 12 mo (Fig. 3D) . Overall, the change in QoL at 12 mo was less than À2.5 points (95% CI À2.85 to À2.16).

Assessment of complications demonstrated an overall rate of 29%, with no difference among the techniques included ( Supplementary Fig. 3 ).

All five uMIST procedures (PAE, UroLift, TIND, Rezum, and intraprostatic injection) can be performed in the office using intravenous sedation and local anesthesia [67] . Oral sedation has also been described for PUL and Rezum. Perioperative management is in line with what is expected for a treatment defined as ultra-minimally invasive. Mean Table 2 ) [67] . Hospital stays range from 0 to 2 d (Supplementary Table 2 ), with only one study that reported 6 d for PAE [28] . Rates of postprocedural catheterization for PUL and Rezum differ, depending on the protocol, with 32-68% of PUL and 55-100% of Rezum patients still having a catheter in place at discharge [67] . Patients undergoing TIND do not require postoperative catheterization, and thus experience better postprocedural comfort. Our analysis showed that the 1-mo IPSS-QoL (2.08 points, 95% CI 1.87-2.29)] and IPSS-QoL change from baseline (À2.74 points, 95% CI À3.17 to À2.32) were lowest in the TIND group (Fig. 3D) .

Compared to other MIST (not uMIST) procedures, TURP [68] and Aquabeam [4] require a significantly longer operative time and a hospital stay for an average of 2.1 d, and a postoperative catheter is always needed.

The number of men requiring surgical intervention vastly exceeds our operative resources, which were further reduced due to pandemic restrictions [69] , so uMISTs might represent an attractive and convenient alternative for both patients and physicians.

Focusing on micturition and functional outcomes, TIND devices guarantee a good decrease in IPSS compared to baseline from the first month postoperatively (À11.05 points, 95% CI À12.25 to À9.86), with relatively stable results at 12 mo (À13.63 points, 95% CI À15.09 to À12.16). Similar findings were recorded for PUL and Rezum. On the contrary, PAE led to a slight improvement in IPSS at the beginning of follow-up (À6.53 points, 95% CI À7.62 to À5.54), with a more significant improvement after 1 yr (À18.21 points, 95% CI À21.25 to À15.17). These differences did not affect the change in Qmax among the different techniques, for which PAE was in line with the other uMISTs. Noteworthy is the UroLift Qmax improvement at 1 mo after intervention (7.80 ml/s, 95% CI 5.78-9.82). PVR was lower in the TIND group at every time point evaluated up to 12 mo of follow-up.

The delayed achievement of a plateau in benefit from PAE can be explained by the different inclusion criteria for patient selection: higher prostate volume might lead to a longer time for the ischemia to induce necrosis in largevolume adenomas. Moreover, the presence of an indwelling catheter could stunt bladder contractility in the first months after the intervention.

Regarding sexual outcomes, a comment should be made with regard to the ideal candidates for these uMISTs. In the past, when first attempts to introduce less invasive treatment options such as transurethral needle ablation and transurethral microwave thermotherapy [70] were made, the target population was often represented by older patients unfit for conventional surgery. Nowadays an everyounger population is interested in uMISTs since patients prefer to avoid daily consumption of oral medications, which can have considerable sexual side effects (such as erectile and ejaculatory dysfunction). However, these patients do not want to undergo a "standard" surgical procedure requiring general anesthesia and longer recovery, and they prefer to avoid the non-negligible risks of complications, including permanent ejaculatory dysfunction.

In our analysis, data on erectile function in terms of IIEF-5 score were only available for PPAE and PAE groups (mean score at 12 mo: 18.70 vs 15.71). A recently published multicenter Italian Rezum study showed a statistically significant increase in IIEF-5 score from baseline at 6 mo (20 vs 23.5 [IQR 21-25.5] ; p = 0.04), with postoperative scores of 4 and 5 for question 9 of the IIEF-15 questionnaire in 81% and 17.1% of cases, respectively, and a score of 5 for question 10 in 98.5% of cases [71] . These results are in line with the data reported for conventional BPH surgical options.

By contrast, ejaculation dysfunction was widely explored. Our analysis revealed no statistically significant difference for the changes in MSHQ-EjD bother at 1, 3, 6, and 12 mo. In terms of MSHQ-EjD function, substantial stability compared to baseline was recorded. Rezum seemed to be the most effective treatment at 12 mo, with the lowest score recorded (À0.30 points, 95% CI À1.08 to 0.48).

No case of EjD was recorded in the PUL, TIND, and PAE groups, except for one trial that reported 13.3% loss of ejaculatory volume after PAE [72] . In the Rezum cohort, EjD ranged from 0% to 4.4%; McVary [55] observed EjD incidence of 2.9% in an RCT, similar to Mollengarden et al [73] (3.1%). More recently, a retrospective review of 62 patients treated in France revealed an even higher anejaculation rate (10.8%) [74] . However, even if Rezum might carry a higher risk of sexual dysfunction compared to PUL and TIND, this risk is relatively low compared with the rate of retrograde ejaculation reported after TURP (65.4%) [75] and HoLEP (70%) [76] .

Cacciamani et al [77] evaluated EjD in a systematic review and pooled analysis of randomized trials and reported that among patients undergoing PUL, MSHQ-EjD bother scores did not reflect significant changes in function score compared to the TURP cohort (À0.1 vs À0.3). The meta-analysis was unable to demonstrate an advantage of PAE over TURP in terms of retrograde ejaculation rates (relative risk 0.73, 95% CI 0.49-1.08; p = 0.11). The physio- logical mechanisms of ejaculation were recently explored in depth and conventional techniques (TURP or HoLEP) were modified with the aim of avoiding EjD [76] .

Acceptable rates of Clavien-Dindo grade III/IV complications have been reported for PAE, PUL, and Rezum. Data for TIND revealed that 9.9% of cases experienced Clavien-Dindo grade III complications in the first month after the procedure, after which no further complications occurred [78] . For PUL, adverse events were mostly limited to the first 3 mo and consisted of mild to moderate dysuria and hematuria [79] . However, serious related adverse events in the first year included an overnight stay for clot retention related to restarting warfarin therapy and a bladder stone formed from bladder gravel that was detected at baseline. Although rare, TIND patients may experience complications during the implantation period that require treatment abortion [57] or immediate retreatment (2.5-6.2% of cases) [78] . Clavien-Dindo grade I/II adverse events included hematuria, dysuria, urgency, pain, and urinary tract infection, while grade III events included eight episodes (9.9%) of acute urinary retention [59] .

Notwithstanding all the above-mentioned benefits of these uMISTs, some obstacles limit their wider adoption, of which equipment limitations represent the first. For example, a specific extra-long bronchoscope lens is necessary for UroLift, and a dedicated computerized radiofrequency steam generator is required for Rezum.

The second limitation of these new technologies is the cost, which amply exceeds s1000 for just the equipment, besides the requirement to perform the procedures in a dedicated operative setting [80] . In fact, as emerged in a cost-effectiveness analysis, the cheaper MITs were $$900 more expensive than the cost of drug therapies over 2 yr. TURP and photovaporization of the prostate provided slightly greater relief of LUTS than MITs at approximately twice the cost over 2 yr [81] .

To date, only TIND perfectly meets the uMIST concept [80] : the entire procedure can be performed under local anesthesia or light sedation (without a dedicated setting) with a standard flexible or rigid cystoscope with no extra costs. The procedure is extremely fast and easy to perform, with promising findings for symptom relief up to 3-yr follow-up [59] .

Our study is not devoid of limitations. First, the studies included are heterogeneous regarding surgical procedures and study design. In fact, some of these new uMISTs (TIND, Rezum) lack a comparison with gold-standard options such as TURP; moreover none of the studies directly compared the uMISTs to each other. Although all the studies report similar outcomes, the timings for evaluation differed and complications were not always classified according to the standard Clavien-Dindo system. The paucity of long-term follow-up data did not allow analysis after the first 12 mo postoperatively, despite the promising data from single-center experiences [33, 39, [55] [56] [57] 59, 65, 78] . Lastly, owing to the lack of comparative data with standard TURP, no direct comparison with network meta-analysis was possible among the different uMISTs.

Available data suggest that uMISTs might offer effective relief from LUTS in patients with BPH. For Rezum, UroLift, and PAE, a minimal impact on patients' sexual function in relation to baseline, especially in terms of preservation of ejaculation, was registered. Longer follow-up and further trials comparing these treatment options with more established techniques are warranted.

Author contributions: Enrico Checcucci had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Checcucci.

Acquisition of data: Piana, Granato, Verri, Sica, Meziere, Piscitello, Carbonaro, Zamengo.

Analysis and interpretation of data: Volpi, Carbonara, Veccia, Piramide, De

Cillis, Pecoraro.

Drafting of the manuscript: Checcucci, Veccia, Autorino.

Critical revision of the manuscript for important intellectual content:

Manfredi, De Luca, Cacciamani, Okhunov, Puliatti, Taratkin, Marenco, Gomez Rivas, Veneziano, Russo.

Statistical analysis: Veccia, Piramide.

Obtaining funding: None.

Administrative, technical, or material support: None.

Supervision: Porpiglia, Fiori, Autorino.

Other: None.

Financial disclosures: Enrico Checcucci certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: None.

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3-Year results following treatment with the second generation of the temporary implantable nitinol device in men with LUTS secondary to benign prostatic obstruction

Safety and feasibility of the prostatic urethral lift: a novel, minimally invasive treatment for

0 2 1 ) 2 8 -4 1 lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH)

Preservation of sexual function with the prostatic urethral lift: a novel treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia

Multicentre prospective crossover study of the 'prostatic urethral lift' for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

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Prostatic urethral lift vs transurethral resection of the prostate: 2-year results of the BPH6 prospective, multicentre, randomized study

Prostatic urethral lift (PUL) for obstructive median lobes: 12 month results of the MedLift Study

New Endoscopic In-office Surgical Therapies for Benign Prostatic Hyperplasia: A Systematic Review

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Durability and retreatment rates of minimal invasive treatments of benign prostatic hyperplasia: a cross-analysis of the literature

Water vapor therapy (Rezum) for lower urinary tract symptoms related to benign prostatic hyperplasia: early results from the first Italian multicentric study

Epub ahead of print

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Treatment of benign prostate hyperplasia using the Rezum1 water vapor therapy system: results at one year

Is transurethral resection of the prostate still justified?

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First-and second-generation temporary implantable nitinol devices as minimally invasive treatments for BPH-related LUTS: systematic review of the literature

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Is it time to offer true minimally invasive treatments (TMIST) for BPH? A review of officebased therapies and introduction of a new technology category

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We would like to thanks Dr. Nicoletta Colombi for her assistance in this study.

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j. euros.2021.08.009.