Is water vapor therapy a treatment option for Benign Prostatic Hyperplasia (BPH)?

Water Vapor Thermal Therapy for BPH

Water vapor thermal therapy (Rezūm) is an effective treatment option for BPH that may be offered to appropriately selected patients, particularly those who prioritize preservation of sexual function. 1

Patient Selection Criteria

Water vapor thermal therapy should only be offered to patients with prostate volume <80g. 1 This is a critical eligibility requirement established by the AUA guidelines.

• Recent evidence suggests the therapy may also be safe and effective for larger prostates (80-150 cm³), though this extends beyond current guideline recommendations 2
• The procedure can treat all zones of the prostate, including median lobes, which is an advantage over some other minimally invasive options 3

Efficacy and Outcomes

Patients must be counseled that evidence of long-term efficacy and retreatment rates remains limited. 1 This is a key caveat in the AUA's conditional recommendation.

Symptom Improvement

• Response to treatment at 3 months is significantly superior to sham (74% vs 31%) 1
• Mean IPSS improvement of 6.9 points compared to sham at 3 months 1
• Two-year data shows sustained improvements in IPSS, quality of life scores, and maximum flow rates 1
• Real-world office experience demonstrates IPSS improvement from 18.3 to 6.9 and Qmax improvement from 10.5 to 16.8 mL/s at 91-180 days 4
• Recent systematic evidence shows typical IPSS reductions ≥50% with peak flow increases of 4-5 mL/s, with five-year retreatment rates of only 4-5% 5

Sexual Function Preservation

Water vapor thermal therapy should be specifically offered to patients who desire preservation of erectile and ejaculatory function. 1 This is a major advantage over traditional surgical options.

• No de novo erectile dysfunction reported in long-term follow-up 1
• No significant changes in erectile function scores or ejaculatory function scores compared to baseline 1
• This preservation of sexual function distinguishes water vapor therapy from TURP and many other surgical interventions 5

Safety Profile

Patients should expect a higher incidence of non-serious transient adverse events compared to sham treatment. 1

• Most common adverse events include urinary tract infections (17%) and transient urinary retention (14%) 4
• Dysuria (13%), gross hematuria (10.5%), and UTIs (2.6%) are reported but typically mild and self-limited 6
• Serious device-related safety events are rare 2
• The procedure can be performed under local anesthesia or conscious sedation in an office or ambulatory setting 4, 3, 6

Clinical Context and Positioning

The AUA provides a conditional recommendation (Grade C evidence) for water vapor thermal therapy, reflecting limited long-term data. 1 This places it as a reasonable option but not a first-line surgical choice.

• The therapy bridges the gap between long-term medication use and more invasive surgery 5
• Approximately 90% of patients can discontinue BPH medications after treatment 4
• The procedure is particularly valuable for patients with multiple comorbidities who may not tolerate more invasive surgery 6
• It can even be considered for catheter-dependent patients in complete urinary retention, with 70% achieving catheter-free status 6

Key Caveats

• The 2020 AUA guideline amendment removed language about poorly defined retreatment rates, suggesting growing confidence in the procedure 1
• Results appear independent of prostate size (within the <80g limit) and presence of median lobe 4
• Patient satisfaction is high, with 86% willing to recommend the procedure to others 4
• The procedure requires specialized equipment and training, which may limit availability 1