What is the Rezum procedure used for in treating benign prostatic hyperplasia (BPH)?

Rezum Procedure for Benign Prostatic Hyperplasia

Rezum is a minimally invasive convective radiofrequency water vapor thermal therapy that delivers steam to ablate obstructive prostatic tissue, providing effective symptom relief for men with moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), with preservation of sexual function and durable outcomes.

Mechanism and Technique

Rezum uses radiofrequency energy to generate water vapor (steam) that is delivered transurethrally into the prostatic tissue 1, 2. The thermal energy causes immediate cell death through coagulation necrosis, with subsequent tissue resorption over weeks to months 1. The procedure is performed under local anesthesia or moderate sedation, avoiding the need for general or spinal anesthesia 2.

Clinical Efficacy

Symptom Improvement

Rezum provides substantial and durable symptom relief comparable to other minimally invasive therapies:

• International Prostate Symptom Score (IPSS) improves by approximately 50%, with reductions maintained through 12 months 3, 2
• Quality of life scores improve by 53% 3
• Peak urinary flow rate (Qmax) increases significantly, with improvements of 7.3 ml/s (from 10.6 to 17.9 ml/s) 3
• Post-void residual volume decreases dramatically by 136 ml 3
• Prostate volume reduces by approximately 40% 3

Catheter-Dependent Patients

All patients requiring catheterization pre-procedure achieved catheter independence by 6 weeks post-treatment 3. This represents a critical quality-of-life outcome for men in urinary retention.

Patient Selection and Prostate Size Considerations

Standard Indications

Rezum is most established for prostates under 80 cc, though emerging evidence supports broader application 4, 1:

• Men with moderate-to-severe LUTS (IPSS >8) who have failed or declined medical therapy 2
• Prostates ranging from 13-80 cc represent the traditional target population 2
• Can treat various anatomical configurations including median lobe protrusion and intravesical prostatic protrusion 1

Large Prostates (≥80 cc)

Recent evidence challenges traditional size restrictions 4, 5:

• Men with prostates ≥80 cc (mean 106.8 cc) achieved comparable symptomatic relief and functional improvements to those with smaller prostates 4
• One case report documented successful treatment of a 186 cc prostate 5
• However, larger prostates require longer catheterization time (9 vs 5.71 days, p=0.003) and have higher urosepsis rates (5.56% vs 0%, p=0.002) 4
• Alpha-blocker usage decreased significantly post-procedure, though nearly two-thirds still required medication at one year 4

Safety Profile

Adverse Events

Rezum demonstrates excellent safety with preservation of sexual function 3, 1, 2:

• No device- or procedure-related serious adverse events in consecutive series 3
• No de novo erectile or ejaculatory dysfunction reported 2
• Transient irritative urinary symptoms are common but resolve within weeks 2
• Temporary urinary retention requiring catheterization occurs but resolves 2
• Post-operative UTI rates: 10-19% 4
• Emergency department visits: 18-22% 4
• Readmission rates: 5-8% 4

Comparative Safety

Trial void success rates exceed 93% regardless of prostate size 4. Retreatment rates remain low at 5-8% 4.

Clinical Context Within BPH Treatment Algorithm

While the 2003 AUA guidelines do not specifically mention Rezum (as it was developed later), they establish the framework for minimally invasive therapies 6. Rezum fits within the minimally invasive therapy category, positioned between medical management and surgical intervention 6.

The guidelines emphasize that minimally invasive therapies should be less effective than TURP but more effective than medical therapy, with fewer adverse events than surgery 6. Rezum meets these criteria while uniquely preserving sexual function 2.

Practical Advantages

• Office-based procedure capability 2
• Rapid return to normal activities 2
• Preservation of ejaculatory function distinguishes it from TURP 1, 2
• Can be offered as first-line treatment to prevent symptom progression and avoid long-term pharmaceutical side effects 1
• Treats median lobes and complex anatomy that may be challenging for other minimally invasive options 1

Key Clinical Pitfall

The primary caveat for larger prostates (≥80 cc) is the significantly increased risk of urosepsis (5.56% vs 0%) and prolonged catheterization 4. Careful patient counseling and aggressive infection prophylaxis are essential when treating prostates above traditional size thresholds.