What are the newer minimally invasive prostatic ablation procedures for symptomatic benign prostatic hyperplasia and how should they be selected based on prostate volume, obstruction severity, comorbidities, and anticoagulation status?

Newer Minimally Invasive Prostatic Ablation Procedures for BPH

The most recent evidence supports three primary ablative minimally invasive surgical therapies (MIST) for symptomatic BPH: Aquablation, Rezum (convective water vapor therapy), and transperineal prostate laser ablation (TPLA), all of which demonstrate excellent efficacy while preserving sexual function—a critical advantage over traditional TURP. 1, 2

Contemporary Ablative MIST Options

Aquablation

• Surgeon-guided, robot-executed, heat-free waterjet ablation that provides sustained functional outcomes at 5 years with complete preservation of sexual activity 1
• Produces significant improvements in maximum flow rate (Qmax) and International Prostate Symptom Score (IPSS) comparable to TURP 2
• Particularly suitable for patients prioritizing sexual function preservation while requiring efficacy approaching traditional surgery 1

Rezum (Convective Water Vapor Therapy)

• Office-based procedure delivering convective water vapor energy into prostatic adenoma to ablate obstructing tissue 1, 2
• Demonstrates significant improvements in Qmax and IPSS while preserving both erectile and ejaculatory function 1
• Can be performed under local anesthesia as an outpatient procedure, reducing hospitalization, operative time, and catheterization duration 2
• Offers decreased financial burden on the healthcare system compared to traditional surgical approaches 2

Transperineal Prostate Laser Ablation (TPLA)

• Office-based technology using diode laser source for thermoablation via transperineal approach 1
• Produces improvements in Qmax, IPSS, and quality of life while specifically preserving ejaculatory function 1
• Represents an alternative access route avoiding transurethral instrumentation 1

Patient Selection Algorithm

Based on Prostate Volume

For prostates <70-80g:

• Prostatic Urethral Lift (UroLift) should be considered for patients with prostate volume <70ml (European Association of Urology) or <80g (American Urological Association) 3
• Critical exclusion: middle lobe obstruction is an absolute contraindication to UroLift 3
• UroLift provides complete preservation of erectile and ejaculatory function but offers significantly less symptom improvement than TURP (73% vs 91% achieving treatment response at 12 months) 3
• 5-year retreatment rate is 13.6%, with failure rates requiring other interventions ranging from 7-22% at 2 years 3

For prostates of any size:

• Aquablation, Rezum, and TPLA can be offered regardless of prostate volume, though specific size limitations may apply based on individual device capabilities 1, 2

Based on Obstruction Severity

Documented urodynamic obstruction (Qmax <10 ml/sec):

• Pressure-flow studies should be obtained to confirm obstruction before proceeding with MIST 4
• Men with Qmax <10 ml/sec are more likely to have urodynamic obstruction and improve with surgical intervention 4
• Traditional TURP or holmium laser enucleation (HoLEP) remain gold standards for severe obstruction with proven long-term efficacy 5

Moderate obstruction:

• MIST options (Aquablation, Rezum, TPLA) are appropriate first-line interventions 1, 2
• Transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA) are established alternatives, though less commonly used currently 6, 7

Based on Comorbidities

High-risk surgical candidates:

• Prostatic stents should be considered only in high-risk patients with urinary retention due to significant complications including encrustation, infection, and chronic pain 6
• Transurethral ethanol ablation of the prostate (TEAP) can be performed under regional anesthesia for medically high-risk patients, showing 73% sufficient response rates 8
• Office-based procedures (Rezum, TPLA) under local anesthesia are preferred to minimize anesthetic risk 1, 2

Standard surgical risk:

• All MIST options are appropriate, with selection based on patient priorities regarding sexual function preservation and treatment durability 1, 2

Based on Anticoagulation Status

Patients on anticoagulation:

• MIST options are particularly advantageous as they demonstrate less bleeding risk compared to TURP 7
• Rezum and TPLA can be performed with minimal bleeding risk under local anesthesia 1, 2
• Aquablation is heat-free and may offer reduced bleeding compared to thermal ablation techniques 1
• Traditional TURP carries higher transfusion risk (>5% of patients) 6

Critical Patient Counseling Points

Efficacy Trade-offs

• All MIST options provide less symptom improvement than TURP but with significantly reduced sexual side effects 3, 2
• Patients must understand that choosing sexual function preservation may mean accepting somewhat lower efficacy and higher retreatment rates 3, 2

Sexual Function Preservation Priority

• For patients prioritizing ejaculatory and erectile function preservation, ablative MIST (Aquablation, Rezum, TPLA) or UroLift are strongly preferred over TURP 3, 1, 2
• TURP carries significant sexual dysfunction risk, though the 2003 AUA guideline noted overall sexual function decline was identical to watchful waiting in the Veterans Affairs Cooperative Study 6

Durability Concerns

• Long-term efficacy data remain limited for newer ablative MIST compared to TURP's decades of follow-up 3, 7
• UroLift has defined 5-year retreatment rates (13.6%), while data for Aquablation, Rezum, and TPLA continue to emerge 3, 1

Common Pitfalls to Avoid

• Do not offer UroLift to patients with middle lobe obstruction or prostate volume >70-80g—this is a setup for failure 3
• Do not use balloon dilation—it is not recommended as a treatment option due to significant long-term failure rates 6
• Do not offer high-intensity focused ultrasound or absolute ethanol injection outside clinical trials—these remain investigational 6
• Do not assume all MIST are equivalent—transurethral microwave thermotherapy offers the longest-term follow-up data among older MIST options 9
• Do not skip pressure-flow studies in patients with Qmax >10 ml/sec considering surgery—they are less likely to be obstructed and benefit from intervention 6, 4