How to assess minimally invasive therapies for BPH

Minimally invasive surgical therapies for BPH have seen a resurgence in recent years, but whether a single treatment modality meets all of the criteria for an “ideal” procedure remains a question. Kevin McVary, MD, of Loyola University Medical Center in Maywood, IL, provides urologists with tips on how to assess the adoptability of these treatments.

How can urologists best assess minimally invasive therapies for the treatment of BPH?

Minimally invasive therapies, or MISTs, are very popular again. There was a period of time of increased popularity, that popularity dropped precipitously, and now there's a resurgence.

Why did they lose popularity and why are they having it now? They lost popularity in the past primarily because of lack of durability. A high percentage of patients asked for retreatment, sometimes in a very short period of time. There were some studies that showed more durability, but nearly uniformly, those reports showed that the impact on symptoms was not substantial. Many of these men ended up going back on medication or on to a more formal surgical approach.

As we turn the clock forward, new technologies have been introduced. So urologists have taken a cautious step back and are saying, "Are these just another prostatic gizmo?" I could give you a list, probably in the mid-20s, of devices that came on board and then left because they didn't work or they didn't work for very long.

Many urologists feel that important criteria, not comprehensive but important criteria, to evaluate are: Number one, is the technology impactful on three or four things that patients care about? is it improving their symptoms? Are the patient-reported outcomes impactful? Second, as urologists, are we improving flow rate--something that we look at as impacting prostatic obstruction? It's a more objective measure of impact. Third is the impact on important aspects like sexual function. Are they impacting erection? Are they impacting ejaculation?

Another important aspect is generalizability. If you do it in a trial, it works at a certain level. And as you transition from clinical research into general practice, does that translate in a parallel fashion? Is it equal? Is it generalizable? Or is it only in a study patient cohort?

In my own view, durability is one question that we need to answer uniformly across the field. Are patients being impacted successfully? Then over time, is there any erosion in that durability? And are we judging durability uniformly? Unfortunately, we do not have an internationally accepted definition of durability, but we're working toward one. Right now it's not there, so in some ways, it's technology defined.

Most urologists would say, not only does the technology need to help symptoms and not at the cost of an impact on sexual function, but can it be done in the office? That's usually a good cost savings for our health system. And can it be done with a minimum amount of Foley catheter drainage or no catheter drainage at all? We have technologies that can be hugely impactful on lower urinary tract symptoms--the standard TURP or laser therapies--but those require nearly uniformly longer term catheter use afterwards. Patients perceive that as a big negative.

If MISTs are going to make a big difference, then part of that acceptance to patients is, minimize the impact on my getting back to life. That catheter time really reflects, how soon can I get back to work? How soon can I resume my hobbies, my physical activity, my golf? How soon can I resume sexual activities? Those are the major hallmarks in terms of acceptability or adoptability of MIST therapies.

Do any of the current therapies meet all of these criteria?

In my own view, the various players don't meet all of them. They all have some aspects where there's work to be done. Maybe the technologies could be done on a slightly modified cohort, or maybe the technologies could be done in a slightly different way to minimize things like catheter time or impact on sexual function. Unfortunately, none of them are actually there yet, although we're certainly better now than we were 10 years ago.