SoBPD: How many ways can you treat BPH or BPD?

Gopal H. Badlani, MD

The Society of Benign Prostatic Disease (SoBPD) is no longer a nascent organization and is growing. Experts in the field met in Orlando, Florida, for its 2025 annual meeting from February 7 to 8. A resident hands-on course was a new addition that brought a lot of young individuals to the meeting. A dizzying array of technologies and acronyms were on display, each trying to corner a niche population of patients.

Benign prostatic hyperplasia (BPH) is an emerging concern in male health with the aging population and changing lifestyle. In 2019, global prevalent cases of BPH in patients aged 60 or older had increased by approximately 119.01% since 1990.¹ This, along with the declining ratio of urologists to the aging patient population, is a concern. Thus there was much discussion at the meeting on the efficacy of treatment and decrease in retreatment rate on the one hand and the personalized selection of a procedure on the other.

Regarding procedures, survey results among urologists show that transurethral resection of the prostate (monopolar or bipolar) still leads, followed by enucleation procedures, predominantly holmium laser enucleation of the prostate (HoLEP), with UroLift and Rezum Water Vapor Therapy competing for the minimally invasive surgical therapies (MISTs).² Evolving experiences with iTIND and Optilume were interesting, especially in the clinical setting. The recent publication of long-term data on Optilume makes it a viable MIST therapy, although the treatment has not made it into the guidelines.³

Joel T. Funk, MD, FACS, gave an interesting presentation on the use of onabotulinumtoxinA (Botox) at the time of outlet procedure with holmium laser ablation of the prostate to reduce the burden of overactive bladder symptoms in the immediate postoperative period without a significant risk of retention.

The use of routine urodynamics preoperatively was not supported by findings from the UPSTREAM study (ISRCTN56164274) in the United Kingdom.⁴ Alexander Glaser, MD, at NorthShore and the University of Chicago Pritzker School of Medicine in Illinois, discussed the use of point-of-care ultrasound and the penile cuff test. Recommendations for work-up before treatment are not standardized; the focus was on imaging for volume and median lobe presence. There was no session on assessment of bladder function prior to procedures. In fact, in a large gland debate, a 100% success rate with HoLEP was mentioned in long-term catheterized patients by Rebecca Gerber, MD, of Atrium Health in Charlotte, North Carolina. The literature does not report such an outcome in patients with chronic retention, and it is unclear whether this applies only to large glands.

Kevin C. Zorn, MD, FRCSC, FACS, of BPH Canada in Montreal, Quebec, Canada, discussed the effective use of media to establish practice and the focused care of patients.

The larger gland debate was dominated by increasing HoLEP experience, although there were presentations on thulium, GreenLight laser therapy, and the 1470-nm diode laser. The robotic single port was presented as an advantage with large median lobe and fossa reconstruction to minimize postoperative morbidity. Aquablation in gland sizes 80 g to 150 g was the sole procedure with ejaculation-preserving experience. The use of additional electrocautery has made this an outpatient experience, noted Sijo J. Parekattil, MD, of Avant Concierge Urology in Winter Garden, Florida in his presentation.

After prior MIST or other treatments, salvage procedures were an advantage for HoLEP, as presented by Nicole L. Miller, MD, FACS, of Vanderbilt University Medical Center in Nashville, Tennessee. The use of UroLift was not a problem, but prior Rezum required modification in surgical techniques based on tissue response.

Two basic science presentations were thought-provoking. William Ricke, PhD, of the Univeristy of Wisconsin in Madison, talked about local hypoxia as a mechanism for response, with mitochondrial dysfunction being the key. The role of oleic acid (olive oil) in the modulation was an intriguing presentation. Aria F. Olumi, MD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, presented findings from his 10-year-plus research on the role of SRD5A2 in response to finasteride, funded by the National Institute of Diabetes and Digestive and Kidney Diseases. He described a trial to study finasteride alone vs finasteride and raloxifene to evaluate the response to SRD5A2 resistance.

Ramy Goueli, MD, MHS, of UT Southwestern Medical Center in Dallas, presented on the role of guidelines and the process of developing them, while Kevin T. McVary, MD, FACS, of Loyola University Medical Center in Maywood, Illinois, presented on the difficulties in changing the statements. The biggest discussion was around the role of prostate artery embolization. Sahil V. Mehta, MD, an interventional radiologist who has encountered more than 1000 patients, chose to enter the lion’s den to defend the subjective response of symptom improvement with a large objective or randomized controlled trial support.

Dean S. Elterman, MD, MSc, FRCSC, gave a presentation on several new devices and stents. Managing patients with prostate cancer on active surveillance and those with outlet symptoms due to BPH, as well as treatment strategies before or after radiation therapy for prostate cancer, resulted in an engaging session with no clear answers. However, the need for an individualized approach is evident.

Sometimes, there is more than a single answer to a question; this certainly applies to patients with benign prostatic disease.

REFERENCES

1. Ye Z, Wang J, Xiao Y, Luo J, Xu L, Chen Z. Global burden of benign prostatic hyperplasia in males aged 60-90 years from 1990 to 2019: results from the global burden of disease study 2019. BMC Urol. 2024;24(1):193. doi:10.1186/s12894-024-01582-w

2. Feiertag JH, Clark JY. National trends in surgical management for benign prostatic hyperplasia from 2013 to 2019 in the United States. Urol Pract. 2024;11(2):303-311. doi:10.1097/UPJ.0000000000000504

3. Kaplan SA, Pichardo M, Rijo E, Espino G, Lay RR, Estrella R. Long-term outcomes after treatment with Optilume BPH: four-year results from the EVEREST study. Can Urol Assoc J. 2024;18(11):E319-E325. doi:10.5489/cuaj.8737

4. Lewis AL, Young GJ, Selman LE, et al. Urodynamics tests for the diagnosis and management of bladder outlet obstruction in men: the UPSTREAM non-inferiority RCT. Health Technol Assess. 2020;24(42):1-122. doi:10.3310/hta24420