AUA 2025: Benign Prostatic Hyperplasia Management: A Surgical Approach

26 Apr - 29 Apr, 25

AUA 2025

Las Vegas, NV

26 Apr - 29 Apr, 25

AUA 2025

Las Vegas, NV

12-Month Outcomes: Prostatic Urethral Stent for BPH

Speaker- Dr. Steven Kaplan

Background and Study Objective:

Dr. Steven Kaplan presented results from a pivotal Phase III trial evaluating the ProVee System, a novel prosthetic urethral stent designed to treat benign prostatic hyperplasia (BPH). The study aimed to assess the safety and efficacy of this spring expander stent over 12 months in comparison to a sham control.

Device Overview:

ProVee Stent: Nitinol-based, low-metal-density stent with no crossing points.

Designed for transurethral delivery, compatible with local anesthesia.

Intended for outpatient or office-based placement.

Study Design

Randomized, sham-controlled multicenter trial.

Included men with prostate volumes 30–80 cc and ≥3.75 cm prostatic urethral length.

Endpoints:

Primary Safety: Serious adverse events (SAEs), need for catheter >7 days post-procedure.

Primary Effectiveness: Reduction in IPSS symptoms score ≥25% over sham and ≥30% from baseline.

All patients unblinded at 3 months; sham group allowed crossover.

Intent-to-treat analysis with 90% 12-month follow-up.

Key Results:

Safety Outcomes

Zero serious adverse events in both arms.

Zero patients required catheterization >7 days post-procedure.

No significant pain or deterioration in sexual function.

No encrustation observed on 12-month cystoscopy.

Effectiveness Outcomes

IPSS improvement:

Treatment: –9.5 points,

Sham: –5.6 points (statistically significant)

Qmax (Flow Rate):

Increased by 5.4 mL/s — superior to many existing minimally invasive devices.

Post-void residuals improved significantly.

Durable symptom relief sustained through 12 months.

Quality of life improved more in treatment vs sham.

Device Tolerability

No reinterventions required for device malfunction.

5 patients opted for device removal (subjective symptom persistence despite objective improvement).

Minimal adverse events: Mild dysuria reported.

Conclusion:

All primary endpoints met (safety and effectiveness).

Demonstrated significant symptom relief, objective improvement in flow, and favorable safety profile.

Minimal pain, no impact on sexual function, no encrustation.

Suitable for local anesthesia, outpatient or office settings.

Promising practice-changing technology pending FDA approval.

Preservation of Ejaculatory Function with BPH Treatments

Speaker- Dr. Kevin Zorn

Clinical and Historical Context:

Ejaculatory function has historically been underappreciated in BPH surgery.

Early BPH surgeries (e.g., open prostatectomy, TURP) had high morbidity and routinely sacrificed ejaculatory function.

MIST (Minimally Invasive Surgical Therapies) now enable the preservation of ejaculatory function with comparable symptom relief.

Physiological Insights:

Ejaculation has two phases:

Emission: Semen moves to the prostatic urethra (sympathetic control).

Expulsion: Rhythmic pelvic floor contractions (sacral reflex).

Contrary to traditional beliefs, bladder neck disruption is not the sole cause of ejaculatory dysfunction.

Damage to ejaculatory ducts and apical structures plays a key role.

Patient Priorities and Outcomes:

Studies show ejaculatory preservation is a top concern for men considering BPH surgery, even among those over 70. Ejaculatory function directly influences orgasmic satisfaction and quality of life. Over 85% of patients prefer surgical options that preserve ejaculation.

Procedural Impact on Ejaculation:

Traditional resective techniques (e.g., TURP, HOLEP) have high rates of retrograde ejaculation.

Newer techniques like UroLift and Aquablation show significantly lower rates:

Aquablation with apex-sparing modifications achieves <15% retrograde ejaculation rates.

Adjusting the depth and trajectory of the “butterfly cut” can protect ejaculatory ducts.

Technical Innovations:

Use of retrograde variography with ultrasound (RVU) allows intraoperative mapping of ejaculatory ducts.

Preservation of the longitudinal muscle column (LMC) near the verumontanum may protect ejaculatory function.

Proposed imaging innovations include micro-ultrasound to visualize ductal anatomy pre-procedure.

Future Directions:

Standardized imaging of ejaculatory ducts could improve surgical planning and preservation.

Quantitative semen analysis is encouraged for objective assessment postoperatively.

Even in regions without access to Aquablation, technical modifications during TURP or laser procedures can improve ejaculatory outcomes.

Conclusion:

Ejaculatory function matters—clinically, psychologically, and for patient satisfaction. Modern BPH therapies can preserve function without compromising IPSS outcomes. Personalized, anatomy-informed techniques and preoperative planning are essential to improving sexual outcomes in BPH surgery. The paradigm is shifting: “You can’t protect what you can’t see.”

Surgical Treatment of the 100g Gland: RASP vs HOLEP

Moderator: Dr. Claus Roehrborn,

HOLEP: Dr. Naren Nimmagadda

RASP: Dr. Rene Sotelo

HOLEP Rebuttal: Dr. Marcelino Rivera

RASP Rebuttal: Dr. Jihad Kaouk

Case: 57-year-old male with severe LUTS, 135g prostate, thickened bladder wall, non-suspicious MRI. Later findings: bladder diverticulum and two bladder stones.

HoLEP Advocacy – Dr. Naren Nimmagadda

Dr. Nimmagadda strongly advocated for holmium laser enucleation of the prostate (HoLEP) based on contemporary data: Meta-analysis of 15 studies (2017–2023): HoLEP outperformed robotic simple prostatectomy (RSP) in:

Operative time: 49.5 minutes shorter

Length of stay: 1.5 days shorter

Catheter duration: ~4 days shorter

Transfusion risk: 75% lower

Despite higher rates of Clavien ≥3 complications, functional outcomes (Qmax, IPSS, QoL) and tissue removal were equivalent to RSP.

HoLEP demonstrated:

Excellent durability (1.4% retreatment over ~9 years)

Strong alignment with patient priorities (low pain, low complication risk)

Low postoperative opioid use (7–8% HoLEP vs. 61% RSP)

Advances like Moses pulse modulation further reduce bleeding and operative time.

Same-day discharge and even same-day catheter removal are now feasible in most cases, even for prostates >175cc.

Incontinence risk: Transient incontinence remains a concern but is mitigated by:

Early apical release (reduces pad use by 4–8x)

Perioperative botox (in pilot and RCT data)

Learning curve is improving with training programs and YouTube dissemination.

Cost-effectiveness and global accessibility of HoLEP equipment favor broader adoption.

RSP Advocacy – Dr. Rene Sotelo

Dr. Sotelo emphasized the superiority of robotic simple prostatectomy in extreme cases and complex anatomies:

Indications: Best suited for very large adenomas (>150g), bladder stones, diverticuli, strictures, or coexistent hernias.

Technique evolution:

From multiport and posterior approaches to single-port transvesical access (SP), preserving anatomy and simplifying recovery.

SP enables complete mucosal reconstruction, reducing raw surfaces, bleeding, and catheter time.

Key advantages:

No urethral access required (avoids risk of strictures)

Eliminates need for morcellation (unlike HoLEP)

Simultaneous correction of bladder pathologies (stones, diverticula, hernias)

Incontinence and transfusion risks are lower in SP-RSP (0% in recent series).

Rebuttal – Dr. Marcelino Rivera

Dr. Rivera reaffirmed HoLEP’s versatility and size independence:

Applicable across spectrum – from 40g to 500g prostates.

Data in underactive and acontractile bladders: 80% regain voiding function; durable at 3 years.

Outcomes in extreme size HoLEP:

Efficient tissue removal (>200–300g)

Lower hospitalization and catheter duration than RSP

Anticoagulation: HoLEP safely performed without stopping DOACs, unlike RSP.

Concurrent surgeries:

HoLEP with cystolitholapaxy adds only 20 minutes.

Diverticula often don’t require resection post-obstruction relief.

Meta-analyses confirm HoLEP's advantages in LOS, complications, and cost.

Closing – Dr. Jihad Kaouk:

Dr. Kaouk concluded with a pragmatic perspective:

For extremely large adenomas (700–900g), robotic simple prostatectomy remains superior. HoLEP is best suited for medium-to-large prostates, but limitations arise with:

Complex strictures

Prior implants (e.g., UroLift)

Morcellation difficulties

Inability to reconstruct or cover raw surfaces

SP-RSP avoids urethral trauma, supports spinal anesthesia, and replicates open outcomes with minimally invasive benefits.

Key Takeaways:

HoLEP excels in minimizing invasiveness, LOS, and complications, especially in anticoagulated or frail patients, and is becoming more accessible with training and technology improvements.

Robotic Simple Prostatectomy remains the preferred option for extremely large prostates, complex urinary tract anatomies, and when complete anatomical reconstruction is desired.

The choice is patient- and anatomy-specific, with both techniques remaining guideline-supported for large BPH.

Male Voiding Dysfunction: Beyond the Prostate

Speaker: Dr. Jose Carlos Truzzi

Dr. Jose Carlos Truzzi’s lecture, delivered as part of the Americana di Urologica session, emphasized a paradigm shift in the understanding and management of male lower urinary tract symptoms (LUTS), advocating for a broader perspective that goes beyond prostate-centric approaches.

Key Takeaways:

Limitations of the Prostate-Centric Model:

While benign prostatic hyperplasia (BPH) has historically been considered the primary cause of male voiding dysfunction, data show that prostate size and histological diagnosis do not reliably correlate with symptom severity. Only a fraction of men with histologic BPH experience obstruction or significant LUTS, and symptoms also occur in men with small prostates.

Evolution of Terminology and Concepts:

The term “prosthetism” was widely used in the 1990s but was replaced by “LUTS” to reflect a broader set of conditions affecting the bladder and voiding function. LUTS is now recognized as a symptom complex, not specific to the prostate, and can arise from various non-prostatic causes.

Under-recognized Contributors to LUTS:

Detrusor Over-activity (DO) and Overactive Bladder (OAB): OAB, characterized by urgency, frequency, and nocturia (with or without incontinence), affects ~20% globally and can occur independently of prostate enlargement. DO may persist even after surgical relief of obstruction.

Detrusor Underactivity (DU): Present in up to 60% of LUTS cases, especially among older men, DU may result from neurogenic, myogenic, or iatrogenic factors. It often mimics obstructive symptoms but requires different management.

Nocturnal Polyuria (NP): A frequent but underdiagnosed cause of nocturia, NP is seen in up to 90% of men with bothersome nocturnal symptoms. It is modifiable through behavioral interventions such as fluid restriction.

Disparities in Clinical Practice:

Despite the AUA guideline's emphasis on individualized evaluation (including prostate size, post-void residual, and urodynamics), many patients undergo surgery without adequate diagnostic workup. A significant portion (15–40%) continue to experience symptoms postoperatively, often remaining on medications aimed at prostate volume reduction.

Multifactorial Pathophysiology and Aging:

Bladder dysfunction may stem from long-term obstruction, age-related structural changes (e.g., increased collagen deposition), and comorbidities like diabetes or vascular disease, all of which influence urinary function. These factors underscore the complexity of LUTS etiology beyond the prostate.

Conclusion:

Dr. Truzzi called for a reorientation in clinical evaluation and treatment of male LUTS. Reliance solely on prostate-targeted therapies may overlook other crucial dysfunctions. Comprehensive diagnostic assessment, including voiding diaries and urodynamics, is essential to differentiate among causes like DU, DO, and NP, ensuring more effective and tailored management.

Best Surgical Option for Retreatment After Prior TURP

Moderator: Dr. Steven Kaplan

Panelists: Dr. Smita De, Dr. Richard Lee, Dr. Jessica Mandeville

This AUA plenary session convened a panel of urologic experts to explore optimal management strategies for men experiencing recurrent benign prostatic hyperplasia (BPH) symptoms following a previous transurethral resection of the prostate (TURP). Three approaches were debated: minimally invasive surgical therapies (MIST), repeat TURP, and holmium laser enucleation of the prostate (HoLEP).

Clinical Context:

A representative case was presented: a 61-year-old man with persistent lower urinary tract symptoms (LUTS) five years after an initial TURP. Qmax: 8 mL/sec, PVR: 94 cc. His prostate volume had decreased from 84cc to 60g, but significant symptoms remained, including bothersome ejaculatory changes. He expressed aversion to bleeding, catheters, and incontinence, placing high value on preserving ejaculation.

Approach 1: Minimally Invasive Surgical Therapies (Dr. Smita De)

Rationale: MISTs are fast, low-risk procedures that preserve continence and ejaculation and often require no general anesthesia. They are ideal for older, frail patients or those on anticoagulation.

Options included: Prostatic urethral lift (PUL), water vapor thermal therapy (Rezūm), and prostate artery embolization (PAE).

Evidence: Studies show effective symptom relief with minimal complications. Notably, PAE and Rezūm were successful even in patients with prior TURP and catheter dependence.

Caveats: Limited long-term data in the reoperative setting. Selection criteria (e.g., prostate size, anatomy) are critical.

Approach 2: Repeat TURP (Dr. Richard Lee)

Rationale: Modern bipolar TURP is safer and more effective than earlier versions. Complication rates have dropped, and the technique has evolved with improvements in resection tools, energy sources, and operative precision.

Advantages: High efficacy, same-day discharge feasible, and even catheter-free outpatient TURP is possible for select patients.

Supporting Data: Meta-analyses show safety profiles comparable to newer techniques, with extensive long-term evidence.

Position: TURP remains the gold standard and benchmark for all other modalities.

Approach 3: HoLEP (Dr. Jessica Mandeville)

Rationale: HoLEP offers durable, complete adenoma removal with the lowest long-term retreatment rate among surgical options.

Evidence: Studies show equivalent safety and functional outcomes between primary and secondary HoLEP, with no major increase in complications or operative difficulty after prior TURP.

Advantages: High success for same-day discharge and voiding trials; safe in patients on anticoagulants.

Limitation: Higher risk of retrograde ejaculation, particularly challenging to preserve in the reoperative setting.

Discussion Highlights:

Retention and MIST: Dr. De emphasized that properly selected patients in urinary retention may still benefit from MISTs.

Ejaculatory Dysfunction: Dr. Mandeville acknowledged the difficulty of sparing ejaculation in reoperative HoLEP but noted emerging techniques that may help.

Why New Techniques? Dr. Lee pointed to evolving technology, patient demand for low-morbidity procedures, and the economic landscape as drivers of innovation beyond TURP.

Conclusion:

No singular “best” retreatment exists; instead, therapy must be tailored to patient comorbidities, anatomical factors, personal preferences (e.g., ejaculation preservation), and surgical expertise. A concluding audience vote was split, affirming that MIST, TURP, and HoLEP each have roles depending on the clinical scenario.

American Urological Association 2025, April 26-29, Las Vegas, NV