EURURO Vol. 72 No. 6

Introduction

Lower urinary tract symptoms (LUTS) considerably impair

quality of life inmen. LUTS represent one of themost common

nonmalignant conditions with significant socio-economic

importance to public health systems worldwide. Male LUTS

due to benign prostatic enlargement (LUTS/BPE) is the most

common reason next to urinary tract infections for urologic

consultation in clinical practice

[1] .

Annual expenditures on

the management of LUTS/BPE are reported to be approxi-

mately $6 billion dollars in the USA

[2] .

In a population with

increasing life expectancy, the economic burden is expected

to follow an upward trend in the future

[3] .

The treatment of bothersome LUTS/BPE comprises

conservative approaches, pharmacological options, and

various surgical procedures

[4,5]

. Medical therapy has a

therapeutic ceiling in terms of efficacy and in addition to the

associated adverse effects including postural hypotension,

dizziness, asthenia, and compromised sexual function are

the main reasons for discontinuation.

Transurethral resection of the prostate (TURP) has stood

the test of time and is justly considered the surgical

reference method offering durable clinical improvement.

Although refinements of the technique improved the safety

profile of TURP over time, considerable morbidity of 20%

and long-term complications including ejaculatory dys-

function (65%), erectile dysfunction (10%), urethral stric-

tures (7%), urinary tract infection (4%), bleeding requiring

transfusion (2%), urinary incontinence (2%), and a retreat-

ment rate of 6% have still to be acknowledged

[4,5]

. The use

of laser enucleation of the prostate has emerged as a very

effective and potentially more efficacious approach com-

parable in terms of efficacy to open simple prostatectomy.

Laser ablation techniques have also been widely explored in

recent years

[6–9]

The development of novel minimally invasive proce-

dures strives for innovative approaches equally effective to

standard techniques with a more favourable safety profile.

A true minimally invasive treatment should be cost-

effective and easy to perform. It should ensure rapid and

durable relief of symptoms and ideally be performed in an

ambulatory setting under local anaesthesia. A short

recovery time and smooth return to normal activity are

important determinants for quality of life after surgery

[10,11]

. Sexual function including erectile and ejaculatory

function is compromised after treatment with current

standard techniques, but should be completely preserved

by a successful minimally invasive approach unless tissue is

ablated. In the past, a plethora of concepts have been

abandoned owing to insufficient clinical outcomes or lack of

reproducibility.

Novel innovative concepts have been introduced into the

interventional spectrum for the management of LUTS and

early clinical results seem to be promising. The develop-

ment of intraprostatic injectables, medical devices, and

innovative techniques of tissue ablation have attracted

renewed interest in the field. The objective of the current

review is to present the early clinical experiences with

novel emerging minimally invasive treatment options for

male LUTS due to BPE.

Evidence acquisition

Medline, PubMed, the Cochrane database, and Embase were

screened for randomised controlled trials (RCTs), clinical

trials, and reviews on novel minimally invasive treatment

options for male LUTS due to BPE. The authors discussed

emerging techniques that were considered novel concepts.

Approaches like intraprostatic ethanol injections or pros-

tatic stents have been investigated in the past with

modifications over time and therefore these were excluded

in this review. As clinical data on new treatment options are

scarce the authors decided to provide a narrative review by

presenting briefly the basic principles of each technique and

the early available clinical data. The objective of this

collaborative review is to inform the reader on new

advances in the field in an informative and objective way

based on published data, without making formal recom-

mendations. We focus on intraprostatic injectables includ-

ing botulinum neurotoxin A (BoNT/A), NX1207, and

PRX302, mechanical devices like the prostatic urethral lift

(PUL) and the temporary implantable nitinol device (TIND),

new techniques for prostate ablation such as the image

guided robotic waterjet ablation (AquaBeam) and proce-

dures based on convective water vapour energy (Rezu- m),

and finally the prostatic artery embolization (PAE).

Conclusions:

Initial promising clinical results on novel minimally invasive treatment

options indicate efficacy comparable to standard techniques, often associated with a more

favourable safety profile, in particular with preservation of sexual function. Many of these

techniques are in their infancy and based on experience of new developments in the past.

Further RCTs are required to evaluate efficacy, safety, and durability of novel techniques

with long-term follow-up and careful evaluation of the selection criteria, which have been

applied in clinical trials. The prostatic urethral lift is the only procedure with Level

1 evidence data and that can therefore be recommended for treatment of male LUTS in

clinical practice for selected patients.

Patient summary:

Minimally invasive treatment options have been developed to provide

relief of lower urinary tract symptoms comparable to standard surgical techniques with a

more favourable safety profile. However, long-term clinical evaluation is still needed for

most of these innovations before they can be recommended to be an effective replacement

for standard surgical treatment.

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 9 8 6 – 9 9 7

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