Clinical Scorecard: Addressing Clinical Failure Following Minimally Invasive Surgical Interventions for BPH: A Comparison of Repeat MIST and Traditional Resection, Enucleation, or Ablation—A Narrative Overview from EAU Endourology

At a Glance

Key Highlights

• MIST techniques (PUL, iTIND, PAE, Aquablation, Rezum) offer reduced invasiveness and preservation of sexual function compared to traditional surgeries.
• Traditional surgeries like TURP and endoscopic enucleation of the prostate (EEP) provide superior long-term urinary flow improvement and durability but with higher risk of complications such as retrograde ejaculation.
• Retreatment strategies after MIST failure are not well defined; TURP is frequently used as a retreatment due to its proven efficacy.

Guideline-Based Recommendations

Diagnosis

• Assess LUTS severity and impact on quality of life using validated tools such as the International Prostate Symptom Score (IPSS).
• Evaluate patient suitability for MIST or conventional surgery considering prostate size, symptom severity, and patient comorbidities.

Management

• Consider MIST for patients prioritizing preservation of sexual function and reduced surgical risk, especially frail or sexually active men.
• Use TURP or EEP as first-line surgical options for durable symptom relief and in cases of MIST failure.
• Retreatment after MIST failure may involve repeat MIST or conversion to conventional surgery, with TURP commonly employed.

Monitoring & Follow-up

• Monitor symptom improvement and quality of life post-procedure using IPSS and patient-reported outcomes.
• Follow-up for potential complications including urinary incontinence and ejaculatory dysfunction.
• Long-term monitoring is essential as some MIST techniques may show slight worsening of symptoms after 5 years.

Risks

• MIST may have inferior long-term efficacy compared to TURP or EEP.
• Conventional surgeries carry risks of retrograde ejaculation and other complications impacting quality of life.
• Spinal anesthesia risks in frail patients should be considered when selecting surgical modality.

Patient & Prescribing Data

Men with BPH undergoing surgical treatment for LUTS

MIST offers a safer profile with preservation of sexual function but may require retreatment; TURP and EEP provide more durable symptom relief but with higher complication rates.

Clinical Best Practices

• Balance efficacy and safety when selecting surgical intervention for BPH, considering patient preferences and comorbidities.
• Inform patients about the potential need for retreatment after MIST and the comparative risks and benefits of each surgical option.
• Use TURP as a reliable retreatment option following MIST failure due to its established efficacy.
• Consider the limited long-term data available for newer MIST techniques when counseling patients.

References

• Manfredi et al. 10-year follow-up on ThuLEP
• Initial PUL observational study 2011
• Rezum FDA approval 2015
• EAU Guidelines on BPH management