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Rezum Prostate Procedure Technique: ‘Less is More’

Author Zachary Schmitz covers Rezum Prostate Procedure Technique: ‘Less is More’ on BackTable Urology

Zachary Schmitz • Aug 22, 2023 • 233 hits

The Rezum procedure uses steam that is injected into the prostate to relieve benign prostate hyperplasia (BPH) symptoms. The Rezum procedure technique can vary by way of needle placement and the number of treatments that an operator administers. Needle placement during a Rezum procedure is affected by various factors: prostate orientation and dimensions, preservation of tissues around the verumontanum and bladder neck, and median lobe size. Urologist Dr. Seth Bechis describes his experience with Rezum treatment techniques, including his ‘Less is More’ philosophy for determining the appropriate number of Rezum treatments. Dr. Jose Silva also weighs in with his needle placement experience when utilizing Rezum.

This article features transcripts for the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Urology Brief

• Median lobe treatment should take into account the encroachment into the bladder to ensure complete treatment. Residual median lobe tissue could lead to therapy failure.

• More proximal treatments might not increase the chances of Rezum retrograde ejaculation, suggesting the preservation of the tissue around the verumontanum may have greater impact than preserving the bladder neck.

• The orientation of the prostate influences the treatment approach: a more vertically oriented prostate may need treatments in a vertical rather than a horizontal orientation. For median lobe treatments, one might need to adjust the angle and number of treatments based on the size of the lobe.

• The "Less is More" approach suggests fewer treatments (two rather than three, or even one if possible) could lead to equivalent outcomes at three to six months post-procedure and potentially fewer short-term irritative symptoms.

Rezum Prostate Procedure Technique: ‘Less is More’

Table of Contents

(1) Rezum Procedure: Needle Placement & Evolution of Practices

(2) Implementing the ‘Less is More’ Philosophy in the Rezum Procedure

Rezum Procedure: Needle Placement & Evolution of Practices

Dr. Bechis and Dr. Silva discusses the technical considerations and outcome variables of the Rezum procedure for prostate enlargement treatment. Dr. Bechis and Dr. Silva delve into the intricacies of needle placement, and discuss how steam escaping during deployment might influence post-operative irritative symptoms. They also focus on their evolving practices, such as modifying treatment for patients with a median lobe that extends into the bladder and how residual median lobe tissue can impact outcomes. The discussion also explores the relationship between treatment positioning and retrograde ejaculation, suggesting that preserving the tissue around the verumontanum might be key to maintaining antegrade ejaculation. The doctors underscore the importance of understanding these technical aspects to ensure the best possible results for patients.

[Dr. Silva]
Do you think in those patients, is it smaller glands that you think that the needle went closer to the capsule, or you think that it doesn't matter?

[Dr. Bechis]
It's a great question. I'm not sure. I used to wonder if that was the case if the needle was going deeper, closer to the capsule, but I almost wonder if it's actually the opposite and if the needle isn't deep enough. Sometimes when you fire the needle in and you see a little bit of bubbles coming out from your hole while you're deploying the steam, I wonder if that bubble is coming out indicates that maybe some of the steam is escaping on the inside edge of the urethra versus-- Sometimes you drop the needle in and it's clean and you might see some color changes beneath the surface.

I have a colleague who is convinced that you want to sink the needle deeper and not see color changes. He thinks that the color changes indicate there's steam at the urothelial lining, which might be more irritative.

[Dr. Silva]
That's what I understand, that if you have some scaping of vapor, it shouldn't cause anything long-term, but definitely the patient should have more retentive symptoms first. To your point, I started doing UroLift before Rezum, so I think I was trying to push the needle more. Just like in the urethra you had you press against the prostate, but the rep told me, “Hey, don't push that much.”

For me, what I do, I push it in a little bit and then try to retarget it just a little bit, so it makes a seal more or less. I haven't seen in the past year, I don't see that much escape. Sometimes it happens, but I see less than what I did when I first started it.

[Dr. Bechis]
That makes sense. I've been measuring prostates now on either on a TRUS or on an MRI or a CT. Usually, the ones we're treating are at least 3.5 centimeters or 4 centimeters in diameter. I was figuring if the needle sticks out in a half centimeter to a centimeter, it'd be unusual if you were to-- You're probably not going to get towards the outer capsule with it. It is impressive seeing how the steam moves through that area and cleans it out if you do a cystoscopy later.

I think the median lobe is one area that I think modified my practice a little bit. Historically, the teaching is to see the bladder neck and come back two fields of view or 1 centimeter distal to the bladder neck. If the median lobe encroaches into the bladder, I'll actually measure 1 centimeter back from where the median lobe starts. I find if you start at the bladder neck, you're missing all of that proximal median lobe tissue.

If I look back in my small number of people who failed Rezum, that seems to be a common theme, is that there's residual median lobe tissue, either that just the steam didn't reach it or maybe there's some weird tissue reaction.

[Dr. Silva]
Looking back, will you have done more treatments there or how will we resolve the problem?

[Dr. Bechis]
I think doing the treatment a little bit more proximal, so either more treatments or slightly more proximal. I think in the ones that didn't work, I was a little bit more distal and the proximal part of the median lobe remained there. Whether it means two more treatments diagonally from the sides and slightly closer in or one twelve o'clock treatment, but more proximal.

[Dr. Silva]
In those cases, if you go more proximal, there's more chances of retrograde ejaculation, or it shouldn't matter?

[Dr. Bechis]
It's a great question. I haven't seen it and I don't know-- I guess it depends on your philosophy of what causes retrograde ejaculation or what causes antegrade ejaculation, whether it's the bladder neck closing or whether it's the parafollicular tissue around the veru. I think there's theories that either one of those is involved in promoting ejaculation, so I don't know-- I think if you stick to the median lobe tissue itself and you're just getting adenoma, the bladder neck is probably preserved underneath there. The detrusor fibers are preserved.

We know in some of these new treatments like the water jet therapy where they're treating the entire bladder neck and doing that butterfly cut where they seem to be able to preserve ejaculation. Maybe it's more important to save that tissue by the veru than it is the bladder neck.

Listen to the Full Podcast

Treating BPH with Rezum with Dr. Seth Bechis on the BackTable Urology Podcast)
Ep 101 Treating BPH with Rezum with Dr. Seth Bechis
00:00 / 01:04

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Implementing the ‘Less is More’ Philosophy in the Rezum Procedure

Dr. Bechis and Dr. Silva consider the specifics of performing Rezum procedure on a 40-gram prostate. The Rezum prostate procedure, typically conducted in an outpatient surgery center, begins with an investigation of the prostate's anatomical structure and measurement of the distance from the bladder neck to the verumontanum. The orientation of the prostate - horizontal or vertical - influences the treatment approach. The emerging "Less is More" paradigm suggests that fewer treatments may yield equivalent outcomes to more intensive treatments at three to six months post-procedure. This approach might also mitigate short-term irritative symptoms. Dr. Bechis underscores the importance of understanding the specifics of each patient's case and the technology to optimize outcomes and minimize discomfort.

[Dr. Silva]
Seth, can you walk us through, let's say, a 40-gram prostate you go in? How do you do the procedure?

[Dr. Bechis]
At my institution, we do them in an outpatient surgery center just because we have a high efficiency there. Then I've never met a patient who didn't appreciate taking a quick nap while the scope was put inside them. It's funny because I see patients who've had other procedures done in the office. You mentioned the option of going to the operating room, and they're all like, "Oh, that sounds amazing." They're like, "I did it once in the office. I had that rigid thing stuck in there. It may not have been painful, but it certainly was still memorable." For us, offering it in the surgery center is a nice plus.

Then we can titrate. The anesthesiologist will adjust. Usually, we do a monitored anesthesia care. They just have oxygen mask on them or they're hand masking. Typically, I use a Uro-Jet for lidocaine jelly either before or at the end of the case. Typically, we use a small amount of propofol if it's a monitored anesthesia care.

Then, basically, I'll insert the scope and once we get inside sort of investigate. Is it a bilobar prostate or is there a median lobe involvement? Then really the first step is measuring that distance from the bladder neck to the verumontanum so you can withdraw the scope. Each field of view on the scope is a half centimeter. If you withdraw and it's four fields of view, then you know it's probably about 2 centimeters, and so potentially you'll give two treatments on each side, potentially.

I say potentially because sometimes the prostate is oriented more horizontally and sometimes it's oriented more vertically like a football. If you have a vertical football orientation, the distance from the bladder neck to the verumontanum may only be 1 centimeter. You can do one treatment in the lateral lobes and then you may actually do a treatment sort of anterior or posterior. You might do two treatments, but more in a vertical orientation than in a horizontal one.

Then, typically, I'll do 1 centimeter between the treatments. I come back from the bladder neck, do a treatment, then I'll rotate to the other side, do a treatment. Then I'll come back again and then double-check where the verumontanum is first and make sure I'm still proximal to that, and then do a treatment. Then if it's a median lobe, I'll either do a single treatment at twelve o'clock, or if it's larger, I'll do two treatments at 45-degree angle from the sides.

We're actually looking at a multi-institutional data set that we've put together with 600 Rezums right now. One thing that we're finding-- and there's been a publication on it called Less is More. We're finding that if you give two or three treatments versus one, it actually looks like by the time you get to three to six months, the end result in terms of IPSS score is the same. The only difference is in the short term you may have less irritative symptoms in the patients who get less treatments.

It’s something that I've started to do is I tend to favor-- If it's all equivocal, if it's looking like two versus three treatments. I'll actually lean towards two treatments and if I can do just one treatment, I've been doing that too, and patients seem to do great. The data's early though, so obviously, and we only have about a year's worth of follow-up, so still remains to be seen if it's durable. I think something to think about, especially if you have a patient who's concerned about irritative symptoms, is just air on the side of less rather than more.

[Dr. Silva]
That's something that thankfully, I started doing Rezums after we knew that less is better. I know or I have seen patients from all urologies that did it when it first started, that they were just doing multiple treatment or too many treatments. Just having the full 13 treatments in a small prostate, and those patients are miserable. They persist with that irritation.

Thankfully, I started doing the less is better, and the reps were really great to say, “Hey, trust the technology. The patient's going to do good.” Like I said, the instant gratification that you get from TURP or GreenLight, or Uro, you don't get it with Rezum, but you need to trust the technology.

Podcast Contributors

Dr. Seth Bechis discusses Treating BPH with Rezum on the BackTable 101 Podcast

Dr. Seth Bechis

Dr. Seth Bechis is a practicing urologist and associate professor with UC San Diego in California.

Dr. Jose Silva discusses Treating BPH with Rezum on the BackTable 101 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2023, June 7). Ep. 101 – Treating BPH with Rezum [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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