BackTable / Urology / Article
UroLift Procedure: Advantages and Limitations
Quynh-Chi Dang • Jun 5, 2021 • 1.4k hits
The UroLift procedure is a common minimally invasive procedure for benign prostate hyperplasia (BPH) patients with medium-sized prostates. The Urolift procedure reduces many operative and postoperative risks, since it requires no incisions or ablation. For this reason, UroLift effectiveness is high for complex patients and those who prioritize ejaculation preservation. However, for very large prostates and prostates with substantial intravesical lobes, the UroLift procedure is more technically challenging than other BPH surgical treatments.
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The BackTable Urology Brief
• Different BPH surgical options can be categorized based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches.
• The UroLift procedure is a minimally invasive, non-ablative BPH treatment that places permanent implants to pull the prostate lobes away from the urethra.
• Because it requires a short operating time and no incisions, the UroLift procedure is recommended for patients who are elderly, who are on blood thinners, and who prioritize the preservation of antegrade ejaculation.
• Although the UroLift procedure is a good choice for medium-sized prostates (30-80 g), it is technically challenging for prostates with substantial intravesical lobes. Other BPH surgical options, such as transurethral resection of the prostate (TURP) and Rezum, can be explored instead.
Table of Contents
(1) UroLift Procedure Overview
(2) UroLift Advantages for Elderly Patients and Patients on Blood Thinners
(3) UroLift Advantages for Preservation of Antegrade Ejaculation
(4) UroLift Limitations for Substantial Intravesical Lobes
UroLift Procedure Overview
There are a variety of new BPH treatments that can be categorized in a multitude of ways: minimally invasive vs. full anesthesia, ablative vs. non-ablative, permanent vs. temporary device implantation, and laser vs. other energy sources. The UroLift system was created in 2013 and is now a popular minimally invasive option for BPH. The UroLift works by introducing a transurethral delivery device that inserts tiny permanent implants that grab and pull the lobes of the prostate back in order to widen the urethra, thus unobstructing urinary flow. No resection, ablation, or incision is required.
[Dr. Aditya Bagrodia]
...As we start talking about the relevant patient characteristics, symptom characteristics, and anatomical considerations, perhaps it would be useful, Claus, if you could give a comprehensive list of options that are available, as you see it.
[Dr. Claus Roehrborn]
...Those treatments nowadays are grouped into minimally invasive (done as an outpatient or an ambulatory surgery center) versus the surgeries that require full anesthesia (done in a hospital setting usually and require more or less an overnight stay).
...You can also group these treatments by if they remove tissue or if they do not remove tissue. I'll give you an example. A TURP classically removes tissue. It's an ablative procedure and it's invasive and it requires hospitalization at least for a day. Non-ablative would be a UroLift. You place the UroLift devices and you push the tissue to the side but no tissue is ultimately removed. So ablative versus non-ablative is another way of differentiating it.
There would be a differentiating between treatments that consist of permanent placement of items, such as a UroLift, and there's a whole slew coming down the pipe, the Zenflow device, the Butterfly device, the Medeon device, all of which are experiencing trials in the United States right now and may or may not be approved by the FDA. Versus treatments that don't use devices that are implanted permanently.
And then there's the categorization by devices that work by laser energy versus electrocautery energy versus other energies. For example the Rezum procedure uses steam, just hot water heated by radio frequency energy, and then is injected and as the steam gives off the energy it destroys the tissue. So the energy source is another question. And to add to that, there is the Aquablation treatment that doesn't use any heat per se--neither electrical generated heat nor laser generated heat nor steam--but it uses basically saline at room temperature with a very intense water pick system to destroy prostate tissue.
You can already see how complex it is, how you can group these treatments by energy source, by ablative or non-ablative, by implant versus non-implant. Then comes the question: are these treatments all suitable for all sizes and shapes? But if you look through the list, minimally invasive devices currently approved and recommended in the United States would be the UroLift device, which is an implant, and the Rezum treatment, which is a steam-based heat treatment that partially ablates tissue. Then amongst the surgical treatments there would be monopolar/bipolar TURP, the PVP, the GreenLight or KTP or 532nm laser ablation of the prostate. Then there would be a host of enucleation techniques and, as you know, enucleation now can be done with the traditional way, the holmium laser enucleation which is called HoLEP, the thulium laser which is called ThuLEP, but people do it with the green-light laser as well and it's called KTP laser enucleation, or even do it with a bipolar resectoscope device and just get into the enucleation plane.
Then we have the treatments for the very large prostates that go beyond the HoLEP or ThuLEP, the robotic or open or robotic-assisted laparoscopic enucleation of the prostate as alternatives for the very large prostates.
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UroLift Advantages for Elderly Patients and Patients on Blood Thinners
The elderly population makes up a large proportion of the BPH patient population. For this reason, minimally invasive treatments that require shorter anesthesia time are preferable. Dr. Roehrborn recommends either the UroLift or Rezum as the first choice, assuming their prostate anatomy allows for it. For patients on blood thinners, urologists must take special precautions to limit excessive bleeding while operating. Once again, he recommends the UroLift because of its non-ablative nature.
[Dr. Aditya Bagrodia]
...Now we'll try to actually jump into patient characteristics, prostate anatomy characteristics, that help guide a decision. Maybe we start out with comorbidities, elderly patients, and thoughts on patients that are on blood thinners. Does that immediately start impacting your decision tree here?
[Dr. Claus Roehrborn]
The age of the patient per se, the chronological age, actually the least I would say. You are an oncology surgeon, you know you operate on elderly folks, you operate on octogenarians if they have cancer. So we have to take a step back or we have to say, "This is a benign disease. It's a quality of life disease. We cannot afford an anesthetic event here." So clearly we are going to dial it down a little bit. If the patient is elderly and is frail, frailty plays a big role in the BPH population, then we'll take it down a notch and we offer treatments that are less invasive and we try to just offer those treatments which we consider minimally invasive, the Rezum treatment or the UroLift treatment if the size of the prostate allows it.
Clearly, if the prostate is too large or if there is a substantial intravesical lobe, if we choose an endoscopic operation, I would choose the KTP laser. Why? Because there is clearly less bleeding and the chances, even small, for a return to the emergency room with clot retention is higher with the TURP compared to a KTP. That's just a fact. Even if it's only 2% or 3% versus .5%, it's a difference for a person in his 80s. If it has to be a TURP then I would say of course a bipolar TURP because the use of saline reduces the risk of hyponatremia, TURP syndrome and all of this will benefit our elderly patient population.
The use of blood thinners is complicated because it's not only antiplatelet agents, which are easier to manage and easier to treat patients under. But the true anticoagulation, which used to be all patients on Coumadin and now it's basically on modern anticoagulation, be it Plavix or be it Eliquis, it's a far more complex issue. I used to say that a patient on Coumadin, we'll take him to the OR and do a green-light laser ablation up to an INR of 1.5, but there are almost no patients on Coumadin any longer. They are on Eliquis and they are on Plavix and other such drugs and you don't have graduation anymore. So those patients are difficult to treat.
Some of the treatments can be done. Sometimes a person who publishes a series of patients on Eliquis treated with even a HoLEP but that's rare. I would say if the patient can't come off the blood thinners, the true anticoagulation, I would say the KTP laser is probably as far as I would take it. In the range of non-ablative treatments, I would certainly do a UroLift placement on a patient on anticoagulation and have done so, on any kind of anticoagulation because the application of that lift device two or four or six times doesn't cause a great risk of bleeding.
UroLift Advantages for Preservation of Antegrade Ejaculation
A common concern that BPH patients have before surgery is the risk of anejaculation, the loss of the ability to ejaculate during sexual climax. Anejaculation can be attributed to interference with the apical tissue in front of the verumontanum and making incisions in the bladder neck. Dr. Roehrborn explains that the UroLift procedure has the lowest risk of anejaculation because the procedure does not involve any incisions. Other BPH surgical options requiring incisions may be explored, but they can be technically challenging and less effective if the patient prioritizes preserving antegrade ejaculation.
[Dr. Aditya Bagrodia]
Okay, fantastic. If I may, for smaller glands of course there's going to be some considerations and perhaps I would ask for you to speak a little bit about transurethral incision of the prostate and even a little bit more broadly on options that are going to be prioritized when preservation of antegrade ejaculation is a priority.
[Dr. Claus Roehrborn]
It used to be said that ejaculation has to do a lot with the bladder neck and every time you mess with the bladder neck you get anejaculation or retrograde ejaculation. And then there is a school of thought that says the antegrade ejaculation hinges on the apical tissue that is right in front of the verumontanum. Currently, most people think that it's just the apical tissue that preserves the ejaculation. Now, just in our meeting this morning I raised this question because it is known that the incision of the bladder neck actually causes 30 to 50% retrograde ejaculation even if you don't come close to the verumontanum. So I'm old school there. I think the bladder neck must play a role in it, perhaps not the only role.
When patients come and they are really, really interested in ejaculation function, fortunately we have excellent studies that use the MSHQ ejaculation questionnaire and they with absolute 100% certainty guide you. The UroLift treatment has no impairment of ejaculation. Period--in no patient that is reported. The Rezum treatment has maybe in 5% maybe in a little bit more but not more than 10% of patients ejaculation impairment. For the incision of the bladder neck either at the six o'clock or four and eight o'clock, up to 30 or 50% of patients have retrograde ejaculation. The Aquablation, due to the fact that the water jet is stopped just shy of the apical tissue, has an ejaculation preservation that is surprisingly high, 95%. So the vast majority of Aquablation treatments enjoy normal ejaculation if you turn this device on so that, with the so-called butterfly cut, this hood of tissue in front of the verumontanum is preserved.
If a man comes in and says ejaculation trumps, then I'll look at him and say, "Okay, let me check your prostate size." If the prostate size is 30, 40, 50g I say, "Let's try a UroLift." If it's a really small prostate I say, "You can try a UroLift. We can also try an incision and I'm not carrying it all the way to the veru. We can see how that works." If it's a larger prostate I say, "Well, let's do the Aquablation treatment because that will give you the best chances of preserving antegrade ejaculation."
Now, full stop. There's a lot of surgeons who claim they can preserve ejaculation to 70, 80, 90% even doing a TURP, doing a GreenLight laser, doing a HoLEP, as long as they preserve this hood of tissue in front of the verumontanum. Well, the problem is that that doesn't seem to be easy to duplicate by others, A. B, the very principle of the HoLEP operation is to make an incision in the mucosa at the apical tissue, so that tissue by definition has to go as part of the package. So I'm really unclear on that. And most of these studies are single center, single investigator. So I'm less enthusiastic about this idea of leaving a little tissue behind close to the verumontanum and I secondarily don't believe you achieve the same efficacy necessarily. So, ejaculation preservation. UroLift tops. Rezum second for the smaller glands. Aquablation for the larger glands. And then comes all this artistry and the individual people who can do it, presumably, with good success, even when they do a standard TURP.
UroLift Limitations for Substantial Intravesical Lobes
For medium-sized prostates (30-80 g) without substantial intravesical (median) lobes, Dr. Roehrborn usually performs Rezum or UroLift procedures, per American Urological Association (AUA) guidelines and clinical studies. However, when a substantial intravesical lobe is present, he prefers to do a transurethral resection of the prostate (TURP). Out of the minimally invasive options (UroLift vs. Rezum), he determines that Rezum is a better choice because it is less technically challenging and poses a smaller risk of creating urinary stones.
[Dr. Aditya Bagrodia]
Okay, fantastic. Now we're moving [towards] average and smaller prostates. Perhaps just give the next layer of options some categorization and phylogeny.
[Dr. Claus Roehrborn]
Clearly for the average size prostate there are a plethora of things that can be done. Both the Rezum and the UroLift are recommended by the AUA guidelines between 30 and 80 g. This was done during the studies. This was the size range that was tested. The Teleflex or NeoTract company has also done a study in patients up to 100 g and the FDA approved UroLift but I personally don't like to use it above 80 g. I think I stick with 30 to 80 g. In that same category is also HoLEP and ThuLEP. In the same category is the KTP laser. In the same category is the transurethral resection or even transurethral vaporization with electrocautery.
[Dr. Aditya Bagrodia]
Maybe I'll interrupt you for just a moment, Claus, and ask you, among all of these options, of which pretty much everything is available, how does the median lobe presence or absence affect your decision?
[Dr. Claus Roehrborn]
I think this is, fortunately, an insight that has made, finally, it's way into the guidelines, both the EAU and to some degree the AUA guidelines, the recognition that the intravesical lobe plays a major role. Starting with the least invasive. The Rezum treatment has clearly shown that if you put the needle in the median lobe, if it's present, you get a better improvement than if there's a median lobe and you don't put the needle in. So putting the needle in, injecting the steam, ablating that median lobe gets you a better improvement than if you leave it alone. So the Rezum works out okay for the median lobe. You'll likely have a longer catheterization time, but it in the end works out.
The UroLift is approved because there is a study that was done, called the MedLift study, where they took a UroLift device and sort of stapled that median lobe to the side. There's a risk in exposing that wire. There's a risk in maybe having material exposed to the urine and forming stones, and there's a risk it doesn't work if you don't do it a lot. So, I don't like to do it because I think there are other treatments available for it, but it is technically approved for it.
...For substantial intravesical lobe I like preferentially to do a TURP because I can very elegantly lob that median lobe off without jeopardizing the trigone, the UOs, taking it flush off the bladder neck and I think that's the most elegant way of going about it.
If people want to stay minimally invasive they can do the Rezum, and if people have access to it they can use the Aquablation. But the Aquablation has its own limitations. In many cases after one passage of the water pressure, water pick ablation, the lowermost component of that intravesical lobe, which basically protrudes into the bladder like a tongue, still is there. It's not completely gone and you have to go in afterwards and take a loop and resect it--at least that last bit of it because the Aquablation often doesn't completely eliminate it.
...So big decision point, the intravesical lobe. No medical therapy. Please don't give medical therapy for substantial intravesical lobe ever. Doesn't work and it's just a waste of time and money. Choose your weapon carefully. If you have access to not much then use your TURP loop. It's the best tool yet. If you have it and you're really good at it you can use the GreenLight laser. You certainly can use the HoLEP procedure. The Aquablation, but caveat, you may have to resect tissue at the end of that Aquablation. And if you have the Rezum you can do it and stick the needle in. And use the UroLift only if you're really, really good at that because it's a technically difficult move to make.
Dr. Claus Roehrborn
Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 23). Ep. 6 – Contemporary Surgical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com
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