Procedural approaches: A clinical summary from the Rezūm System — A minimally invasive water vapor thermal therapy for obstructive benign prostatic hyperplasia

Published in “How I Do It” in the Canadian Journal of Urology International, June 2019¹

The Rezūm Therapy procedure provides versatility for application to a variety of prostate gland morphologies including the median lobe or enlarged central zone. We have been able to offer this minimally invasive treatment option to men disenchanted with suboptimal LUTS improvements on medical therapy or facing the need for long-term medical therapy, and in selected patients as an alternative to more invasive surgical approaches.

For median lobe tissue, entering from a point midway from the base to apex at a 45 degree angle is most useful. For most median lobes, two treatments are adequate.* With larger protrusions, a stacked treatment may be required. Starting about 0.5 cm from the distal aspect of the protrusion and working back to the base in 1 cm increments allows for complete treatment. Wider based median lobes may also require a single treatment placed at the apex of the median lobe to ensure complete treatment of the median lobe tissue.

When a patient has had a prior PUL, there may be an increased risk of exposure of the internal implant stainless steel tab. It is recommended to perform a post-treatment cystoscopy at 3 months to ensure no foreign body is present within the prostate fossa that would need to be removed due to the risk of encrustation. Patients with prior radiation have been intentionally avoided due to the loss of the intracellular spaces replaced by scar tissue.

The retreatment rate for Rezūm Therapy randomized controlled trial patients over 3 years* of follow-up was reported to be 4.4% (6 of 135 patients) including 2 patients with Rezūm Therapy, 3 with TURP, 1 prostatectomy (see sidebar).² Four of these six secondary interventions included the presence of a median lobe, identified but not previously treated.² Given that no permanent implant is placed, as with PUL, failure is typically due to residual tissue and there is no hesitation to consider repeat Rezūm Therapy treatment of patients with suboptimal results after appropriate evaluation.

Treating patients in urinary retention managed either by clean intermittent catheterization (CIC) or with an indwelling Foley catheter is feasible and successful with careful patient selection. In this situation, it is recommended to perform urodynamic studies prior to proceeding to ensure detrusor function is not impaired enough to prevent emptying once the prostate obstruction is relieved. Flexible cystoscopy and prostate ultrasound represent further baseline evaluations.²

Obviously, these patients need complete sterilization of bacteriuria prior to Rezūm Therapy treatment. Prolonged catheter management — either continuous or CIC — following treatment is critical to allow post-procedural bladder drainage. Persistent catheter drainage for approximately 1 month following the procedure is typical in those who present in urinary retention. This is based on timing of symptom improvement observed as early as within 1 month in the Rezūm pivotal trial. During the acute inflammatory period following treatment, it would not be expected to see resolution of obstruction until a month or more. If the patient fails trial of void at 1 month, consider repeat voiding trials at 1- to 2-week intervals or management with CIC and tracking residual volumes.