“Whenever a new medical technology is introduced—such as prostatic urethral lift (PUL) for benign prostatic enlargement and lower urinary tract symptoms (BPE/LUTS)—it is important to understand its impact on real-world practice and how it performs outside of a trial or academic setting,” explains Irina Jaeger, MD. “For benign prostatic hyperplasia (BPH), many technologies come and go, often because a particular technology may not perform as well in the real world as it does in initial reports. PUL is being widely adapted by urologists since it is less invasive than many traditional treatments and because patients experience quick recovery and report a high rate of satisfaction. Still, my colleagues and I wanted to evaluate how this new technology holds up against some of the more invasive treatment options in a real-world setting.”

For a study published in The Journal of Urology, Dr. Jaeger, Jonathan E. Shoag, MD, and colleagues sought a better understanding of the relative uptake, complications, and retreatment rates of contemporary endoscopic procedures for BPE/LUTS across diverse practice types. They performed a retrospective study of inpatient and ambulatory surgery encounters in the Premier Healthcare database. The researchers included men who underwent endoscopic procedures for BPE/LUTS between 2000 and 2018 and determined 30- and 90-day readmission rates, as well as retreatment rate. Multivariate logistic regression was used to assess the association of procedure type with outcomes for the three most performed procedures.

PUL Associated With Lower Odds of Readmission

“Using a large electronic healthcare database, we assessed men undergoing PUL and looked at the adoption of this procedure over time, compared with other BPH treatments,” says Dr. Shoag. “We wanted to observe how many men who had undergone the procedure underwent second procedures or experienced complications.”

The study team identified 175,150 men treated with endoscopic surgery for BPE/LUTS. The annual percent utilization of the PUL increased from less than 1% in 2014 to 10.4% in 2018, according to Dr. Shoag. Compared with transurethral resection of the prostate (TURP) and prostate photovaporization (PVP), PUL was associated with lower odds of readmission at 30 (odds ratio [OR], 0.58) and 90 days (OR, 0.55) but with higher odds of retreatment with 2 years of follow-up (OR, 1.78).

“We were surprised by the commonality of PUL, reaching as many as 10% of BPH procedures in 2018, up from less than 1% in 2014,” Dr. Jaeger observes. “As other research has shown, PUL had low complication rates, but it did have higher odds of a patient getting a second procedure when compared with TURP. However, the absolute rate of second procedures that we were able to detect was small. Also, when we accounted for patient and provider characteristics, PUL was associated with a lower readmission rate than either TURP or PVP (Table).”

New Treatment Options Rapidly Emerging

This study reinforces much of what has been learned about PUL from academic and trial settings, Dr. Jaeger says. “We know that PUL is relatively safe, but it may not be as durable as some other treatments, such as TURP or PVP,” she adds. “Our findings contain important information for urologists when discussing the pros and cons of various BPH treatment options with new patients, as the BPH field is constantly changing, with new treatment options rapidly emerging.”

The study team concurs that more research is needed in this area. “We need longer-term data on retreatment rates,” Dr. Jaeger says. “If we find that the proportion of patients needing a second procedure following PUL is very high within 10 years, this may be an argument against doing this procedure as an intermediate step. To some patients, however, staying off medications, preserving ejaculatory function, or avoiding a more involved procedure may be sufficient reasons to justify PUL. We also need to compare PUL to other minimally invasive treatment options as new data emerge.”