Lower Urinary Tract symptoms (LUTs) caused by bladder outlet obstruction secondary to Benign Prostatic Hyperpalsia (BPH)

HISTORY

Mr X is a 54 year old solicitor who presented with gradual onset lower urinary tract symptoms (LUTs). On further questioning he reported that the symptoms developed over 3-4 years. His predominant symptoms were decreased flow rate (weak stream), hesitancy (difficulty starting), intermittency (stop starting) and incomplete emptying (needing to void frequently). He was an otherwise fit gentleman and happily married with normal erectile function. He had no family history or other risk factors for prostate cancer.

He had seen another urologist previously who had done a thorough assessment and diagnosed Benign Prostatic Hyperplasia (BPH) as the cause of his LUTs. He commenced him on tamsulosin (alpha blocker) which had only made a minor improvement to his symptoms. On subsequent review a discussion was made on trialling combination medical therapy with Duodart.   Due to the possible side effect of erectile dysfunction and decreased libido this was declined. This urologist therefore offered him Transurethral Resection of Prostate (TURP). The patient was concerned about the recovery period, retrograde ejaculation (dry orgasm) and possible erectile dysfunction from this procedure and wanted to look at other options.

Online research led Mr X to Rezum treatment and a consultation at Melbourne Urology Centre was arranged.

PHYSICAL EXAMINATION

On examination Mr X was an athletically built, healthy-looking gentleman. The bladder was not palpable/distended and genital and scrotal examination was unremarkable. His digital rectal examination confirmed a benign smooth prostate with no concerning nodules.

INVESTIGATION FINDINGS

Serum biochemistry (UEC) was normal and his PSA was 1.6 (normal for his age). Urine MCS showed no blood or signs of infection. Renal tract ultrasound showed a 75cc prostate and normal kidneys with no hydronephrosis. The initial bladder volume was 535ml and he retained 292ml after voiding.

International prostate symptom score (IPSS) was 26 (significant bother). On flow study he voided 220ml over 1 min 20 sec with a very poor maximum flow rate of only 8mls/s and retention of 180ml.

TREATMENT

Following an in-depth discussion on management options Mr X decided on Rezum therapy. Consideration was given to medical therapy, Urolift as well as ‘cavitating’ procedures such as TURP, HoLEP and Greenlight laser surgery. What resonated the most was the quick recovery from the procedure and very remote risk of sexual dysfunction.

He underwent treatment on a Thursday afternoon and was discharged the next morning. Other than a mild burning sensation and lightly blood stained urine, there were no post-operative issues. He was discharged with an indwelling catheter with a small flip/flow tap attached, simply requiring him to empty the bladder every four hours during the day with a bag connected for overnight drainage.

He was back at work the following Monday.

FOLLOW UP

Mr X was admitted on day 6 to have the catheter removed (trial of void). He had three voids with each of them having a reasonable flow only leaving 50-100ml remaining on ultrasound.

He returned for eight week follow up very pleased with the results. His international prostate symptom score (IPSS) was now 12 (mild bother). On his flow he voided 360mls over 45 seconds with a maximum flow rate of 19mls/sec and only retained 22mls. He maintained his normal sexual function and ejaculation.

He returned for four months follow up still very pleased with the results. His international prostate symptom score (IPSS) was now only 8. On his flow study he voided 315ml over 38 seconds with a maximum flow rate of 18mls/sec and only retained 16ml. Again, he did not report any sexual dysfunction.

His next appointment is at six months.

Rezum treatment is a minimally-invasive thermal water vapour (steam) therapy for the treatment of BPH (benign prostatic hyperplasia). The Rezum system utilizes technology that is delivered through a handheld device using cystoscopy (keyhole surgery). The radiofrequency generated water vapor in the form of steam delivers thermal energy to the enlarged prostatic tissue. This leads into the natural process of apoptosis (programmed cell death). Your body’s natural immune system will absorb the tissue allowing a more open channel for improved voiding/urinary flow. Rezum treatment does not require any cutting, it is a minimally-invasive prostate surgery that could be done in a clinic. Recovery is quicker allowing for early return to normal daily activities.