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Optimizing Patient Selection for Minimally Invasive Surgical Therapies in Male LUTS: The Role of Videourodynamic Study

S. Hu¹, C. Lin¹, C. Mei¹, K. Chiu¹, J. Li¹

¹Taichung Veterans General Hospital, Department of Urology, Taichung, Taiwan

Introduction:

Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in men over the age of 50. In addition to pharmacologic therapy, treatment options include transurethral resection of the prostate (TURP), laser enucleation or vaporization, and simple prostatectomy. In recent years, minimally invasive surgical therapies (MIST) have been incorporated into international guidelines. In Taiwan, UroLift and Rezūm—two MIST options—were introduced in 2023 as self-pay procedures not covered by national health insurance. However, BPH accounts for only approximately 40% of refractory male LUTS cases. Therefore, appropriate patient selection is crucial for maximizing the therapeutic efficacy and patient satisfaction of MIST. Advanced urodynamic studies may enable precise patient stratification and significantly aid shared decision-making between clinicians and patients.

Material and methods:

From May 2024 to January 2025, 54 patients with refractory male LUTS who underwent MIST for presumed BPH were prospectively enrolled. All patients received preoperative evaluations including transrectal ultrasound, prostate-specific antigen testing, uroflowmetry, and the International Prostate Symptom Score questionnaire. Selected patients with suspected not purely BPH-related LUTS underwent preoperative videourodynamic studies to assess bladder and outlet function. Postoperative uroflowmetry and IPSS were recorded at 1 and 3 months post-treatment.

Results:

26 underwent the UroLift procedure and 28 received Rezūm water vapor therapy. The mean age was 64.8 years in the UroLift group and 68.8 years in the Rezūm group. The average prostate volume was 42.8 cm³ in the UroLift group and 60.3 cm³ in the Rezūm group. Preoperative mean Qmax was 12.0 mL/sec and 11.1 mL/sec, respectively. Videourodynamic studies revealed various etiologies aside from prostatic obstruction, including detrusor underactivity, bladder neck dysfunction, and dysfunctional voiding. MIST yielded the greatest benefit in patients with pure prostate obstruction and preserved detrusor contractility, while outcomes were suboptimal in those with detrusor underactivity, severe bladder neck dysfunction, or dysfunctional voiding.