Urologists have been searching for the “Holy Grail” of BPH treatment for decades. The ideal therapy is:
- Easy and painless to perform
- Without sexual or serious side effects
- Associated with a quick recovery
Several BPH treatment options have come and gone through the years, but they all failed to deliver on these promises (like those semi-hot college girlfriends who really didn’t treat you well).
Worry no more! There are two new kids on the block. Rezum vs. Urolift. Have we finally found the ideal BPH therapy? Which option is better? I’m here to help.
Let’s do a deep dive together into the differences of these minimally invasive therapies and see if there’s a clear winner.
What is BPH?
Before we talk about Rezum vs. Urolift, we should make certain that we have a clear understanding of BPH and how it affects men.
BPH or benign prostatic hyperplasia is the fancy doctor term for an enlarged prostate. We tend to diagnose or label someone with BPH if they are a man over the age of 40 years old and start complaining of urinary difficulties. By age 80, up to 50% of men will have urinary difficulties due to BPH.
The most common symptoms of BPH are:
- Slow, intermittent stream
- Difficulty starting a stream
- Sensation of not emptying the bladder completely
- Dribbling of urine after urinating
- Urinary frequency and urgency
- Excessive nighttime urination
Background of Minimally Invasive BPH Therapies
Rezum and Urolift fall into the category of Minimally Invasive Surgical Therapies (MIST). MIST therapies are typically performed under minimal anesthesia (office or outpatient surgery center) and aim to relieve urinary symptoms while minimizing side effects.
These differ from more invasive treatments (TURP, HoLEP, Greenlight laser) which are intended to remove all BPH tissue and are associated with more complications and a longer recovery.
The predecessors to Rezum and Urolift were TUNA and TUMT (microwave therapy). These treatments were typically done in the office on awake patients with minimal sedation. A catheter was usually inserted and heat was delivered to the prostate through a catheter (Ouch!).
Not only were these procedures anecdotally painful, according to my patients who had them elsewhere, they didn’t work long term. 100% of men were back on their BPH medications or required a different treatment at some point.
I never performed these procedures for these reasons. If it’s that uncomfortable AND you’ll eventually need to be back on your medication, then why do it? Unfortunately, they made a lot of doctors a lot of money so many patients received these therapies.
In 2012, things started to change.
What is Urolift?
The UroLift System uses a novel approach to treating BPH that lifts and holds the enlarged prostate tissue so it no longer blocks the urethra. FDA approved in 2012, it is the only currently available BPH treatment that does not require heating, cutting, or removal of the prostate tissue.
A series of small titanium and stainless steel clips connected by a suture are placed within the prostate via cystoscopy (scope in the penis). The clips “tack” or hold open the prostate lobes, relieving the obstruction due to BPH.
The procedure is typically performed using minimal sedation in a physician’s office or ambulatory surgery center. Patients return home the same day, typically without a catheter.
What is Rezum?
Rezum was FDA approved in 2015. It is a device that is inserted into the urethra in an office setting under sedation. A small needle is inserted into the BPH tissue of the prostate in 4-5 locations. Radiofrequency energy is used to generate steam vapor that travels within the prostate tissue ultimately leads to cell death.
The treated area of the prostate shrinks over time, leading to a relief of urinary obstruction. Due to the type of energy delivered, there is no heat damage to areas outside of the prostate.
Urology (AUA) Guidelines on BPH
The American Urologic Association (AUA) is the national organization to which most urologists belong. Composed of urologists, the AUA periodically releases treatment guidelines to provide some consensus on the standard-of-care for certain conditions.
The last AUA Guideline on BPH was released in 2018. Since Rezum and Urolift are relatively new procedures, a lot can change in medicine over 2 years (hello COVID-19, I’m talking about you!).
According to these Guidelines, both Rezum and Urolift can be offered to men with BPH who desire treatment and want to maintain sexual function (yes, please).
They did not recommend either therapy for men with very large prostates (>80 g) nor did they recommend Urolift if a median lobe (portion of prostate growing into the lower bladder opening) was present.
How should we interpret these guidelines?
Rezum and Urolift are the first minimally invasive surgical therapies to receive a definitive recommendation from the AUA. This is great.
On the other hand, the recommendations were made with only 3-5 years of data. As we will see with Urolift, as experience and techniques have improved since 2018, we now have data showing the use of Urolift for median lobes and larger prostates (up to 100 g).
Finally, we should take these recommendations for what they are: guidelines. They are meant to guide decision-making rather than be interpreted as absolute truths. Nothing replaces an informed discussion with a urologist you trust.
Comparison of Rezum vs. Urolift
Let’s get to the juicy part of our discussion (I can’t help myself with urology puns). What are the outcomes with Rezum vs. Urolift? Which is better? Rezum or Urolift?
First and foremost, a procedure has to work. In the case of a BPH treatment, we want improved urine flow and symptom relief. These parameters are easily measured with pre and post-procedure urine flow rates (how quickly a volume of pee comes out) and the IPSS score (standard BPH survey that men fill out in their urologists office).
The original L.I.F.T. study published in 2013 confirmed that Urolift improves flow rates by 44% and BPH symptom scores by about 50%. These improvements were detectable by patients, as evidenced by an improved overall quality of life score as well.
What about Rezum? 3 year data was published in 2018 showing similar improvements to Urolift in urinary flow rates and symptoms scores. Although published in separate studies, both Rezum and Urolift patients had similar baseline measurements and similar post-procedure improvements.
This is where Rezum and Urolift really shine. There have been no reported instances of new (de novo) erectile dysfunction with either therapy. 2% of men after Rezum have reported decreased semen volume, but this has not been seen with the Urolift.
In comparison to a TURP (complete removal of BPH tissue via a laser or cautery) where instances of new ED are 5-10% and loss of ejaculation is seen in 75-100% of men.
If you want to stay busy in the bedroom with similar performance, then Rezum and Urolift seem to be your best options for the treatment of BPH.
Complications and Recovery
Major complications (blood transfusion, bladder leakage) from either Rezum or Urolift are exceedingly rare. When it comes to operating on “your business” this is of the utmost importance to say the least.
Recovery from a Urolift procedure is about a week. I warn patients that you won’t like me for 7 days. Frequency, urgency, and burning with urination usually subside by then. Some men report minimal discomfort and recover even more quickly. About 10% of patients need a temporary catheter that is usually removed the next day.
In studies and anecdotally, recovery from Rezum can be a bit longer (2-4 weeks). The reason for this is that Rezum is destroying portions of the prostate. During this time there can be more swelling, irritation of the prostate and urethra.
A catheter is often placed for an average of 4 days after Rezum due to the initial swelling of the prostate. Once the catheter is removed, changes in the prostate continue for 2-4 months.
WINNER: Urolift, due to shorter recovery
In the follow-up to the original L.I.F.T study, 5 year data on Urolift was published. This showed a 13.6% surgical retreatment rate after Urolift. Over 85% of men were still showing improved flow rates, symptom scores and quality of life.
Since Rezum is a newer therapy, 4 year data was just released showing a surgical treatment rate of 4.4%. Again, the initial improvements in symptoms were sustained after 4 years.
13.6% vs. 4.4% retreatment rates. Is this a big deal? Hard to say. It’s all about expectations. If you’re achieving 86-95% long-term success with a low-risk surgical procedure, you’re hitting a home run in my book.
There is a nuance to performing Urolift procedures. As experience improves, I further suspect treatment rates to decrease. In discussion with colleagues who are very experienced with Urolift, they are seeing <10% retreatment rates.
The beauty of both procedures is you’re not burning any bridges in terms of future retreatment. You can always place more Urolift implants, perform another Rezum or crossover to a different therapy.
How Do We Choose Rezum vs. Urolift?
First and foremost, find a trusted, reputable urologist. These procedures are not difficult to perform and have a learning curve of 5-10 procedures. Sometimes the urologist who does the most of these procedures is the urologist making the most money from the procedure. They have a hammer and every prostate looks like a nail.
Ask the urologist why they perform a particular procedure. Personally, I perform more Urolift procedures because I like the novel aspect of how it works. It’s the first procedure that attempts to relieve urinary blockage without destroying tissue.
I also prefer that Urolift has the quickest recovery for my patients. Catheters are painful. Sexual side effects are terrible.
That being said, I’m impressed with the low retreatment rates of Rezum. It’s a longer, more painful recovery but decreases retreatment rates for 9% of men.
There is a financial aspect to these therapies as well. As a urologist you can start performing Urolift procedures quickly with no capital expense. Rezum ultimately requires an investment that may influence the decision making of a urologist.
So, which one is right for you? If you want a quicker, more comfortable recovery, Urolift is the best choice. If you want the therapy that currently demonstrates the lowest retreatment rate, Rezum has the edge.
Honestly, they are both great options. Just make sure you’re seeing the right urologist who engages you in an informed discussion.
Regardless, let’s keep you busy in the bedroom and out of the bathroom.
Dr. P (see, another urology pun)