Benign prostate enlargement, also known as benign prostatic hyperplasia (BPH), is extremely common as men get older. As the prostate enlarges, it can compress the urethra and interfere with the normal passage of urine from the bladder.

For some men, lifestyle measures or medication provide adequate relief. Others develop persistent or troublesome urinary symptoms and begin considering a procedure. Rezūm Water Vapour Therapy is a minimally invasive treatment designed to reduce the prostate tissue responsible for urinary obstruction while minimising the impact on sexual function.

What symptoms can an enlarged prostate cause?

Benign prostate enlargement can produce lower urinary tract symptoms (LUTS) including:

• A slow or weak urinary stream
• Difficulty starting urination
• Intermittent or stop-start flow
• Straining to urinate
• A sensation that the bladder has not emptied completely
• Urinary frequency
• Urgency
• Getting up several times at night to urinate
• Occasionally, an inability to urinate or urinary retention

Not every man with an enlarged prostate requires treatment. The decision to proceed with an intervention depends on the severity and impact of symptoms, prostate anatomy, bladder function, medical history and personal preferences.

What is Rezūm therapy?

Rezūm is a minimally invasive water vapour treatment for benign prostate enlargement.

Rather than cutting or surgically removing prostate tissue, Rezūm delivers small, controlled amounts of sterile water vapour into selected areas of enlarged prostate tissue.

The thermal energy carried by the steam disrupts the targeted prostate cells. Over the following weeks and months, the body gradually reabsorbs this treated tissue. The prostate tissue surrounding the urethra contracts, creating more space for urine to flow.

The treatment can be applied to the lateral lobes of the prostate and can also treat an obstructing median lobe.

Who may be suitable for Rezūm?

Rezūm may be considered for men with bothersome urinary symptoms caused by benign prostate enlargement, particularly when:

• Lifestyle measures have not provided adequate improvement.
• Medication is ineffective.
• Medication causes unacceptable side effects.
• The patient does not wish to take prostate medication indefinitely.
• Preservation of ejaculation and erectile function is an important consideration.
• The patient would prefer a minimally invasive procedure rather than conventional prostate surgery.
• There is obstructing lateral-lobe or median-lobe prostate tissue.

The pivotal clinical trial studied men over 50 with moderate-to-severe symptoms, prostate volumes of 30–80 mL and reduced urinary flow rates. Five-year follow-up demonstrated sustained improvement in urinary symptoms and urinary flow.

What about prostates larger than 80 mL?

Traditionally, the strongest evidence for Rezūm has been in prostates between approximately 30 and 80 mL.

Increasing evidence, however, suggests that Rezūm can also be successfully performed in selected men with prostates larger than 80 mL. Outcomes in larger prostates may depend more heavily on prostate anatomy, baseline urinary function and appropriate patient selection.

For substantially enlarged prostates, other procedures such as laser enucleation, HoLEP or other surgical techniques may provide more predictable removal of obstructing tissue.

What happens before Rezūm?

A proper assessment is important because urinary symptoms are not always caused by the prostate.

Evaluation may include:

• Medical history and examination
• International Prostate Symptom Score (IPSS)
• Urinalysis and urine culture
• PSA where clinically appropriate
• Digital rectal examination
• Measurement of urinary flow rate
• Ultrasound assessment of bladder emptying and post-void residual urine
• Assessment of prostate size
• Cystoscopy in selected patients
• Urodynamic testing where there is uncertainty about bladder function or the cause of the urinary symptoms

It is particularly important to distinguish prostate obstruction from poor bladder muscle function, as removing prostate obstruction cannot necessarily correct a bladder that is unable to contract adequately.

Urinary infection should be treated before proceeding with treatment.

How is Rezūm performed?

Rezūm is performed through the urethra, meaning that there are no external surgical incisions.

A small instrument is passed through the urethra until the prostate is visualised.

A fine needle is then deployed into predetermined areas of obstructing prostate tissue. Each treatment delivers a controlled amount of water vapour into the prostate.

The number and location of treatments depend upon:

• Prostate length
• Prostate volume
• Degree of lateral-lobe enlargement
• Presence and size of a median lobe
• Individual prostate anatomy

The procedure itself is relatively short and is commonly performed as a day procedure. Anaesthesia varies according to the patient, surgeon and treatment setting.

Will I need a catheter?

Many patients require a temporary urinary catheter following Rezūm.

The prostate initially becomes swollen following treatment. This swelling can temporarily make urination more difficult before the prostate begins to shrink.

The catheter is commonly left in place for several days, although the duration varies according to prostate size, pre-existing bladder emptying, swelling and whether the patient was already in urinary retention.

Some patients may temporarily require reinsertion of a catheter if they cannot urinate after the original catheter is removed.

When will Rezūm start working?

Rezūm does not produce an immediate improvement in urinary flow.

In fact, urinary symptoms can temporarily become worse because the treated prostate becomes inflamed and swollen.

As the treated tissue is gradually reabsorbed, the channel through the prostate opens.

Some men notice improvement within a few weeks, but improvement generally continues over approximately three months and sometimes for several months thereafter.

This delayed response is an important difference between Rezūm and procedures that physically remove prostate tissue during the operation.

What are the advantages of Rezūm?

For appropriately selected men, potential advantages include:

• Minimally invasive treatment
• No external incision
• Short procedural time
• Usually performed as a day procedure
• Reduced dependence on BPH medication
• Treatment of median-lobe enlargement
• Relatively rapid return to normal activities
• Low risk of significant bleeding
• Preservation of erectile function
• A relatively low risk of ejaculatory dysfunction compared with many conventional prostate operations

Preservation of sexual function is one of the major reasons some men choose Rezūm rather than conventional prostate surgery.

In the pivotal five-year study, there were no reports of device- or procedure-related sexual dysfunction or sustained new erectile dysfunction.

What are the side effects and risks of Rezūm?

Most side effects are temporary and relate to inflammation of the prostate and urinary tract following treatment.

Burning or discomfort when urinating

Dysuria is common during the early recovery period. Symptoms usually improve as inflammation settles.

Blood in the urine

A small amount of blood in the urine is relatively common following treatment and may occur intermittently during the healing process.

Blood in the semen

Blood or discolouration of the semen can occur and may persist for several weeks.

Urinary frequency and urgency

Some patients temporarily experience increased frequency, urgency or nocturia as the prostate and bladder outlet recover.

Urinary retention

Swelling of the prostate can temporarily prevent urination, requiring continued catheterisation or reinsertion of a catheter.

Urinary tract infection

Infection can occur following any procedure involving instrumentation of the urinary tract. Antibiotics may be required.

Pelvic or perineal discomfort

Temporary pelvic discomfort, pressure or irritation may occur following treatment.

Ejaculatory changes

Rezūm has a relatively favourable sexual side-effect profile, but changes in ejaculation, including reduced ejaculatory volume, can occur. Preservation of ejaculation cannot be guaranteed.

Potential adverse effects reported for water-vapour therapy include dysuria, haematuria, haematospermia, urinary infection, frequency, urgency and urinary retention.

How successful is Rezūm?

Rezūm has demonstrated durable improvement in urinary symptoms.

In the pivotal randomised clinical study, men treated with Rezūm demonstrated sustained improvement at five years, including approximately:

• 48% reduction in IPSS urinary symptom score
• 44% improvement in maximum urinary flow rate
• 45% improvement in quality of life
• 4.4% surgical retreatment rate at five years

Importantly, symptom and flow improvements remained significant throughout the five-year follow-up period.

These results make Rezūm an attractive middle ground between long-term medication and more invasive prostate surgery.

What is the risk of needing another prostate procedure?

Rezūm does not guarantee that a patient will never require another treatment.

In the pivotal study, the surgical retreatment rate was approximately 4.4% over five years.

Retreatment may be necessary because of:

• Incomplete relief of the original obstruction
• Undertreated prostate tissue
• Persistent median-lobe obstruction
• Continued prostate enlargement
• Recurrence of urinary symptoms
• Progression of bladder dysfunction
• Development of another urinary tract problem

A repeat procedure might involve another minimally invasive treatment or a more definitive operation such as TURP or laser surgery, depending upon the circumstances.

Can the prostate continue to enlarge after Rezūm?

Yes.

This is an important point when considering any minimally invasive BPH treatment.

Rezūm treats the prostate tissue causing obstruction at the time of treatment, but it does not prevent the remaining prostate tissue from undergoing further benign growth as a man ages.

BPH is an age-related biological process. Therefore, prostate enlargement may continue over subsequent years.

This does not mean that symptoms will necessarily return. Five-year clinical results demonstrate durable improvement for most appropriately selected patients.

However, particularly in younger men with many years of potential prostate growth ahead of them, it is important to understand that another BPH treatment may eventually become necessary.

When may Rezūm not be appropriate?

Rezūm is not the best treatment for every enlarged prostate.

It may be unsuitable, contraindicated or require additional consideration in patients with:

• Active urinary tract infection
• Suspected prostate cancer requiring further investigation
• Significant urethral stricture disease
• Certain previous prostate or urethral operations
• Very poor bladder contractility
• Urinary symptoms that are predominantly caused by overactive bladder rather than prostate obstruction
• Bladder stones or other pathology requiring simultaneous surgical treatment
• Prostate anatomy unlikely to respond adequately to water-vapour treatment
• A need for rapid and highly predictable relief of severe obstruction

An active urinary infection should be treated before Rezūm. Patients with suspected prostate cancer should also undergo appropriate investigation rather than assuming their urinary symptoms are simply due to benign prostate enlargement.

Importantly, a median lobe is not a contraindication to Rezūm. Modern evidence also suggests that a prostate larger than 80 mL, previous BPH surgery or urinary retention should not automatically exclude treatment, although these situations require careful assessment and individualised counselling.

Rezūm versus more conventional prostate surgery

Rezūm offers a different balance of advantages and disadvantages compared with procedures such as TURP or laser prostate surgery.

The principal attraction is that it is minimally invasive and generally has a lower risk of sexual side effects, particularly ejaculatory dysfunction.

The trade-off is that improvement is gradual rather than immediate and a small proportion of men will require additional treatment in the future.

For men with severe obstruction, very large prostates, bladder stones, recurrent urinary retention or other complications of BPH, a more definitive tissue-removing procedure may sometimes be preferable.

Is Rezūm right for me?

Choosing treatment for benign prostate enlargement should not be based on prostate size alone.

The most appropriate treatment depends upon:

your symptoms + prostate size and anatomy + urinary flow + bladder function + general health + medications + sexual priorities + personal preference.

For the right patient, Rezūm can provide a useful bridge between medication and conventional prostate surgery: substantial improvement in urinary symptoms with a short procedure and a favourable sexual side-effect profile.

The key is appropriate patient selection.

A urological assessment can determine whether your symptoms are genuinely caused by prostate obstruction and whether Rezūm, another minimally invasive procedure, medication or more definitive prostate surgery is the most appropriate treatment.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on consultation with a qualified urologist and assessment of each patient’s symptoms, prostate anatomy, bladder function and general health.

Come chat with your local Brisbane based Urologist, Dr Jo, to discuss Rezum with you. Jo and one other Urologist in QLD were the first to start this technique in QLD.