Compliments to the authors for a very well documented video capturing the detailed steps of the prostatic urethral lift (PUL) for patients with benign prostatic obstruction (BPO) with obstructive median lobe.1 Although the side-by-side demonstration of the hand movements and endoscopic view is a good way for training for any procedure, the case selection and evaluation of the cases for this study are suboptimal, as the authors used PUL for a 120 gm adenoma with a vesical calculus without any documentation and grading of the intravesical prostatic protrusion (IPP) before the decision of PUL. Voiding is normally an interplay between the outlet resistance caused by an enlarged prostatic adenoma and the pressures generated by the detrusor contractions. IPP would hamper this physiology by preventing the complete opening of the bladder neck and distortion of the funnelling effect of the normal vesicourethral angle. It is known that an enlarged middle lobe with IPP causes severe symptoms and a ‘ball-valve’ type obstruction. Large IPP strongly correlates with significant bladder outlet obstruction (BOO) on urodynamic assessment. A large study of 239 individuals showed that a IPP >5.5 mm had a 66.7% sensitivity, 80.5% specificity for BOO on UDS.2 Over nearly a decade, there is an increasing interest in the use of minimally invasive surgical treatment (MIST) options for the management of BOO with an intent of improving the quality of life of these patients. It is accepted that MIST would minimize the impact of BPO treatments on sexual function at the cost of reduced symptomatic improvements. MIST carries a variable retreatment rate of up to 10% at 3–5 years follow-up. MIST is ideally suited for a man with mild-moderate symptoms without any absolute indications for surgical intervention. Based on the type of the MIST procedure, there are specific patients where MIST can be used. As per the present guidelines, these would be a man interested in maintaining his sexual function and has a prostate not larger than 80 g without a median lobe.3 It may be used rarely for a patient who is unfit for a definitive prostatectomy. The present guidelines still consider the median lobe a contraindication for the PUL procedure. EAU guidelines present a strong recommendation to offer PUL to men with LUTS with prostates 80 gm. Water wave thermotherapy is better suited for patients with the middle lobe, with sustained appreciable improvements (47% reduction) for each IPSS domain.8 The surgical re-treatment rate is low at 4.4% at 4 years, and not treating the middle lobe was a primary indication for re-treatment after water wave thermotherapy.9 Prostate artery embolization (PAE) is also not an alternative for BOO due to BPO with the median lobe, as PAE fails to alter the preexisting anatomy. Ball-valve type obstruction might worsen as post-PAE, the ischemic prostatic tissue softens and becomes increasingly mobile, leading to an increase in the severity of LUTS and an increased rate of AUR.10 A temporary implantable nitinol device and an Optilume paclitaxel-coated balloon have no place in patients with a median lobe. Robotic waterjet-based resection of prostate (Aquablation) is an alternative for men with a large median lobe, as the treatment planning protocol can map and ablate the middle lobe. The questions to be asked would be whether PUL should be done for a 120 gm prostate with vesical calculus, or a 70 gm prostate in a patient with cognitive impairment? Can we consider all patients with IPP as similar? Results may differ between those with low-grade and high-grade IPP. Data could be looked at based on the thickness-to-height ratio of the IPP.10 The shape or morphology of IPP may be more important than its presence. Current literature does not contradict PUL for middle lobe enlargement, but caution needs to be exercised, given the risk of persistent or worsening symptoms in this group of patients. A recent report concluded that, apart from sexual side-effects and low risk of complications, a high rate of success is equally important.11 Men seek the treatment that also manages bothersome storage symptoms. Surgical sexual side effects may be important for some men, but for most, personal, physical, financial, emotional, relational, and social factors are more important in treatment decision-making. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Maheshwari et al. (Fri,) studied this question.
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