Comparison of water vapor thermal therapy and prostate artery embolization for fragile patients with indwelling urinary catheters: Preliminary results from a multi-institutional study.

PURPOSE: To report our preliminary experience with water vapor thermal therapy with the Rezum™ System and Prostate Artery Embolization (PAE) for treatment of medically refractory, complete urinary retention to achieve successful cessation of catheter dependency in frail-patients. PATIENTS AND METHODS: A multi-institutional study was conducted including all patients who underwent Rezum™ procedure and PAE between October 2017 and June 2020. The included population focused on frail-patients unsuitable for conventional surgery with complete urinary retention. Rezum™ patients were identified and matched (1:1) with patients who underwent PAE. The matching criteria were age, Charlson score, prostate volume and duration of follow-up. The primary outcome was catheter-free survival, defined as spontaneous voiding and release from catheter dependence. RESULTS: Eleven patients from the Rezum™ group were matched to 11 embolized patients. PAE and Rezum™ patients were comparable in age (median: 77 vs. 75 years), Charlson score (median: 6 vs. 6) and prostate volume (74 vs. 60 cc). Procedures were significantly longer in the PAE group compared to the Rezum™ procedures (median: 148 vs. 8min, P<0.001). After a median follow-up of 12 months, spontaneous voiding was conserved in all cases (100%) after the Rezum™ procedure and in 5 cases (45.4%) after PAE (P=0.01). In catheter-free patients, the rate of benign prostatic hyperplasia medication use after procedure was 40% for PAE and 18.2% for Rezum™ patients (P=0.54). CONCLUSIONS: Our preliminary experience for treatment of complete urinary retention in frail-patients shows the feasibility of PAE and Rezum™ to restore spontaneous urination without being associated with the occurrence of major complications. Early data suggests that Rezum™ may provide superior results in terms of cessation of catheter dependence. Future studies are needed to definitively assess which treatment would be best suited for each patient. LEVEL OF EVIDENCE: 3.

Holmium laser enucleation and water vapor thermal therapy for the treatment of symptomatic benign prostatic hyperplasia: A cost analysis.

PURPOSE: To perform a cost analysis of the current gold standard operation of Holmium Laser Enucleation of the prostate (HoLEP) compared to the new technique of water vapor thermal therapy with the Rezum™ system for the treatment of symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Between October 2017 and January 2020, consecutive patients with invalidating lower urinary tract symptoms due to BPH who underwent Rezum™ and HoLEP procedures from the Aix regional hospital were identified. The outcome of each technique was assessed in terms of cost from the institutional perspective. Detailed expense reports based were provided by the accounts department of the hospital. These were used to compare in-hospital costs for each procedure. RESULTS: A total of 53 and 94 consecutive patients underwent respectively water vapor thermal therapy and HoLEP. The median costs for the surgical procedure were €1344 (IQR 1331-1361) and €669 (IQR 584-824), respectively for Rezum™ and HoLEP (median difference €675; P<0.001). The median costs of the hospital stay were €869 (IQR 869-869) for Rezum™ and €1295 (IQR 1295-1330) for HoLEP (median difference €426; P<0.001). Finally, the median total costs per patient were lower for HoLEP (€2005 [IQR 1902-2150]) than for Rezum™ (€2228 [IQR 2209-2243]) procedure, and the median difference of €233 was significant (P<0.001). CONCLUSIONS: One of the anticipated benefits of Rezum™, reduced length of hospital stay with an associated reduction in cost, did not materialize within this study. The patient's clinical condition and expectations should also be taken into account when deciding between Rezum™ and standard therapies. LEVEL OF PROOF: 3.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]. / Traitement chirurgical et interventionnel de l'obstruction sous-vésicale liée à une hyperplasie bénigne de prostate : revue systématique de la littérature et recommandations de bonne pratique clinique du Comité des Troubles Mictionnels de l'Homme.

OBJECTIVE: The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). METHODS: All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. RESULTS/GUIDELINES: Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. CONCLUSION: Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

[An update on the most recent mini-invasive surgical and interventional techniques in the management of benign prostatic obstruction]. / Mise au point sur les nouvelles techniques chirurgicales et interventionnelles dans la prise en charge de l'obstruction sous-vésicale liée à l'hyperplasie bénigne de la prostate.

INTRODUCTION: New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies. MATERIAL: A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France. RESULTS: The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries. CONCLUSION: These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.

Treatment of benign prostate hyperplasia using the Rezum® water vapor therapy system: Results at one year.

PURPOSE: To report the results of convective radiofrequency (RF) water vapor thermal therapy in men with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) with one-year follow-up evaluation. MATERIAL AND METHOD: The study was conducted in 2 French hospitals, for men with moderate to severe LUTS secondary to BPH, as an alternative to classical surgery treatment. The pre- and postoperative evaluation of urinary symptomatology was based on the International Prostate Symptom Score (IPSS) questionnaire, measures of peak urinary flow rate (Qmax) and post-void residual volume (PVR). Erectile and ejaculatory functions were evaluated via the IIEF5 and MSHQ-ejd questionnaires. Rates of retreatment and complications were also reported. RESULTS: Sixty-two outpatients including 8 with urinary retention were treated. The median preoperative prostate volume was 47 (27-200) mL. At 6months postoperative, the IPSS had decreased significantly by 13.9 points (68.1%, P<0.001) and, at one year, by 12 points (61.5%, P<0.001). The quality of life (QoL) score at one year had decreased by 3.2 points (P<0.001) and the Qmax had improved by 6mL/s (P<0.001). All patients with urinary retention were weaned from bladder catheterization. No serious side effects (>Clavien II) were observed. No cases of de novo erectile dysfunction and an anejaculation rate of 10.8% was reported. The surgical retreatment rate at one year was 2.1%. CONCLUSION: The short-term results are encouraging, with significant efficacy on urinary symptoms and respect of sexual function. Nevertheless, it will be necessary to pursue the follow-up of this cohort to evaluate the mid-term and long-term evolution. LEVEL OF EVIDENCE: 3.

Perioperative and economic analysis of surgical treatments for benign prostatic hyperplasia: A study of the French committee on LUT.

PURPOSE: To evaluate perioperative cost related to surgical treatments of benign prostatic obstruction (BPO): photoselective vaporization of the prostate (pvp), holmium/thullium laser enucleation (HoLEP/ThuLEP), transurethral resection of the prostate (TURP) and open prostatectomy (OP). MATERIAL AND METHODS: We retrospectively collected data from 237 patients who consecutively underwent a surgical treatment for BPH between January 2012 and June 2013 at nine institutions in France. An economic simulation model was constructed to estimate the cost of hospitalization related to surgical procedure from the hospital perspective and a cost minimization analysis was performed. RESULTS: TURP, OP, HoLEP/ThuLEP and PVP were performed in 99 (42%), 23 (10%), 64 (27%) and 51 (21%) patients, respectively. For men with prostate size<80mL: mean operative time was shorter with mTURP and PVP than HoLEP/thuLEP (P<0.001); Mean postoperative length of stay were 1.9, 3 vs. 3.4 days, for HoLEP/Thulep, PVP and TURP respectively (P=0.006); Costs of first hospitalization were comparable between HoLEP/ThuLEP and TURP but higher with PVP (P<0.001). For men with prostate size≥80mL: Compared to PVP and HoLEP/ThuLEP, OP was associated with shorter operative time (P<0.001) but longer length of stay (2.4, 4.2 vs. 7.8 days, respectively, P<0.0001); Costs of first hospitalization were significantly higher with OP than HoLEP/ThuLEP or PVP (P<0.001). CONCLUSIONS: PVP and HoLEP/ThuLEP were associated with a shorter LOS than TURP and OP. This benefit suggests these procedures could be more cost effective than OP, but still not cheaper alternatives to TURP. LEVEL OF EVIDENCE: 5.

[Medicoeconomic aspects of benign prostatic hyperplasia medical treatment]. / Aspects médicoéconomiques des traitements médicamenteux de l'hypertrophie bénigne de la prostate : une revue de la littérature du Comité des troubles mictionnels de l'homme de l'Association française d'urologie.

INTRODUCTION: The medicoeconomic issues of drug management of benign prostatic hyperplasia (BPH) are essential due to the aging population and the increasing number of therapeutic options. It is thus essential to assess the cost-effectiveness in order to define the most appropriate therapeutic strategies economically. The objective of this work was to conduct a literature review on the medicoeconomic studies on the drug therapy of BPH. METHOD: After analyzing the literature, 43 articles were found and 9 were selected for their relevance. RESULTS: Based on Markov models, we observed that: combination therapy and combined treatments (alphablockers and inhibitors of 5-alpha reductase [5ARI]) seemed to have the best cost-effectiveness. Then came the alphablockers, less expensive but exposing to a greater risk of progression and to the necessity of surgical treatments. Then came the 5ARI monotherapy and finally simple monitoring. CONCLUSION: The Markov models are imperfect tools, and resources invested in care depend on both the economic model and the value that individuals and society give to efficiency and cost.

[Serious and unexpected complications of benign prostatic obstruction surgery: Results of the LUTS Committee survey from urologists of the French Urological Association]. / Complications graves et inattendues de la chirurgie de l'hyperplasie bénigne de prostate : résultats de l'enquête du CTMH auprès des urologues de l'AFU.

PURPOSE: Rare and severe complications of benign prostatic hyperplasia (BPH) surgery are poorly documented in the literature. Our purpose was to make an inventory of severe and unexpected complications of BPH faced by urologists of the French Association of Urology (AFU). MATERIAL AND METHODS: A declarative 13-question survey was sent by e-mail 2 months before the 108th French Congress of Urology to the urologist's members of the AFU. Complications were split in complications due to material and complications directly related to the surgery. RESULTS: Overall, 216 (16.2%) urologists surveyed but only 85 forms were usable. Complications related to the material was divided into: excessive temperature of the serum irrigation leading to urethral and bladder burns (n=5), material default leading to interruption of the procedure (n=1) or incomplete hemostasis (n=2) and endoscope rupture (n=1). Peroperative complications related to surgery were divided into surgical complications: haemorrhage (n=7), urethral wounds (n=6), perforation and/or explosion (n=16), rectal wounds (n=11), obstructive renal failure (n=1); and medical complications: TURP syndrome (n=2), cardiovascular (n=5) and septic shock (n=6). CONCLUSION: This is the first French declarative study having allowed the identification of severe and unexpected complications of BPH surgery. The recorded occurred complications were very eclectic and secondary to all types of techniques used.

[Guide dedicated to general practitioner for the management of lower urinary tract symptoms related to benign prostatic hyperplasia]. / Guide de prise en charge en médecine générale des symptômes du bas appareil urinaire de l'homme liés à une hyperplasie bénigne de la prostate.

OBJECTIVE: To establish a guide dedicated to general practitioner for the diagnosis, the follow-up, and the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH). METHOD: Guidelines already published for urologists were modified to make them relevant for general practitioners. The role of specialist's referral was defined. The whole content of the document was submitted to the formal consensus process in which urologists and general medicine teachers were involved. RESULTS: Initial assessment has several aims: making sure that LUTS are related to BPH, assessing bother related to LUTS, and checking for a possible complication. Initial assessment should include: medical history, physical examination with digital rectal examination, and urinalysis. Some other explorations such as frequency volume chart, serum PSA or creatinine, and ultrasonography of the urinary tract were found optional, meaning they are necessary only in specific situations. Referring to urologist is justified when LUTS might not be related to BPH (particularly when urgencies are predominant), or when a severe bladder outlet obstruction is suspected (severe symptoms, palpable bladder, post-voiding residual volume>100ml), or when a complication is assessed. Follow-up without treatment is justified for patients with no bothersome symptoms related to not complicated BPH. Several drugs are available for the treatment of bothersome symptoms related to BPH. Alpha-blockers and plants extracts might be offered as monotherapy. Five alpha reductase inhibitors might be offered to patients with LUTS related to a significant prostate hypertrophy (>40 ml) ; they might be given for a minimum duration of one year, alone or in association with alpha-blocker. The association of antimuscarinic and alpha-blocker might be used in patients with persistent storage LUTS in spite of alpha-blocker treatment. Phosphodiesterase 5 inhibitors might be offered to patients with erectile dysfunction associated with LUTS related to BPH. In case of complicated BPH, or when medical treatment is not efficacious or not tolerated, a surgical option should be discussed. CONCLUSION: The male lower urinary tract symptom committee of the French Urological Association and general practitioner present the first guide for the management of LUTS related to BPH dedicated to general practitioner. LEVEL OF EVIDENCE: 5.

[Evaluation of the impact of CTMH guidelines on the management of benign prostatic hyperplasia]. / Évaluation de l'impact des recommandations du Comité des troubles mictionnels de l'homme sur la prise en charge de l'hypertrophie bénigne de prostate.

INTRODUCTION: The French guidelines on the management of benign prostatic hyperplasia (BPH) have been published in 2012 by the LUTS committee of the French Urological Association. The aim of this study was to evaluate the impact of these guidelines on the BPH management by French urologists. MATERIAL AND METHODS: A questionnaire has been distributed by email to 1141 urologists members of the French Association of Urologists in November 2013. RESULTS: We collected 222 responses (response rate: 19%). The guidelines have been read by 73% of the urologists. The guidelines were followed most of the time by 76% of them, 11% followed them systematically and 4.5% did not follow them. The new terminology was used by 28 to 52% according to the items. The symptoms were evaluated by the IPSS score (33%), by interrogatory alone (64%) or by neither of them (3%). Prostate volume was not systematically taken for account in the treatment strategy by 57% of the urologists. Sexual function was assessed systematically by 28% of the urologists, 11% used a questionnaire (IIEF: 92%). PSA was tested respectively by 70 and 51% of the urologists at the initial evaluation and the follow-up. After introduction of a monotherapy, 56% of the urologists evaluated the efficacy at 3 months. CONCLUSION: The French guidelines for the management of benign prostatic hyperplasia (BPH) by the LUTS committee of the French Urological Association were well known and used by French urologists. Some improvements can be expected for the use of the IPSS score, the evaluation of the sexual function, and the use of the new terminology. LEVEL OF EVIDENCE: 4.

[Conservative treatment of male non-neurologic urinary incontinence: a review by the LUTS committee of the French Urological Association]. / Traitements palliatifs et conservateurs de l'incontinence urinaire masculine non neurologique: une revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the conservative treatment of male non-neurologic urinary incontinence. METHOD: A systematic review was conducted using PubMed/MEDLINE with the following keywords: "incontinence", "male stress urinary incontinence", "pelvic floor training", "biofeedback", "absorbant products", "life style", "penile clamp". RESULTS: Palliative devices like penile clamps, penile sheaths and absorbent products were transitory options that were poorly evaluated. Life style modifications (scheduled voiding, controlled hydric absorption, decreased caffeine and spice intake) were useful in complement of other treatments especially in case of overactive bladder. Pelvic floor training (PFT) was useful after radical prostatectomy but remained optional for other types of incontinence. It accelerated the continence recovery postoperatively but it results at 1 year were uncertain. These results were maintained 1 year. Conservative treatments were useful postoperatively especially early supervised PFT. The benefit of biofeedback and perineal stimulation was controversial. Balder catheterization was a last resort option. Penile sheaths were better than urethral catheterization if there were no post-voiding residual urines. CONCLUSIONS: Palliative options have a limited efficacy but are mini-invasive and might be helpful complementary options.

[Treatment of non-neurogenic masculine urinary incontinence due to overactive bladder: a review by the LUTS committee of the French Urological Association]. / Traitement de l'incontinence urinaire masculine non neurologique par hyperactivité vésicale : une revue de la littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the treatment of masculine urinary incontinence due to idiopathic overactive bladder. METHOD: A systematic review was conducted using PubMed/MEDLINE with the following keywords: "overactive bladder", "male urinary incontinence", "urgency", "antimuscarinic", "onabotulinumtoxinA", "neurostimulation", "cystoplasty". RESULTS: Antimuscarinic treatments were the first line option for overactive bladder incontinence (decreased incontinence under tolterodine versus placebo respectively -71% vs. -40%, P < 0.05). Their main side effects were dry mouth (16-29.6%) and constipation (4%), which might decrease the observance. In case of failure, neuromostimulation could be prosed with a 67% efficacy rate. Intra-detrusorian injections of onabotulinumtoxinA were an option, however there were still not validated for this indication and their efficacy decreases with time and after repeated injections. The ultimate option in case of refractory major over-activity was cystoplasty, which involves major morbidity for inconstant efficacy. CONCLUSIONS: The same treatments are available for non-neurologic urinary incontinence by bladder over-activity for men and women: antimuscarinic drugs, neurostimulation, onabotulinumtoxinA. However, only few data is available for masculine population exclusively.

[Initial assessment of male non-neurogenic incontinence: systematic review of the literature by the LUTS committee of the French Urological Association]. / Bilan initial d'une incontinence urinaire masculine (non neurologique): revue de la littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the initial evaluation of male urinary incontinence (MUI). METHOD: A systematic review was conducted using Pubmed/Medline from 1995 to 2013. RESULTS: Definition of MUI and its prevalence is variable according its definition and the population. Tools for its evaluation have been mainly studied in female population or only in patients with UI after radical prostatectomy. Objectives of the initial evaluation are to assess the type of incontinence, to evaluate its severity and the bother associated, and define the choice of treatment. Medical history, clinical assessment, and urine analysis are the first steps of the evaluation. Bladder diary, questionnaires and pad test can be useful to evaluate MUI. Post-void residual volume assessment is necessary if lower urinary tract symptoms are associated. Imaging is not routinely used in MUI. A specialist referral and further investigations such as urethrocystoscopy and urodynamics should be considered in case of invasive treatment, recurrent incontinence and specific situations. CONCLUSIONS: Initial assessment of MUI should be sequential with systematic investigations and optional ones.

[Initial assessment, follow-up and treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: guidelines of the LUTS committee of the French Urological Association]. / Bilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l'AFU.

AIM: To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH). METHOD: A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique. RESULTS: Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate. CONCLUSION: Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

[Surgical management of benign prostatic hyperplasia by endoscopic techniques using electricity and open prostatectomy: A review of the literature by the LUTS committee of the French Urological Association]. / Traitement de l'hyperplasie bénigne de prostate par techniques endoscopiques électriques et adénomectomie voie haute : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the surgical treatment of benign prostatic hyperplasia (BPH) by endoscopic electric resection and vaporization, and by open prostatectomy. METHOD: A systematic review of recent literature was performed. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Both monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Endoscopic electric alternatives are monopolar and bipolar prostate vaporisation as well as bipolar resection. These techniques seem to show similar functional results than TURP and open prostatectomy, as well as an advantage in terms of bleeding.

[Surgical management of BPH by laser therapies: A review of the literature by the LUTS committee of the French urological association]. / Traitement chirurgical de l'hyperplasie bénigne de la prostate par laser : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on the surgical treatment of benign prostatic hyperplasia (BPH) by laser. METHOD: A systematic review of recent literature was performed. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Alternative endoscopic options are laser photoselective vaporisation, holmium enucleation and thulium resection. These techniques seem to show functional results similar to those obtained after TURP and open prostatectomy, as well as an advantage in terms of bleeding.