The Prostatic Urethral Lift Procedure: Enough Bang for the Buck?

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.

In this issue of European Urology, Sønksen et al [1] report on the first randomized trial comparing the prostate urethral lift (PUL) procedure [2], [3], [4], [5], and [6] to transurethral resection of the prostate (TURP). In a study encompassing 80 patients among ten European centers, the authors assessed the efficacy and morbidity of the two procedures using a six-component composite metric, dubbed BPH6. The metric includes measures for lower urinary tract symptoms (LUTS) reduction, erectile function, ejaculatory function, continence, complications, and recovery after the procedure. While statistically significant improvements in LUTS were noted in both groups compared to baseline, TURP was superior in terms of its impact on International Prostate Symptom Score (IPSS; –15.4 vs –11.4), quality of life (–3.1 vs –2.8), peak flow rate (+13.7 vs +4.0), and postvoid residual volume (–70 vs +7.4), whereas PUL was superior in minimizing side effects related to ejaculatory dysfunction. The overall rate of adverse events was similar between the two procedures, with the exception of a higher rate of retrograde ejaculatory dysfunction after TURP (40%, p < 0.0001). PUL patients had shorter hospitalization (1.0 vs 1.9 d, p < 0.0001) and catheterization durations, resulting in a faster return to preoperative activity (11 vs 17 d, p = 0.04). Overall, 52.3% of PUL patients achieved the BPH6 endpoint at 12 mo after surgery, compared to 20.0% of TURP patients (p = 0.005).

The authors propose use of the BPH6 metric as a more comprehensive proxy that not only addresses improvement in LUTS but also adjusts for morbidity associated with treatment, such as incontinence, sexual side effects, pace of recovery from surgery, and complications. Although the BPH6 metric remains unvalidated as a new measure, it is interesting to note that the superior performance of PUL over TURP according to the metric was not driven by the degree of improvement in LUTS, but rather by better performance in terms of recovery after surgery and a lower rate of ejaculatory dysfunction. Indeed, fewer patients noted a 30% improvement in IPSS score for PUL (72%) compared to TURP (91.2%, p = 0.05), whereas others noted preservation of sexual function after the PUL procedure [7] and [8]. This study perhaps serves as a reminder of the old adage, “You get what you pay for.” Patients treated with TURP tended to have better improvement in LUTS but at the price of a longer recovery period and a higher rate of retrograde ejaculation compared to PUL.

The PUL procedure represents another attempt to create an office-based therapy for bladder outlet obstruction. Can we replicate the efficacy of TURP while minimizing morbidity ideally using an in-office procedure? Prior attempts such as transurethral microwave thermotherapy and needle ablation have fallen out of favor because of their relative lack of efficacy. Initial data for the PUL procedure appear to demonstrate reasonable efficacy, and it will likely play a role in the treatment of bladder outlet obstruction. The ultimate issue lies in patient selection. It is clear that certain patients will elect to undergo a PUL procedure over TURP, but it is likely that not every man will choose this option. Thus, the field has perhaps further built on the concept initially pioneered by medical therapy via the creation of new options and possibilities for patients before they need to endure truly invasive surgery that may involve prolonged recovery.

It will be interesting to observe how indications for the PUL procedure change over time. To date, studies have only included patients with prostate glands <60 cm³ in size or those without an obstructing median lobe. The efficacy of the PUL procedure in patients who fall outside these boundaries is still unknown, and patient selection will continue to be critical in the future.

Finally, this study also touches on a facet of clinical care often overlooked by clinicians. We tend to focus more directly on peri- and postoperative clinical outcomes. For example, are the patient's LUTS improved by the procedure in question? Similarly, can this improvement be achieved with minimum adverse events or complications? What we often do not focus on is the length of time needed by patients to achieve a full recovery. Lost productivity due to longer recovery from treatment represents an indirect cost that has traditionally been difficult to capture or measure, and can in fact be greater than the direct costs of surgery or its related complications. We should not fail to overlook the importance of this factor when offering different treatment options to patients.