Do patients Rezum medications?—a real-world analysis of medical retreatment after water vapor thermal therapy

Introduction

Multiple surgical modalities are available for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Notably, there has been growing interest in minimally invasive options that aim to balance efficacy with reduced morbidity, such as preserving sexual function and faster recovery (1,2). Among the recent advances in minimally invasive surgical techniques, water vapor thermal therapy (WVTT; Rezum, Boston, Scientific, Marlborough, MA, USA) has emerged as a promising surgical option for symptomatic BPH (3). WVTT utilizes radiofrequency-generated water vapor that is delivered transurethrally to ablate hyperplastic prostatic tissue through localized thermal energy release (2,4,5). WVTT has been shown to provide lasting improvements in LUTS while preserving erectile and ejaculatory functions (2,6,7).

We previously found that WVTT is associated with a low surgical retreatment rate; risk factors included a greater number of treatments per lobe and worsening International Prostate Symptom Scores (IPSS) at 6 months postoperatively (8). However, the incidence and predictors of medical retreatment following WVTT have not been well studied. Herein, we sought to assess potential clinical factors associated with resumption or initiation of medical therapy after WVTT therapy. Specifically, our objectives were to determine the overall incidence of medical retreatment in our patient cohort, identify patient and procedural factors potentially associated with increased likelihood of retreatment, and evaluate patterns of medication reinitiation. By elucidating these factors, we aim to contribute to a more comprehensive understanding of WVTT for symptomatic BPH to ultimately better inform patient counseling. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-568/rc).

Methods

We performed single institution, retrospective analysis of consecutive patients who underwent WVTT by a single surgeon at an academic center (University of California San Diego) between July 2018 and January 2024.

All data were collected from the electronic medical record and deidentified. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB) of the University of California, San Diego (IRB #812653). Informed consent was waived in this retrospective study. Preoperative variables included age (years), race, insurance, prostate volume (cc), prostate-specific antigen (PSA) levels (ng/dL), prostate cancer diagnosis, baseline IPSS, uroflowmetry parameters [maximum flow rate (Qmax) and postvoid residual (PVR)], previous BPH surgery, presence of median lobe on cystoscopy, and use of alpha blocker, 5 alpha reductase inhibitor, or daily tadalafil at time of preoperative visit. Perioperative variables included total number of thermal injections administered, number of injections per lobe, treatment of median lobe (if present), as well as duration of postoperative catheter. Postoperative parameters included any adverse events encompassing urinary tract infections (UTIs), catheter retention, emergency department visit, hospital readmission, surgical retreatment, urinary retention requiring replacement of foley catheter, and medical retreatment.

We included patients with prostate volume between 30 and 80 cc per the American Urological Association guidelines (9). Monitored anesthesia care was administered for the procedure in an ambulatory surgery center. BPH medications were stopped 4–6 weeks after the procedure. Postoperative data included repeat IPSS at 1, 3, 6, and 12 months. Patients lost to follow up were excluded. The primary outcome of this study was medical retreatment, defined as restart or new initiation of BPH medication after WVTT for persistent or recurrent LUTS within 2 years of original treatment.

Statistical analysis

All statistical analysis was conducted utilizing SPSS version 29. Descriptive statistics were performed. The bivariate Pearson correlation test was used to determine correlation between continuous variables. The Chi-squared test of independence was used to determine correlation between categorical variables. The one-way analysis of variance (ANOVA) was used to assess correlation between continuous and categorical variables. Given the retrospective design of the study, we could not blind participants or investigators to eliminate bias.

Results

A total of 155 patients who underwent WVTT were included in this analysis. Mean and median follow-up duration were 19.5 and 14.0 months, respectively. Medical retreatment occurred in 48 patients (31%). The mean and median time to medical retreatment were 9.8 and 4.0 months, respectively (Figure 1).

Figure 1 Summary of study findings. WVTT, water vapor thermal therapy.

Baseline demographic and clinical characteristics are summarized in Table 1. There was no significant difference between the two cohorts in age (67.4±10.3 vs. 68.8±10.8 years; P=0.28), race (72.3% vs. 74.8% Caucasian; P=0.44) and insurance status (56.3% vs. 50.5% government; P=0.50). Mean PSA levels (2.0±1.9 vs. 3.0±3.1 ng/dL; P=0.06) and concomitant prostate cancer diagnosis (2.1% vs. 2.8%; P=0.80) were similar between the cohorts.

Patients who underwent medical retreatment were significantly more likely to be on prior BPH medications including preoperative alpha blockers (95.8% vs. 84.1%; P=0.04), 5 alpha reductase inhibitors (39.6% vs. 23.4%; P=0.04), and daily tadalafil (35.4% vs. 15.0%; P=0.004).

There was no significant difference in history of urinary retention (6.3% vs. 3.7%; P=0.49) or prior BPH surgery (transurethral resection of prostate: 0% vs. 0.9%; Urolift: 0% vs. 0.9%; WVTT: 4.2% vs. 3.7%; P=0.82). Likewise, prostate volume (43.5±14.1 vs. 47.8±13.1 cc; P=0.09) and presence of median lobe on cystoscopy (75.0% vs. 75.5%; P=0.95) were similar between the two groups.

Baseline symptom burden was comparable between groups, with no statistical difference in baseline Qmax (12.4±7.7 vs. 12.4±13.0 mL/s; P=0.99), PVR (83.3±79.5 vs. 92.7±147.8 mL; P=0.71), and total IPSS (18.7±7.7 vs. 19.1±7.6; P=0.74). Preoperative baseline IPSS quality of life (QoL) was significantly lower in the medical retreatment group (4.1±1.5 vs. 4.5±1.2; P=0.05).

Intraoperatively, there were no differences between the two cohorts in regards to total number of WVTT treatments administered (4.0±1.7 vs. 4.6±2.3; P=0.08), number of WVTT treatments per lobe (1.8±0.8 vs. 2.0±1.0; P=0.17), treatment of median lobe if present (42.6% vs. 55.8%; P=0.13), and duration of postoperative catheter (3.4±1.9 vs. 3.3±1.4 days; P=0.51).

Postoperatively, uroflowmetry parameters of Qmax and PVR were similar at 1, 3, 6, 12, and 24 months. IPSS total and QoL were similar at 1, 6, 12, and 24 months. However, IPSS total (15.5±7.9 vs. 9.8±6.1; P=0.002) and QoL (3.2±1.6 vs. 2.4±1.5; P=0.05) were significantly higher in the medical retreatment group at the 3 month mark.

There was no significant difference in postoperative adverse outcomes between the two groups (Table 2), including rates of UTI (4.2% vs. 0.9%; P=0.18) and urinary retention requiring catheter replacement (16.7% vs. 15.1%; P=0.80). For those who required catheter replacement, catheter duration was similar (15.8±10.6 vs. 16.4±20.4 days; P=0.94). 30-day rates of Emergency Department visits (6.3% vs. 5.6%; P=0.87) and readmission (2.1% vs. 0.9%; P=0.56) were similar.

Overall surgical retreatment rate within 3 years was 9.7%, with a mean time to surgical retreatment of 29.6 months. Though not statistically significant, a higher proportion of the medical retreatment cohort underwent surgical retreatment (12.5% vs. 8.4%; P=0.43). The medical retreatment cohort also had a nonsignificant shorter time to surgical retreatment (27.7±28.3 vs. 30.9±19.6 months; P=0.80).

Among the 48 patients who underwent medical retreatment, the most commonly restarted medication was an alpha blocker (40.5%), followed by daily tadalafil (25.5%) and 5 alpha reductase inhibitor (10.6%). Twenty-three point four percent (23.4%) of patients resumed multiple BPH medications (Figure 2).

Figure 2 Proportions of medications restarted. BPH, benign prostatic hyperplasia.

Discussion

Our study is one of only a few that specifically evaluates medication retreatment after WVTT for BPH in a real-world population. We found that over 30% of patients who underwent WVTT required medical retreatment, defined as the resumption or initiation of BPH pharmacotherapy, over a mean follow-up period over 19 months. Mean time to medical retreatment was 9.8 months, underscoring that patients become symptomatic enough to warrant treatment within one year of the index procedure. A recent systematic review concluded that pharmacological rates after office-based BPH therapies are poorly reported, with WVTT studies rarely detailing medication restarts (10); nonetheless, available data suggest up to 11% of WVTT patients resumed BPH medications by 5 years post-procedure (4,11). McVary et al. reported that following WVTT, initiation rate of alpha blocker use was 0.7%, 2.2%, 3.7%, and 5.2% at 1, 2, 3, and 4 years, respectively (4). The discrepancy between those findings and the current study likely reflects differences in patient populations and real-world practice patterns. It may also reflect the fact that we defined retreatment as both new initiations and restart of pharmacotherapy.

Likewise, the surgical retreatment rate of 9.7% within 3 years amongst our cohort was higher than previously reported rates of 4–7% (5,11). It is not surprising that there was a trend towards higher surgical treatment amongst the medical retreatment cohort (12.5% vs. 8.4%), which likely correlates to more bothersome symptomatology. When considering overall retreatment, including both surgical and pharmacologic interventions, our findings suggest that the total burden of retreatment may be greater than previously recognized. This distinction is clinically relevant, as it underscores the importance of setting appropriate expectations during patient counseling regarding the benefits of the procedure as well as potential need for resumption of therapy in the future. Though medical retreatment is often viewed as “less risky” than a second trip to the operating room, medications can still incur a significant cost and be associated with unwanted side effect profiles (12,13).

A key finding in our study is that preoperative medication use was predictive of post-WVTT medication retreatment. These medications are often markers of more advanced or complex BPH; for example, 5 alpha reductase inhibitor usage typically indicates larger prostate volumes or a need to prevent progression (14). One can also postulate that perhaps patients who were on medications preoperatively do not find reinitiation of pharmacotherapy as cumbersome.

Additionally, our study supports that patients who did not require retreatment achieved significantly greater symptom improvement early on. By 3 months post-WVTT, the no-retreatment group had significantly lower IPSS total scores and a trend toward better IPSS QoL scores. This early divergence in symptom relief carries important clinical implications, suggesting that early postoperative symptom trajectory can be an indicator of long-term success. Persistent elevated symptom scores or minimal improvement within the early postoperative period may serve as an indicator of suboptimal treatment response and warrant closer clinical follow-up (8).

As a minimally invasive intervention, WVTT offers effective symptom relief for symptomatic BPH in selected patients. The resumption of BPH medications post-treatment should not necessarily be interpreted as treatment failure, as many patients still experienced meaningful improvements in symptom burden and urinary function as evidenced by the trends of the IPSS scores. Our work highlights the importance of aligning patient goals of care with post procedural expectations in order to yield the greatest satisfaction and success. For example, patients may be willing to accept a higher medical retreatment rate if they value preservation of ejaculatory function. Post-procedural pharmacologic retreatment may serve as an additional mechanism for symptom maintenance in appropriately selected patients.

This study has several limitations including its single surgeon, single institution, retrospective design. Follow-up duration may be considered modest in this setting with a mean of 19 months; however, we did track surgical retreatment up to 3 years. Furthermore, we did not exclude data from patients in the medical retreatment group after initiation of the medications; thus, it is possible that improvement in IPSS scores after medication resumption may have confounded the comparison between the two cohorts. For example, there was a difference in IPSS at 3 months, before the mean and median times to resume medication (9.8 and 4.0 months, respectively), but not 6, 12, and 24 months. Our findings are also not generalizable to men with larger prostates given we excluded prostate volume greater than 80cc per the AUA guidelines in place at the time of the study. However, a recent meta-analysis demonstrated short-term improvement in patients with larger prostates; thus, this is an intriguing area of future study (15). Despite these limitations, our study provides valuable real-world insight into sustainability of symptom improvement with WVTT. Future prospective, multi-institutional studies and longer-term registries should aim to capture both surgical and medical retreatment to further assess the therapeutic durability of WVTT and surrounding predictive factors of treatment success.

Conclusions

In our series, nearly one-third of patients who underwent WVTT required medical retreatment, typically within the first year after their index procedure. Preoperative use of BPH medications was associated with higher likelihood of medical retreatment, and IPSS scores at 3 months were significantly higher among those retreated. Early postoperative symptom trajectory may serve as a predictor of long-term outcomes. Appropriate patient selection and close symptom monitoring may help guide postoperative management and optimize the therapeutic durability of WVTT.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-568/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-568/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-568/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-568/coif). S.K.B. reports receiving consulting fees from Boston Scientific, Dornier, Ambu Medical, Calyxo, BD and payment for lectures from Karl Storz. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB) of the University of California, San Diego (IRB #812653). Informed consent was waived in this retrospective study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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