Minimally invasive surgical therapies for catheter-dependent men with benign prostatic hyperplasia: expanding the treatment paradigm

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting ageing men, with histological evidence present in approximately 50% of men in their sixth decade and up to 80–90% of those aged over 70 years (1). The risk of acute urinary retention increases with advancing age, worsening lower urinary tract symptoms (LUTS) and clinically diagnosed BPH, representing disease progression (2). Although many men regain spontaneous voiding following a successful trial without catheter, recurrent retention is common and some ultimately require definitive bladder outlet surgery or long-term catheterisation (3).

Conventional endoscopic surgery, including transurethral resection of the prostate (TURP), and endoscopic enucleation of the prostate (EEP) remain the benchmark against which newer therapies are generally compared. Minimally invasive surgical therapies (MISTs) have emerged as attractive alternatives because of reduced anaesthetic requirements, lower perioperative morbidity and the potential to be performed in an outpatient setting (4). These include water vapour thermal therapy (Rezūm), prostatic urethral lift (UroLift), transperineal laser ablation (TPLA), and prostate artery embolisation (PAE). However, these benefits are often balanced by lower efficacy and reduced durability compared with conventional surgery, and current guideline recommendations remain limited.

Historically, catheter-dependent men have fallen outside traditional indications for MISTs. Increasing clinical experience, however, has extended their use to older, frailer and more complex patients in whom conventional surgery may carry greater anaesthetic and peri-operative risk. Consequently, evidence supporting the use of MISTs in catheter-dependent men has expanded in recent years. This article aims to highlight the available evidence for MISTs in catheter-dependent men and to consider how these emerging data should inform contemporary clinical practice.

Prostatic UroLift

UroLift was initially developed for younger men in whom preservation of sexual function is a priority. Early studies favoured smaller prostates without significant median lobe obstruction and generally excluded men with urinary retention (5). Consequently, evidence supporting its use in catheter-dependent patients has largely emerged from post-marketing experience rather than prospective randomised trials.

Despite these limitations, outcomes in selected patients have been encouraging. Reduced anaesthetic requirements have facilitated its use in older and frailer men unsuitable for more invasive surgery (6). In a prospective cohort of 200 patients, of whom more than half were catheter dependent, more than 80% achieved catheter-free voiding on the day of surgery (7). However, outcomes for those presenting with urinary retention were not reported separately, limiting interpretation of efficacy in this subgroup.

Prospective data from the Prostatic Urethral Lift for Subjects in Urinary Retention (PULSAR) study (n=51) demonstrated catheter independence in 73% of patients at 12 months (8). Success was associated with younger age, lower baseline PSA and post-void residual volume, and shorter pre-procedural catheter duration, reinforcing the importance of patient selection. Similarly, a multicentre real-world study (n=165) reported catheter-free rates of 87%, although outcomes were again not stratified according to baseline retention status (9).

Collectively, these studies suggest that UroLift can facilitate catheter-free voiding in appropriately selected patients, although the evidence remains limited. UroLift is generally best suited to men with smaller prostates and favourable anatomy, while significant median lobe enlargement remains a relative contraindication. In addition, the permanent metallic implants may generate magnetic susceptibility artefacts on subsequent prostate MRI, potentially compromising transition zone assessment. Although this is unlikely to affect every patient, it should be considered when counselling younger men or those likely to require future prostate imaging.

Water vapour thermal therapy (Rezūm)

Among currently available MISTs, Rezūm has one of the strongest evidence bases in catheter-dependent patients. A pooled analysis of 12 studies including more than 640 catheterised men reported catheter-free rates of up to 95% (10). However, these findings are derived predominantly from retrospective, single-arm studies with wide inclusion criteria, variable definitions of treatment success and relatively short follow-up. Unlike mechanical therapies, Rezūm achieves deobstruction through gradual tissue necrosis and remodelling. Consequently, patients should be counselled that postoperative catheterisation is often required for several weeks, with durations of up to 35 days reported.

More recently, Ali et al. reported one-year catheter independence in 87.5% of 80 frail men with urinary retention (11). Similarly, a prospective Italian study of 60 men aged >75 years reported no intraoperative complications and only two cases of postoperative clot retention, supporting the safety profile of Rezūm in elderly patients (12). Although generally well tolerated, Rezūm should not be considered complication-free. Although uncommon, serious adverse events have been reported as experience with Rezūm has expanded into increasingly complex patient populations, reinforcing the importance of careful patient selection, appropriate counselling and realistic expectations (13).

PAE

PAE has emerged as a potential treatment option for catheter-dependent men, those with larger prostates, significant comorbidity or elevated operative risk. Among current MISTs, PAE has one of the more mature evidence bases, although available data remain largely observational (14,15). Treatment response appears influenced by prostate morphology. Kristensen et al. demonstrated a positive relationship between prostate volume and clinical improvement following PAE, suggesting that larger prostates derive greater benefit, whereas smaller prostates or marked intravesical prostatic protrusion may favour alternative deobstructive strategies (16).

Patient selection should also consider procedural feasibility. Ironically, the patients in whom PAE may appear most attractive i.e., older, frail men with multiple comorbidities, are also more likely to have advanced atherosclerotic vascular disease. Vascular tortuosity or occlusive disease may render embolisation technically challenging or even preclude treatment.

Although retreatment rates remain higher than after conventional endoscopic surgery, this may represent an acceptable trade-off for patients in whom the potential morbidity burden is higher (16,17). Perhaps the greatest challenge for PAE, lies in identifying the patients most likely to achieve durable benefit.

Other minimally invasive therapies

Evidence supporting iTind in catheter-dependent men remains limited. Most studies have excluded patients with established urinary retention or elevated post-void residual volumes, leaving its safety, efficacy and durability in this setting uncertain (18). At present, its role in this setting should therefore be considered investigational.

Similarly, dedicated data for TPLA remain sparse, although its ability to reduce prostate volume under local anaesthesia makes it an attractive alternative. A recent Delphi consensus supported its use in frail patients and those with urinary retention, with 77% of experts endorsing its role in catheter-dependent men (19). Although encouraging, this consensus should not be regarded as a substitute for prospective clinical evidence.

Another emerging technology is the Optilume BPH Catheter System, which combines mechanical dilatation with local paclitaxel delivery (20). Early studies have reported promising outcomes in men with LUTS, but evidence in catheter-dependent patients is currently lacking.

Various transurethral stents have also been evaluated. In a recent Danish series of thermo-expandable nitinol stents (Memokath^TM), 87% of catheter-dependent patients resumed spontaneous voiding and 71% remained catheter free after a median follow-up of 11 months (21). However, concerns regarding migration, encrustation, irritative symptoms and reintervention continue to limit widespread adoption.

Discussion

Although these therapies differ in their mechanisms of action, they share the common objective of relieving bladder outlet obstruction whilst minimising procedural morbidity. Mechanical approaches, such as UroLift and iTind, improve urinary flow without tissue ablation, whereas Rezūm, TPLA and PAE achieve deobstruction through tissue ablation or infarction. However, focusing solely on the intervention risks overlooking what is arguably the more important determinant of outcome: appropriate patient selection.

Catheter-dependent men should not be regarded as a homogeneous group. Treatment outcomes are influenced not only by prostate size and morphology, but also by bladder function, duration of catheterisation, frailty and individual treatment goals. Successful catheter-free voiding therefore depends not only on effective relief of bladder outlet obstruction, but also on recovery of bladder function. In men with prolonged catheter dependence, irreversible detrusor underactivity may for example, limit the likelihood of successful voiding despite technical success. This has important implications when interpreting the expanding literature on MISTs. The available evidence suggests that several minimally invasive therapies can achieve encouraging rates of catheter-free voiding in appropriately selected patients, particularly those in whom reduced perioperative morbidity is prioritised over long-term durability. However, these treatments should not be regarded as interchangeable. Rather, each has characteristics that make it more suitable for particular anatomical and clinical settings, and no single intervention is likely to be optimal for all catheter-dependent patients.

The current evidence base nevertheless remains limited by retrospective study designs, heterogeneous patient populations, variable definitions of treatment success and relatively short follow-up. Direct comparisons between individual technologies should therefore be interpreted with caution. More importantly, future studies should move beyond demonstrating that a treatment is effective in binary terms and instead, identify the anatomical, functional and clinical characteristics that predict durable catheter-free voiding. Developing robust approaches to patient stratification is likely to prove more valuable than further comparisons between individual devices, allowing treatment to be tailored more effectively to the individual patient.

As the range of available MISTs continues to expand, the principal challenge is no longer the lack of treatment options, but determining which intervention is most appropriate for which patient. Ultimately therefore, further progress is likely to depend less on the development of new technologies than on improving our understanding of the anatomical, functional and clinical factors that determine successful outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0497/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-2026-0497/coif). The 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.

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/.

References

1. Roehrborn CG. Benign prostatic hyperplasia: an overview. Rev Urol 2005;7:S3-14.
2. Meigs JB, Barry MJ, Giovannucci E, et al. Incidence rates and risk factors for acute urinary retention: the health professionals followup study. J Urol 1999;162:376-82.
3. Fitzpatrick JM, Desgrandchamps F, Adjali K, et al. Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia. BJU Int 2012;109:88-95. [Crossref] [PubMed]
4. Grossmann NC, Berjaoui MB, Choudhary O, et al. State-of-the-art in minimally invasive treatments for benign prostatic obstruction. Investig Clin Urol 2026;67:1-14. [Crossref] [PubMed]
5. Jones P, Rajkumar GN, Rai BP, et al. Medium-term Outcomes of Urolift (Minimum 12 Months Follow-up): Evidence From a Systematic Review. Urology 2016;97:20-4. [Crossref] [PubMed]
6. Juliebø-Jones P, Somani BK, Tzelves L, et al. Complications and device failures associated with urolift: Findings from the MAUDE database. Urologia 2023;90:636-41. [Crossref] [PubMed]
7. Siu BWH, Chan CHL, Yuen RWY, et al. The "swipe" technique for prostatic urethral lift: a comparative analysis of 200 patients in a prospective cohort. Prostate Int 2026;14:68-74. [Crossref] [PubMed]
8. Rochester M, Doherty R, Page T, et al. Prostatic urethral lift for subjects in urinary retention (PULSAR): 12-Month results of a prospective controlled trial compared with real-world outcomes. BJUI Compass 2024;5:60-9. [Crossref] [PubMed]
9. Eure G, Gange S, Walter P, et al. Real-World Evidence of Prostatic Urethral Lift Confirms Pivotal Clinical Study Results: 2-Year Outcomes of a Retrospective Multicenter Study. J Endourol 2019;33:576-84. [Crossref] [PubMed]
10. Scilipoti P, Chicaud M, Abdallah MA, et al. Minimally Invasive Surgical Therapies in Patients with Catheter-Dependent Urinary Retention: A Collaborative Mini-review. Eur Urol Focus 2026;S2405-4569(26)00037-4.
11. Ali AI, Tayeb W, Kalantan SA, et al. Rezum therapy for management of frail patients with catheter dependent urinary retention due to benign prostate hyperplasia: A 1 year follow up study. Urologia 2026;93:192-9. [Crossref] [PubMed]
12. Minore A, Morselli S, Franzoso F, et al. Is water vapor thermal therapy safe and feasible in elderly and frail men? The Italian experience. World J Urol 2024;42:60.
13. Cindolo L, Minore A, Schwartzmann I, et al. Water vapor thermotherapy and high-grade Clavien-Dindo complications: retrospective analysis of 10 cases. World J Urol 2026;44:392. [Crossref] [PubMed]
14. Altman R, Ferreira R, Barragan C, et al. Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis. BMC Urol 2024;24:22. [Crossref] [PubMed]
15. Ini' C, Vasile T, Foti PV, et al. Prostate Artery Embolization as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: An Updated Systematic Review. J Clin Med 2024;13:2530. [Crossref] [PubMed]
16. Kristensen-Alvarez A, Lund-Frank C, Stroomberg HV, et al. Long-term Outcomes of Prostatic Artery Embolisation: A Nationwide Prospective Cohort Study. Eur Urol Focus 2025;11:991-8. [Crossref] [PubMed]
17. Bhatia S, Bhatia A, Richardson AJ, et al. Prostatic Artery Embolization: Mid- to Long-Term Outcomes in 1,075 Patients. J Vasc Interv Radiol 2025;36:456-66. [Crossref] [PubMed]
18. Chughtai B, Elterman D, Shore N, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicenter, Randomized, Controlled Trial. Urology 2021;153:270-6. [Crossref] [PubMed]
19. Cocci A, Pezzoli M, Bianco F, et al. Transperineal laser ablation of the prostate as a treatment for benign prostatic hyperplasia and prostate cancer: The results of a Delphi consensus project. Asian J Urol 2024;11:271-9. [Crossref] [PubMed]
20. Elterman DS, Gao B, Zorn KC, et al. How I Do It: Optilume BPH catheter system. Can J Urol 2023;30:11568-73.
21. Arch A, Thamsborg A, Winck-Flyvholm L, et al. Thermo-expandable intraprostatic nitinol stents in the treatment of bladder outlet obstruction: a consecutive case series. Scand J Urol 2024;59:169-72. [Crossref] [PubMed]