Lower urinary tract symptoms (LUTS) due to prostatic enlargement resulting in bladder outflow obstruction are common. Transurethral resection of the prostate (TURP) remains the gold standard in operative management, however it is not without its risks. In this multicentre European prospective randomised trial, TURP is compared with prostatic urethral lift (PUL) to evaluate whether this offers a viable alternative treatment to TURP. The primary endpoint of the study was to demonstrate non-inferiority of PUL compared to TURP using the novel BPH6 composite outcome assessment, involving six elements: LUTS relief, quality of recovery, erectile function preservation, ejaculatory function preservation, continence preservation and safety. Secondary endpoints included International Prostate Symptom Score (IPSS), flow rate and post-void residual volumes. Ninety-one patients were initially enrolled, with 80 undergoing treatment (45 PUL vs. 35 TURP), and followed up for a total of 12 months. Overall, the composite BPH6 endpoint assessment demonstrated superiority of PUL over TURP. On analysing the individual elements, TURP was superior to PUL in terms of LUTS relief, however PUL was superior in terms of quality of recovery and ejaculatory function preservation. In fact, this study was probably the first to quantify the recovery experience after TURP on a visual analogue scale. There was no significant difference in the other three elements. The study was not powered to ensure for meaningful assessment of secondary endpoints. This study has demonstrated promising initial results of PUL. The small sample size needs to be considered when evaluating this new technique, as although it was powered to address the primary endpoint, it was not sufficiently powered to detect meaningful differences between secondary endpoints. Follow-up beyond one year has not been reported –the long-term durability of PUL compared with TURP remains unclear, and patients need adequate counselling in this regard. The study only included those with prostate volume ≤60cm3 and excluded an obstructive median lobe, which may have excluded a number of candidates who would have been suitable for TURP. The BPH6 endpoints gave a more holistic outcome, with symptom relief accounting for only one of the six outcomes. Arguably the procedure is done with the intention of symptomatic relief, however in a number of patients the other endpoints are of significant importance, therefore PUL may provide a good alternative treatment option for them.
