# Management of clinical failure after minimally invasive surgical therapies (MIST) for BPH: repeat MIST versus resection, enucleation or ablation—a narrative review from EAU endourology

## TL;DR

This review discusses options for treating BPH when minimally invasive procedures fail, comparing repeat procedures with more traditional methods.

## Contribution

The paper provides a narrative review on retreatment strategies after MIST failure, focusing on clinical decision-making.

## Key findings

- Repeat MIST is technically feasible for most procedures except iTIND, with low and variable retreatment rates.
- TURP is preferred for severe symptoms or when concomitant conditions are present.
- Choosing the right initial treatment and ensuring proper training can minimize the need for retreatment.

## Abstract

Minimally invasive surgical therapies (MIST) for benign prostatic hyperplasia (BPH) have an advantage over other treatment options as they preserve sexual function and may be performed even in frail patients, often under local anesthesia. However, risks of clinical failure after such procedures may be considerably higher compared to standard modalities, making it important to assess the feasibility of repeat MIST in cases requiring retreatment.

A literature review was conducted in 2 databases, PubMed (Medline) and Google Scholar, with the following search query: (Aquablation OR PUL OR iTIND OR PAE OR Rezum) AND retreatment. The review only included articles that presented reoperation type (repeat MIST or conventional procedures) and its rate after MIST. Data was extracted and summarized in a tabular form.

Repeat MIST as a form of retreatment is technically feasible and has been reported for all modalities except iTIND (temporary implantable nitinol device) owing to the limited number of clinical trials. However, literature is sparse with detailed information about type of retreatment procedures and their outcomes, and reported rates of retreatment are low and variable: from 0% to 28.6% for PAE, 0–6.7% for Aquablation, 1–6.2% for Rezum, 2–20% for PUL. It is important to determine the exact cause of treatment failure. For persistent lower urinary tract symptoms (LUTS) attributable solely to BPH, such as incomplete treatment because of deviation from surgical protocols or untreated median lobe during the initial MIST, as well as BPH recurrence, repeat MIST may be appropriate if technically feasible. If any concomitant conditions (e.g., urethral stricture, bladder neck sclerosis, necrotic tissue after previous procedure) are suspected, and postoperative cystourethroscopy is indicated, combining diagnostic endoscopy with transurethral resection of the prostate (TURP) may be more reasonable. TURP is also preferred strategy in patients with severe LUTS.

Rates of retreatment and need for ongoing therapy following MIST are generally low, and repeat MIST is feasible. Perhaps the best way to minimize re-intervention is to choose the appropriate primary treatment according to evidence based guidelines and to ensure proper surgical training. In case of retreatment, a surgeon should choose between repeat MIST or conventional approaches depending on the cause of relapse and patient’s preferences (TURP or Aquablation for maximum durability and effectiveness; PUL, Rezum or PAE for minimal invasiveness, preservation of sexual function or reduction of operational risk).