Prostatic urethral lift (PUL) is a minimally-invasive intervention for symptomatic benign prostatic hyperplasia (BPH). PUL is currently recommended for prostatic hyperplasia, 30-80cc in size (recently increased to 100cc), in patients who are not catheter dependent. Here, we report outcomes utilizing PUL within a US military veteran population employing a wider range of procedural indications.

After institutional review board approval, charts of patients who underwent PUL at our institution from 2013 to present were reviewed, noting demographics, baseline patient characteristics and operative details. Pre- and post-operative International Prostate Symptom Score (IPSS), uroflowmetry, and post-void residual (PVR) were recorded. Statistical comparisons were performed using simple t-tests.

From 2013 to 2019, 91 patients underwent PUL at our institution. Mean age was 70 (range 55-92) years. The vast majority of our patients classify as American Society of Anesthesiologists (ASA) class 3 versus the general population at ASA class 2. Mean prostate size, as measured on transrectal ultrasound, was 40 (range 14-115) cc. Three patients had prostates larger than 80cc; one patient had a prostate larger than 100cc. Three patient had bladder stones, necessitating concomitant cystolithalopaxy. Fifty-three procedures were performed under general anesthesia, 35 with intravenous sedation and intravesical/urethral lidocaine, and 3 under spinal anesthesia. Average number of implants was 5 (range 2-13). 

Post-operatively, IPSS decreased by an average of 43% (23 to 13, p < 0.001). Of note, IPSS worsened over the course of follow-up, though not to a statistically significant degree (p=0.08). There was a mean 41% decrease in PVR (179 to 101cc, p=0.009), which was durable for a follow-up of up to 54 months. Maximum urinary flow rate improved by an average of 32% (9.3 to 12.3 cc/s, p=0.003), which was also durable throughout follow- up. 

Forty-four patients required catheterization pre-operatively: 26 used clean intermittent catheterization (CIC), and 18 had indwelling catheters. Of these patients, 16 (38.6%) required catheterization post-operatively: 13 (29.5%) performing CIC and 4 (9%) requiring indwelling catheters. Therefore, 27 patients (61.4%) were rendered catheter-free by PUL. 

Thirty-nine patients were taking antiplatelet medications peri-operatively, and 13 took anticoagulants. Only one patient (on warfarin) experienced hematuria requiring re-admission with catheter placement -- no additional operative intervention was required.

Prostatic urethral lift produced durable improvement in subjective and objective measures of voiding dysfunction, including IPSS, maximum urinary flow rate, and post-void residual.  There were minimal complications in our veteran population.  These results applied to patients outside of the typical PUL indications, including those requiring catheterization, with bladder stones, and on antiplatelet/anticoagulant agents.

PUL produced effective and generally durable results in our veteran population, including in patients requiring catheterization, those with bladder stones, and those on antiplatelets/anticoagulants.