Minimally invasive surgical therapies (MIST) for bladder outflow obstruction (BOO) are now
commonplace in many urological centres. These are often day case procedures performed
under general anaesthetic (GA), or local anaesthetic (LA) requiring oral or intravenous
sedation. Our centre has adopted an outpatient clinic LA-only setting to deliver Rezum,
Urolift and iTind using a combination of prostatic block and local anaesthetic gel. We aimed
to compare our one-year outcome to determine feasibility of delivering MIST in this setting.

We retrospectively audited our outcomes using routinely collected clinical information. This
included patient demographics, pre and post operative symptom questionnaires, flowmetry
tests, and visual analogue scores (VAS) during the procedure. We compared pre and post
operative changes using paired t-test, using a p value of & <0.05 as significant.

Results
A total of 81 procedures were performed, 38 (46.9%) Rezum, 22 (27.2%) Urolift, 21 (25.9%)
iTind. Median age was 68 (IQR 63-74). Pre-operatively the mean IPSS was 20.2, QOL score
4.6, Qmax 10.7ml/s, post void residual (PVR) 121ml, PSA 2.5 and prostate size 48.8mls.
70.4% of patients were on an alphablocker, 44.4% on a 5-ARI, 11.1% on an anticholinergic and
8.6% on mirabegron. Mean number of treatments on each lateral lobe was 1.7 for Rezum
and 1.5 for Urolift. The mean VAS was 4.3 out of 10. Total immediate post-operative
complication rate was 14.8%, all less than Clavien-Dindo 3.
91.4% attended 3-month follow-up. Post-operatively the mean IPSS was 11.3 (44.1%
reduction, p<0.01), QOL score 2.4 (47.8% reduction, p<0.01), Qmax 13.1ml/s (22.4%
improvement, p<0.01), PVR 68ml (43.5% reduction, p<0.01). Patients on an alpha-blocker had
reduced to 34.6%, 5ARIs to 13.6%, anti-cholinergic to 4.9%, however 8.6% remained on
mirabegron.

We demonstrate the feasibility of delivering MIST under LA alone, without sedation, and
report significant improvements in symptom scores and flowmetry outcomes, similar to
previously reported outcomes in clinical trials and cohort studies. Moreover, patients are
not required to fast, tolerate the treatment well without sedation, and have a short stay (<2
hours) for their procedure, enabling the service to be delivered in an office-based or
outpatient clinic setting. This reduces in-patient waiting list for BOO surgery and re-allocates
patients and resources from GA lists to out-patient setting. Further research is required for
long-term outcomes in this setting, but early results are promising in driving a change to
how MIST is delivered in Urology units.

It is safe and feasible to perform Minimally Invasive Surgical Techniques for BOO purely under Local Anaesthetic, in the office setting, without the need for any sedation.