Kevin T. McVary

Purpose: Lower urinary tract symptoms (LUTS) can result from several conditions, including but not limited to benign prostatic hyperplasia, diabetes, stress urinary incontinence, and metabolic syndrome. In 2011, it was estimated that nearly 2 billion people (45.2% of the world population) experience one or more LUTS. To date, there is no single underlying mechanism identified in lower urinary tract symptoms or the associated conditions. However, a recent body of evidence has demonstrated that mitochondrial dysfunction may contribute to conditions associated with LUTS. Furthermore, patients with inherited mitochondrial disease exhibit lower urinary tract symptoms at rates above the general population. Given that mitochondrial dysfunction is an under-investigated area of urinary disease research, this review aims to summarize the existing literature in the field. Methods: PubMed was used as the primary database for literature search. Keywords included “lower urinary tract symptoms”, “mitochondria”, “urinary dysfunction”; additionally, once identified, further disease-specific searches were performed (e.g., “urinary dysfunction in type 1 diabetes”). Studies published earlier than August 2025 were included, and a specific focus was placed on clinical or human studies. Urologic conditions lacking at least three publications investigating mitochondrial dysfunction were not included; studies examining mitochondrial dysfunction in urologic cancers were also outside the scope of this review. Results and conclusions: Mitochondrial dysfunction is a potential novel intersection of diseases associated with LUTS, including aging, metabolic syndrome, diabetes, stress urinary incontinence, benign prostatic hyperplasia, and overactive bladder. While initial studies are promising, more investment into identifying underlying mechanisms and new potential treatments is needed. Additionally, as mitochondrial modulators undergo trial as treatments in other conditions, careful consideration should be given to their potential as treatments for LUTS.

Background/objective Convective water vapor thermal therapy (CWVTT) effectively treats Lower Urinary Tract Symptoms (LUTS) from Benign Prostatic Hyperplasia (BPH). While sexual outcomes have been studied across BPH procedures, the influence of prostate size on sexual function after CWVTT is unclear. We aimed to determine whether preservation of sexual function, measured by the Sexual Health Inventory for Men (SHIM), differs by prostate volume, particularly in larger glands. Subjects/methods Following IRB approval, patients aged ≥18 undergoing CWVTT from October 2018 to August 2022 were identified by CPT codes 53,852 and 53,854. After applying inclusion/exclusion criteria, patients were stratified into prostate tertiles: small (≤38.5 cc), medium (38.5–55.6 cc), and large (>55.6 cc). SHIM scores were tracked longitudinally. Results Baseline demographics were similar across tertiles. Mean SHIM change from baseline to 3 months was −1.02, −2.10, and −0.46 for small, medium, and large prostates, respectively; only the medium group showing a statistically significant decline. Beyond 3 months, SHIM scores improved across all tertiles. Large prostates demonstrated a significant increase in SHIM over time (+0.18/month, p = 0.01) though significance was lost after adjusting for age, comorbidities, and baseline SHIM. Severe baseline erectile dysfunction (ED) predicted the greatest postoperative improvement, while men with no ED experienced mild decline. Age and baseline SHIM were the strongest predictors of outcomes. Conclusions Men with larger prostates who undergoe CWVTT do not appear at increased risk of ED. In fact, the men with larger prostates have a faster recovery of sexual function than other prostate sizes. Patients with severe ED should be counseled on the potential for improvement in their sexual function following their procedure, especially 3 months onward with the exact mechanism being unknown. Finally, prostate volume likely plays a role in timing of recovery, although it is overshadowed by the influence of baseline SHIM scores and age.

Background: Lower Urinary Tract Symptoms secondary to Benign Prostatic Hyperplasia (LUTS/BPH) are a ubiquitous condition estimated to affect over 50% of men over the age of 50 years. Various treatment options exist for men presenting with LUTS/BPH, including lifestyle and behavioral modification and medical or surgical treatment. Although multiple medical treatments exist, innovation for the medical treatment of BPH has not significantly progressed. Methods: A comprehensive narrative review was performed to evaluate prostate fibrosis as a contributor to LUTS/BPH and to identify potential antifibrotic therapies that may be applicable to the treatment of LUTS/BPH. A literature search was conducted in PubMed and ClinicalTrials.gov for molecular, translational, and clinical studies relevant to fibrosis in benign prostatic diseases. Keyword searches included “benign prostatic hyperplasia”, “lower urinary tract symptoms”, “prostate fibrosis”, “fibrosis”, “antifibrotics”, as well as combinations of these terms. Results: In this narrative review, we review the rationale and evidence for pursuing antifibrotic therapy as a novel treatment strategy for LUTS/BPH. We discuss potential antifibrotics that could be used for the treatment of LUTS/BPH. Finally, we discuss diagnostic studies that could be used in the future to identify patients with LUTS secondary to prostate fibrosis. Conclusions: Emerging evidence suggests that prostate fibrosis contributes to the development of LUTS. No antifibrotic therapies are currently being used, leaving LUTS secondary to fibrosis untreated. Antifibrotics are a novel medication class that could be used to treat patients who progress on current BPH medications.

Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) affects quality of life. Convective water vapor thermal therapy (CWVTT - Rezum) is a minimally invasive surgical treatment for LUTS/BPH which produces significant improvement of LUTS in men with prostates between 30cc-80 cc with minimal de-novo sexual dysfunction. However, outcomes across the prostate volume (PV) spectrum are incompletely described. We aim to elucidate the relationship between PV and outcomes post-CWVTT in men with LUTS/BPH. Patients undergoing CWVTT at a tertiary care center were included. The primary outcome was change in IPSS pre-CWVTT compared post-CWVTT between PV tertiles - small (≤38.5 cc), medium (38.5 - ≤55.6cc), and large (>55.6cc). Secondary outcome was time to a minimally clinically important difference (MCID) of 25% decrease in IPSS. 171 patients were divided into small (n=56), medium (n=54), and large (n=61) PV tertiles. The change in IPSS pre-operatively to 3-months was significant for all tertiles with mean difference of [-7.51 (-10.14, -4.83)], [-10.12 (-12.71, -7.53)], and [-11.72 (-14.14, -9.29)] for small, medium, and large PV, respectively (p=<0.001). In multivariable analysis, having diabetes was associated with increased IPSS after 3mo with average increase (95% CI) of [3.67 (0.23,7.11), p=0.037] compared to not having diabetes The median time (Q1, Q3) to -25% in IPSS for small, medium, and large PV were 16.1 (12.1, 17.5), 12.3 (7.1, 15.7), and 13.8 (10.8, 16.3) months, respectively. In multivariable analysis, medium PV had significantly increased incidence of 25% decrease compared to small PV [HR (95%CI): 2.10 (1.19, 3.72), p=0.011]. CWVTT results in significant and durable LUTS improvement across the prostate volume spectrum. All prostate volumes experience the same improvement in LUTS post-CWVTT. However, medium and large glands may improve more quickly than small glands.

Objectives: Convective water vapor thermal therapy (CWVTT‐Rezum) is a minimally invasive surgical therapy that is being increasingly utilized for bladder outlet obstruction. Most patients leave the site of care with a Foley catheter in place for a mean reported duration of 3–4 days. A minority of men will fail their trial without catheter (TWOC). We aim to identify the frequency of TWOC failure following CWVTT and its associated risk factors.Methods: Patients who underwent CWVTT at a single institution from October 2018 to May 2021 were retrospectively identified and pertinent data extracted. The primary endpoint was TWOC failure. Descriptive statistics were performed, and rate of TWOC failure was determined. Potential risk factors for failed TWOC were assessed through univariate and multivariate logistic regression.Results: A total of 119 patients were analyzed. Seventeen percent (20/119) had a failed TWOC on their first attempt. Of those, 60% (12/20) failed in a delayed fashion. In patients who failed, the median number of total TWOC attempts required for success was two (interquartile range [IQR] = 2–3). All patients eventually had a successful TWOC. The median preoperative postvoid residual for successful and failed TWOC was 56 mL (IQR = 15–125) and 87 mL (IQR = 25–367), respectively. Preoperative elevated postvoid residual (unadjusted odds ratio [OR] 1.02, 95% CI: 1.01–1.04; adjusted OR 1.02, 95% CI: 1.01–1.04) was associated with TWOC failure.Conclusions: Seventeen percent of patients failed their initial TWOC after CWVTT. Elevated postvoid residual was associated with TWOC failure.

Purpose With the ubiquity of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in older men, costs related to this highly prevalent disease are likely significant but not well defined. With this study, we hoped to define costs related to LUTS/BPH care. Methods We utilized the Optum^© de-identified Clinformatics® Data Mart Database (CDM) for privately insured male enrollees aged 40–64 years with LUTS/BPH (N ≈ 100,300 annually) and the Centers for Medicare and Medicaid Services Medicare 5% Sample for male beneficiaries aged 65 + years with LUTS/BPH (N ≈ 147,800 annually). Annual LUTS/BPH-related expenditures from 2004 to 2013 were age standardized and calculated overall and by age and service location. Results The Medicare cohort demonstrated a 23% increase in total costs over the study period with a 28% decrease in CDM costs. Decreases in inpatient hospital charges (45% for Medicare, 55% for CDM) were offset by increasing hospital-based outpatient fees (120% for Medicare, 87% for CDM). Overall, we estimated a total cost of at least $1.9 billion for treatment of men with LUTS/BPH for 2013. Per person expenditures increased with age within cohorts with an average per-person cost of $269 (CDM) and $248 (Medicare) in 2013. Conclusion The distribution of healthcare expenditures for LUTS/BPH shifted across practice settings from 2004 to 2013, with increasing outpatient relative to inpatient expenditures. Total direct costs for LUTS/BPH in 2013 were at least $1.9 billion, not accounting for indirect costs or certain unmeasured populations.