Asia-Pacific collaborative consensus statements on water vapor thermal therapy (Rezūm) incorporating a systematic review, a two-round Delphi survey, and a consensus meeting

Brian Wai Hei Siu; Jeremy Man Hon Ho; Xeng Inn Fam; Yu-Chao Hsu; Min Gu Park; Jae Hyun Jung; Weida Lau; Adistra Satjakoesoemah; Teerapon Amornvesukit; Suntchai Wirotsaengthong; Angus Man Chung Chan; Varat Woranisarakul; Anand Dharaskar; C Mallikarjuna; Chi Fai Ng; Ka Lun Lo

doi:10.1016/j.prnil.2026.04.004

. 2026 Apr 29;14(2):173–190. doi: 10.1016/j.prnil.2026.04.004

Asia-Pacific collaborative consensus statements on water vapor thermal therapy (Rezūm) incorporating a systematic review, a two-round Delphi survey, and a consensus meeting

Brian Wai Hei Siu ^a, Jeremy Man Hon Ho ^a, Xeng Inn Fam ^b, Yu-Chao Hsu ^c, Min Gu Park ^d, Jae Hyun Jung ^e, Weida Lau ^f, Adistra Satjakoesoemah ^g, Teerapon Amornvesukit ^h, Suntchai Wirotsaengthong ⁱ, Angus Man Chung Chan ^a, Varat Woranisarakul ^j, Anand Dharaskar ^k, C Mallikarjuna ^l, Chi Fai Ng ^a,^⁎, Ka Lun Lo ^a

PMCID: PMC13316396 PMID: 42382551

Abstract

Background

Water vapor thermal therapy (WVTT) is a minimally invasive surgical therapy (MIST) for benign prostatic hyperplasia (BPH). While its efficacy has been demonstrated, high-quality evidence concerning optimal patient selection and perioperative management is limited, leading to heterogeneous application. This is an Asia-Pacific (APAC) collaborative effort aiming to develop a consensus statement to standardize various aspects of WVTT therapy for clinical practice and to guide future research.

Methods

The consensus statement was developed using a modified Delphi method, consistent with previous urological consensus statements. First, a systematic review was performed to identify areas of uncertainty across the entire WVTT clinical pathway. Next, 150 urologists from the Asia-Pacific region with experience in WVTT were invited to complete a two-round online Delphi survey. Finally, a 13-member consensus panel meeting (each with ≥50 cases of experience) was held to review, discuss, and re-vote on statements without prior consensus. ‘Consensus agree’ was pre-defined as follow: ≥70% of participants scoring a statement 7-9 and ≤15% scoring it 1-3 (on a 9-point Likert scale).

Results

Based on the ‘uncertainties’ review of 197 studies, 92 statements were generated. Through two rounds of Delphi survey, consensus was reached on 74 statements. The consensus panel reached agreement on a further 10 out of 18 statements, resulting in 84 final statements. The statements provide guidance on six domains: case selection (e.g., feasibility in refractory retention and median lobes), preoperative preparation (e.g., management of antithrombotic medications), patient counseling, surgical procedure (e.g., anesthesia and injection strategies), postoperative management and follow-up (e.g., medication discontinuation), and data reporting and outcome measures.

Conclusions

Using a modified Delphi method, this APAC collaborative consensus provides comprehensive recommendations to standardize and optimize the use of WVTT. It aims to serve as a critical reference for clinicians and inform future research until more robust, long-term comparative evidence becomes available.

Keywords: Benign prostatic hyperplasia, Consensus, Minimally invasive surgical therapy, Rezum, Water vapor thermal therapy

1. Introduction

Benign prostatic hyperplasia (BPH) is a prevalent histological condition leading to lower urinary tract symptoms (LUTS) in aging men.1, 2, 3, 4 Water vapor thermal therapy (WVTT) has emerged as a minimally invasive surgical therapy (MIST) that utilizes the convective thermal energy in water vapor to ablate prostatic adenoma.⁵^,⁶ While a sham-controlled randomized controlled trial has demonstrated its efficacy and safety,⁷^,⁸ high-quality evidence concerning optimal patient selection, perioperative management, and follow-up protocols remains limited.

Consequently, numerous unanswered questions persist in clinical practice, leading to heterogeneity in its application. This absence of robust guidelines resulted in inconsistent patient outcomes. Therefore, the objective of this Asia-Pacific (APAC) collaborative project was to develop a consensus statement to standardize the application of WVTT, aiming to optimize clinical practice and guide future research. It aims to serve as a critical reference for healthcare professionals across the APAC region and beyond.

2. Methodology

We developed the consensus statement on WVTT using a modified Delphi method, a well-established structured communication technique designed to achieve a convergence of opinion among experts.⁹ The development process comprised three key stages: a systematic review to identify areas of uncertainty, a two-round Delphi survey to gauge expert agreement, and a final face-to-face consensus meeting to resolve statements without prior consensus (Fig. 1a). This methodology aligns with previously published urological consensus projects.10, 11, 12, 13

Fig. 1a — Overview of the consensus development process. Abbreviations: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses.

2.1. Systematic review

An 'uncertainties' systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.¹⁴ The study protocol was registered on PROSPERO.¹⁵ The objective of this review was to identify and catalogue uncertainties in the entire clinical pathway of WVTT, including case selection, preoperative preparation, surgical procedure, postoperative management, and follow-up schedules.

A comprehensive literature search was performed using MEDLINE, EMBASE, and the Cochrane Library (CENTRAL and Cochrane Database of Systematic Reviews) from 2015 [i.e. when the first report of WVTT was published¹⁶] to September 2025. The search strategy employed a combination of keywords and MeSH terms related to “benign prostatic hyperplasia,” “lower urinary tract symptoms,” “transurethral water vapor therapy,” and “Rezum” (full strategy is provided in the Supplementary Material). We included randomized and non-randomized comparative studies, single-arm case series, case reports, conference proceedings, and guidelines published in English. Reference lists of included studies were also screened for additional relevant publications. The risk of bias for the included RCTs were assessed using the Cochrane ROB 2.0 tool. Two reviewers (B.W.H.S., A.M.C.C.) independently evaluated each study across five domains, any conflict between the two reviewers were resolved by a third reviewer (K.L.L.). Studies were categorized as being at low, moderate or high risk of bias.

Areas of uncertainty were extracted verbatim from the included literature. These uncertainties were then categorized according to the management pathway for WVTT. To synthesize the data, statements relating to the same conceptual uncertainty were merged to identify evidence gaps. These uncertainty statements were subsequently reframed into draft consensus statements that could be agreed or disagreed upon. These draft statements were reviewed and finalized by the steering committee before being incorporated into the Delphi survey.

2.2. Two-round Delphi survey

The Delphi survey was employed to promote anonymity among participants and to mitigate the influence of dominant or authoritative voices, while still allowing for controlled feedback.⁹^,¹⁷ The survey was administered online using the SurveyMonkey platform.¹⁸

A target of 150 urologists from the Asia-Pacific region involved in the field of WVTT, was purposively sampled to ensure a broad representation of expertise, geographical diversity, and a wide range of clinical experience – from generations who perform TURP predominantly and are transitioning to the MIST era, to those who begin their urology career learning about MIST. The steering committee identified and invited known experts in the field. Interested urologists were verified for their procedural experience before receiving an invitation and a link to the survey. Informed consent was taken upon registration before proceeding with the online survey.

In each round, participants were asked to rate their agreement with each statement on a 9-point Likert scale (1 = strongly disagree, 9 = strongly agree). An “unable to score” option was also provided, and participants were explicitly instructed to select this instead of a neutral score (i.e. 5) if they lacked the knowledge or expertise on a particular item, as these concepts are qualitatively different. During the first round, participants could suggest statements to be amended, added or subtracted in the second round, subject to review by the steering committee. Only those who completed the first round were invited to participate in the second. In the second round, participants were reminded of their previous score and shown the anonymous distribution of the group's scores for each statement, allowing them to reconsider their position relative to their peers.

Consensus was pre-defined using a balanced criterion used in other urology consensus meetings:¹⁰^,¹²^,¹³

•
Consensus Agree: ≥70% of participants scoring the statement 7-9 and ≤15% scoring it 1-3.
•
Consensus Disagree: ≥70% of participants scoring the statement 1-3 and ≤15% scoring it 7-9.
•
Statements not meeting these criteria after the second round were deemed to have “no consensus” and were advanced to the consensus meeting.

This definition attains a balance between being overinclusive and exclusive whilst still allowing a consideration of divergent opinions.¹⁹

2.3. Consensus meeting

A final face-to-face consensus meeting was held in Bangkok, Thailand on 4^th October 2025. The panel consisted of 13 APAC urologists, each with at least 50 cases of experience in WVTT (with the majority exceeding 100 cases), and many serve as proctors for the procedure in their respective localities.

The meeting agenda was structured as follows: First, the results of the systematic review and the two Delphi rounds were presented. Panel members were provided with a hard-copy overview of the Delphi voting results, including their own previous votes. Statements that had reached a clear consensus in the Delphi survey were briefly reviewed to ensure their validity. Subsequently, statements for which more than five participants had selected “unable to score” were discussed to explore the reasons behind the uncertainty. Finally, statements that did not achieve consensus in the Delphi survey were discussed in depth. Following discussion, these statements were re-voted upon anonymously by panel members using their smart devices with the SurveyMonkey application. The same pre-defined consensus definitions were applied during this final voting session. The same consensus definitions were used.¹⁹ The final consensus statements (Table 4) were graded according to their quality of evidence and strength of recommendation, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.²⁰ (Table 5)

Table 4.

Final consensus statements on water vapor thermal therapy (WVTT)

No.	Statement	Consensus Stage	Direction	GRADE Quality of Evidence	GRADE Strength of Recommendation
*Case selection*
1	Water vapor thermal therapy (WVTT) is feasible for patients with bothersome lower urinary tract symptoms (LUTS) despite medical therapy⁷^,²³	Delphi	Agree	High	Strong
2	WVTT is feasible for patients with bothersome LUTS who are not on medical therapy²¹	Meeting	Agree	Low	Weak
3	WVTT is feasible for patients with benign prostatic hyperplasia (BPH)-related gross hematuria	Meeting	Not reached	-	-
4	WVTT is feasible for patients with BPH-related recurrent urinary tract infection (UTI)	Meeting	Agree	Very low	Weak
5	WVTT is feasible for patients with history of urinary retention⁴²	Delphi	Agree	Moderate	Strong
6	WVTT is feasible for patients with refractory retention (on indwelling catheters)²⁴^,⁴³	Meeting	Agree	Moderate	Strong
7	WVTT is feasible for patients with acute urinary retention complicated by obstructive uropathy (renal impairment)³²	Meeting	Not reached	-	-
8	WVTT is feasible for patients with chronic urinary retention	Meeting	Not reached	-	-
9	WVTT is feasible for patients with prostate size <30 ml	Delphi	Not reached	-	-
10	For patients with prostate size <30 ml, workup (e.g. cystoscopy, urodynamic study) should be considered before WVTT	Meeting	Agree	Very low	Strong
11	WVTT is feasible for patients with prostate size between 30-80 ml⁷	Delphi	Agree	High	Strong
12	WVTT is feasible for patients with prostate size >80 ml⁴⁴	Meeting	Agree	Moderate	Strong
13	WVTT is feasible for patients with median lobes³²^,²⁴	Meeting	Agree	High	Strong
14	WVTT is feasible for patients with intravesical protrusion (IPP) < 10 mm³²	Meeting	Agree	High	Strong
15	WVTT is feasible for patients with IPP >10 mm⁴⁴	Meeting	Agree	Low	Weak
16	There is no high-level evidence to support recommendation on WVTT for patients with concomitant bladder stones, and the sequence of WVTT and cystolithotripsy	Meeting	Agree	N/A	Strong
17	There is no high-level evidence to support recommendation on WVTT for patients with LUTS and concomitant prostate cancer	Delphi	Agree	N/A	Strong
18	WVTT is feasible for patients whose antithrombotic medications can be stopped perioperatively²⁷	Delphi	Agree	High	Strong
19	For patients whose antithrombotic medications (other than aspirin - acetylsalicylic acid 80 mg daily) cannot be stopped, other options of BPH surgery should be offered	Meeting	Not reached	-	-
20	For patients with prior BPH surgery, WVTT is feasible for managing BPH-related symptoms or complications (e.g. urinary retention)²⁵	Meeting	Agree	Low	Weak
*Preoperative preparation*
21	Prostate sizing must be performed before WVTT, via transabdominal/transrectal ultrasonography or recent cross-sectional imaging (i.e. computed tomography CT or magnetic resonance imaging MRI)	Delphi	Agree	Very low	Strong
22	Flexible cystoscopy before WVTT should be considered, especially if cystoscopy findings (e.g. patency of prostate channel, alternate pathology) may change the management plan	Delphi	Agree	Very low	Weak
23	Urine culture must be saved before WVTT³⁸	Delphi	Agree	Low	Strong
24	Positive urine culture must be treated before proceeding with WVTT³⁸	Delphi	Agree	Low	Strong
25	Prostate-specific antigen (PSA) testing before WVTT should follow recommendations from European Association of urology guidelines	Delphi	Agree	N/A	Strong
26	Shared decision-making is recommended for preoperative PSA testing in catheter-dependent patients, due to risk of factitious elevation	Delphi	Agree	N/A	Weak
27	Digital rectal examination must be performed before WVTT	Delphi	Agree	Very low	Strong
28	Aspirin (acetylsalicylic acid) at the dose of 80 mg daily can be continued perioperatively²³^,²¹^,²⁴	Delphi	Agree	Very low	Weak
29	Antithrombotic medications - other than aspirin 80 mg daily -- should be withheld perioperatively	Delphi	Agree	Very low	Weak
*Patient counseling*
30	Current sexual function and patient's expectation of postoperative sexual function should be discussed before WVTT	Delphi	Agree	N/A	Strong
31	The level of current evidence on WVTT, and the lack of head-to-head comparison to transurethral resection of prostate (TURP) in prospective and randomized setting, should be discussed before WVTT	Delphi	Agree	N/A	Strong
32	Patient should be informed of the need of indwelling urethral catheters postoperatively	Delphi	Agree	N/A	Strong
33	The lack of pathological specimen in WVTT, in contrast to TURP which could detect T1a/1b prostate cancers, should be discussed	Delphi	Agree	N/A	Strong
*Surgical procedure*
34	WVTT is feasible under general anesthesia³²^,²³^,³¹	Delphi	Agree	High	Strong
35	WVTT is feasible under neuraxial anesthesia³²^,²³^,³¹	Delphi	Agree	High	Strong
36	WVTT is feasible under local anesthesia³²^,²³^,³¹	Delphi	Agree	High	Strong
37	In local anesthesia setting, the combination of transurethral local anesthetic gel and transperineal peri-prostatic block is feasible²³^,³¹	Delphi	Agree	Low	Strong
38	In local anesthesia setting, the combination of transurethral local anesthetic gel and intravenous analgesics is feasible²³	Delphi	Agree	Low	Strong
39	WVTT is feasible in an office-based setting³²^,²³^,²⁴	Delphi	Agree	High	Strong
40	Intravenous antibiotics -- tailored to any positive urine cultures - must be given before operation³⁸	Delphi	Agree	Low	Strong
41	If preoperative cystoscopy was not performed, cystoscopic examination (with a flexible or rigid cystoscope) should be performed before introduction of the WVTT device, to rule out alternative pathology	Delphi	Agree	Very low	Strong
42	Prostate length should be measured with reference to fields of vision (FOV)	Delphi	Agree	N/A	Strong
43	The presence of median lobe must be noted during cystoscopy	Delphi	Agree	N/A	Strong
44	The locations of external urethral sphincter and ureteric orifices should be noted, and injections should be avoided at their proximity	Delphi	Agree	N/A	Strong
45	Treatment cycles per unit prostate volume (CPV) can be considered to guide the number of treatment cycles²⁴^,³³	Delphi	Agree	Moderate	Weak
46	In catheter-dependent patients, a more aggressive approach - with CPV greater than 0.15 -- can be considered²⁴^,³³	Meeting	Agree	Moderate	Weak
47	Bladder washout should be performed till clear effluent is observed before leaving the operating theatre³³	Delphi	Agree	Very low	Weak
*Postoperative Management and follow-up Schedule*
48	Same-day discharge is feasible and encouraged in most cases³²^,²³^,²⁴^,³¹	Delphi	Agree	Moderate	Weak
49	Postoperative antibiotics is not routinely required	Delphi	Not reached	-	-
50	There is no high-level evidence on the use of postoperative antibiotics, and it should depend on local guidelines	Delphi	Agree	N/A	Strong
51	A course of postoperative antibiotics can be considered in those who were catheter-dependent preoperatively²⁴^,³³	Delphi	Agree	Very low	Weak
52	A course of postoperative antibiotics can be considered in those who were NOT catheter-dependent preoperatively³²^,³³	Delphi	Agree	Very low	Weak
53	BPH medications should be continued postoperatively at least till trial without catheter (TWOC)³²	Delphi	Agree	Very low	Strong
54	Date of first TWOC should depend on preoperative catheter dependence²⁴^,³²	Delphi	Agree	Very low	Weak
55	Date of first TWOC should depend on prostate size	Delphi	Agree	Very low	Weak
56	Date of first TWOC should depend on patient preference	Delphi	Not reached	-	-
57	Patients who fail TWOC should be allowed to repeat TWOC until three months, at which further prostate shrinkage is not expected²⁴^,³²	Delphi	Agree	Very low	Weak
58	Flexible cystoscopy should be arranged for patients who fail TWOC at three months	Delphi	Agree	Very low	Strong
59	Flexible cystoscopy should be arranged for patients with suboptimal symptom improvement at three months	Delphi	Agree	Very low	Weak
60	Flexible cystoscopy should be arranged for patients with suboptimal uroflowmetry results at three months	Delphi	Agree	Very low	Weak
61	Urodynamic study should be arranged for patients who fail TWOC at three months	Delphi	Agree	Very low	Strong
62	Urodynamic study should be arranged for patients with suboptimal symptom improvement at three months	Meeting	Not reached	-	-
63	Urodynamic study should be arranged for patients with suboptimal uroflowmetry results at three months	Meeting	Not reached	-	-
64	International prostate symptom score (IPSS) should be monitored postoperatively	Delphi	Agree	N/A	Strong
65	Uroflowmetry should be repeated postoperatively	Delphi	Agree	N/A	Strong
66	Erectile function should be assessed postoperatively	Delphi	Agree	N/A	Strong
67	Patient should be followed up in three months post WVTT²⁴	Delphi	Agree	Very low	Weak
68	Patient should be followed up till at least one year post WVTT²⁴	Delphi	Agree	Very low	Strong
69	PSA testing after WVTT should follow recommendations from EAU guidelines	Delphi	Agree	N/A	Weak
*Data Reporting and outcome measures*
70	In studies of WVTT, preoperative catheter dependence must be documented	Delphi	Agree	N/A	Strong
71	In studies of WVTT, preoperative prostate size must be documented	Delphi	Agree	N/A	Strong
72	In studies of WVTT, preoperative maximal flow rate (Qmax) must be documented	Delphi	Agree	N/A	Strong
73	In studies of WVTT, preoperative post void residual urine volume (PVR) must be documented	Delphi	Agree	N/A	Strong
74	In studies of WVTT, preoperative international prostate symptom score (IPSS) must be documented	Delphi	Agree	N/A	Strong
75	In studies of WVTT, preoperative erectile function should be documented using scores such as international Index of erectile function (IIEF-5)	Delphi	Agree	N/A	Strong
76	In studies of WVTT, the operative time is an important outcome measure	Meeting	Not reached	-	-
77	In studies of WVTT, the need of bladder irrigation is an important outcome measure	Meeting	Not reached	-	-
78	In studies of WVTT, hospital stay is an important outcome measure	Delphi	Agree	N/A	Weak
79	In studies of WVTT, the time to successful TWOC is an important outcome measure	Delphi	Agree	N/A	Weak
80	In studies of WVTT, the complication rate is an important outcome measure	Delphi	Agree	N/A	Strong
81	In studies of WVTT, the occurrence of urinary tract infection is an important outcome measure	Delphi	Agree	N/A	Strong
82	In studies of WVTT, the occurrence of hematuria is an important outcome measure	Delphi	Agree	N/A	Strong
83	In studies of WVTT, the occurrence of urinary retention is an important outcome measure	Delphi	Agree	N/A	Strong
84	In studies of WVTT, the occurrence of urinary incontinence is an important outcome measure	Delphi	Agree	N/A	Weak
85	In studies of WVTT, the 3-month Qmax is an important outcome measure	Delphi	Agree	N/A	Strong
86	In studies of WVTT, the 3-month PVR is an important outcome measure	Delphi	Agree	N/A	Weak
87	In studies of WVTT, the 3-month IPSS is an important outcome measure	Delphi	Agree	N/A	Strong
88	In studies of WVTT, the 3-month IIEF-5 score is an important outcome measure	Delphi	Agree	N/A	Weak
89	In studies of WVTT, the prostate volume reduction is an important outcome measure	Delphi	Agree	N/A	Weak
90	In studies of WVTT, the use of BPH medication at 1 year is an important outcome measure	Delphi	Agree	N/A	Strong
91	In studies of WVTT, the use of BPH medication at 3 years is an important outcome measure	Delphi	Agree	N/A	Strong
92	In studies of WVTT, the use of BPH medication at 5 years is an important outcome measure	Delphi	Agree	N/A	Strong
93	In studies of WVTT, the 1-year surgical retreatment rate is an important outcome measure	Delphi	Agree	N/A	Strong
94	In studies of WVTT, the 3-year surgical retreatment rate is an important outcome measure	Delphi	Agree	N/A	Strong
95	In studies of WVTT, the 5-year surgical retreatment rate is an important outcome measure	Delphi	Agree	N/A	Strong

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Table 5.

Grading of recommendations assessment, development and evaluation (GRADE) definitions for quality of evidence and strength of recommendations

GRADE Category	Definition
Quality of evidence
High	Further research is very unlikely to change our confidence in the estimate of effect.
Moderate	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low	Any estimate of effect is very uncertain.
Strength of recommendation
Strong	The desirable effects of an intervention clearly outweigh the undesirable effects (or vice versa). Most informed patients would choose the recommended course of action. Clinicians can confidently deliver this intervention.
Weak (Conditional)	The trade-offs are less certain—either because of low quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced, or there is uncertainty in the values and preferences, or whether it represents a wise use of resources. Shared decision-making is essential.

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3. Results

3.1. Uncertainties review

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram detailing the study selection process is presented in Fig. 1c. The initial systematic literature search, conducted across MEDLINE, EMBASE, and the Cochrane Library from 2015 to September 2025, yielded a total of 1141 records. After removing 351 duplicate publications, 790 unique records remained for screening. After reviewing titles and abstracts, 559 records were excluded as they were not relevant to the scope of this uncertainties review. The full texts of the remaining 231 articles were then thoroughly assessed for eligibility. Of these, 34 articles were excluded for the following specific reasons: duplication (n = 2), unclear intervention (n = 13), unclear patient population (n = 4), and unclear outcomes (n = 15). Consequently, 197 studies were included in the final qualitative synthesis to inform the generation of uncertainty statements. The studies included in the uncertainties review are listed in the supplementary material. Overall, two of the included RCTs were judged to have some concerns of bias, while the other one had high risk. The most frequent source of bias identified was due to the measurement of the outcome and deviations from the intended interventions. It was noted that, even for the pivotal sham-controlled RCT, as subjects were unblinded after three months, there was significant concern on the risk of bias in the long-term outcomes. These limitations suggest that the certainty of the current evidence for WVTT remains limited. The risk of bias assessment is presented in Fig. 1d.

Fig. 1c — PRISMA flow diagram. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses.

Fig. 1d — Risk of bias assessment of the included randomized controlled trials.

3.2. Two-round Delphi survey

Based on the results of the systematic review, 92 statements were generated for the first-round survey. After the first-round survey, a meeting was held within the steering committee. Two statements were amended: statement 9 was revised to become statement 10, and statement 49 was revised to become statement 50. One statement was cancelled: statement 56. One new statement was added: statement 52. This resulted in a revised total of 92 statements for the second round of the Delphi survey. Statement 56 ‘Date of first trial without catheter (TWOC) should depend on patient preference’ was cancelled after review by the steering committee as respondents of the survey noted ambiguity on the term ‘patient preference’ (Fig. 1b).

Fig. 1b — Summary of the two-round Delphi survey and consensus meeting.

The statements were grouped under six domains as follows:

1.
Case Selection
2.
Preoperative Preparation
3.
Patient Counseling
4.
Surgical Procedure
5.
Postoperative Management and Follow-up Schedule
6.
Data Reporting and Outcome Measures

In the first-round survey, there were 97 respondents out of 150 invitations (64.7%). Among the first-round survey respondents, 84 completed the second-round survey (86.6%). As detailed in Table 1a, the respondents represented diverse experience levels and geographical subregions across Asia. In terms of clinical experience, close to 60 percent of the respondents had more than 10 years of urology clinical practice. Geographically, participants were drawn from Southern and Western Asia (52.6%), Southeastern Asia (25.8%), and Eastern/Central Asia (21.6%). This distribution was maintained in the second round of the Delphi process.

Table 1a.

Characteristics of the Delphi participants who completed both rounds of survey

	Round 1 n (%)	Round 2 n (%)
Country (by Asia subregion)
Southeastern Asia	25 (25.8%)	22 (26.2%)
Eastern Asia/Central Asia	21 (21.6%)	18 (21.4%)
Southern Asia/Western Asia	51 (52.6%)	44 (52.4%)
Years of practice
1–5	22 (22.7%)	19 (22.6%)
6–10	20 (20.6%)	17 (20.2%)
11–15	20 (20.6%)	18 (21.4%)
16–20	15 (15.5%)	14 (16.7%)
21–25	8 (8.2%)	7 (8.3%)
26–30	10 (10.3%)	7 (8.3%)
>30	2 (2.1%)	2 (2.4%)
Specialty
Urologist	97 (100%)	84 (100%)
Total	97 (100%)	84 (100%)

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After the two-round Delphi survey, a consensus was reached on 74 (80.4%) statements (Table 2). The remaining 18 (19.6%) statements without consensus were advanced to the face-to-face consensus meeting. Table 1b lists the characteristics of the panel members. After the discussion and re-voting processes, the consensus panel was able to reach a consensus on 10 out of 18 (55.6%) statements (Table 3).

Table 2.

Summary of statements and consensus status after two rounds of the Delphi survey

Domain and Statement Number	Statement	Round 1						Round 2
Domain and Statement Number	Statement	% Disagree	% Equivocal	% Agree	Total n	Unable to score n	Consensus Status	% Disagree	% Equivocal	% Agree	Total n	Unable to score n	Consensus Status
Case Selection
1	Water vapor thermal therapy (WVTT) is feasible for patients with bothersome lower urinary tract symptoms (LUTS) despite medical therapy	6.5	9.8	80.4	92	3	Agree	7.2	10.8	78.3	83	3	Agree
2	WVTT is feasible for patients with bothersome LUTS who are not on medical therapy	22.6	6.5	67.7	93	3	Not reached	22.9	7.2	66.3	83	3	Not reached
3	WVTT is feasible for patients with benign prostatic hyperplasia (BPH)-related gross hematuria	25.0	18.5	46.7	92	9	Not reached	27.7	19.3	42.2	83	9	Not reached
4	WVTT is feasible for patients with BPH-related recurrent urinary tract infection (UTI)	22.6	21.5	51.6	93	4	Not reached	24.1	22.9	48.2	83	4	Not reached
5	WVTT is feasible for patients with history of urinary retention	9.8	6.5	81.5	92	2	Agree	10.8	7.2	79.5	83	2	Agree
6	WVTT is feasible for patients with refractory retention (on indwelling catheters)	14.0	15.1	68.8	93	2	Not reached	4.8	9.6	83.1	83	2	Agree
7	WVTT is feasible for patients with acute urinary retention complicated by obstructive uropathy (renal impairment)	29.3	18.5	50.0	92	2	Not reached	31.3	20.5	45.8	83	2	Not reached
8	WVTT is feasible for patients with chronic urinary retention	23.7	20.4	52.7	93	3	Not reached	26.5	21.7	48.2	83	3	Not reached
9	WVTT is feasible for patients with prostate size <30 ml	35.5	21.5	39.8	93	3	Not reached	-	-	-	-	-	-
10	For patients with prostate size <30 ml, workup (e.g. cystoscopy, urodynamic study) should be considered before WVTT	-	-	-	-	-	-	34.9	21.7	39.8	83	3	Not reached
11	WVTT is feasible for patients with prostate size between 30-80 ml	3.2	9.7	84.9	93	2	Agree	3.6	10.8	83.1	83	2	Agree
12	WVTT is feasible for patients with prostate size >80 ml	17.4	21.7	56.5	92	4	Not reached	19.3	22.9	53.0	83	4	Not reached
13	WVTT is feasible for patients with median lobes	7.6	18.5	69.6	92	4	Not reached	8.4	20.5	66.3	83	4	Not reached
14	WVTT is feasible for patients with intravesical protrusion (IPP) < 10 mm	7.6	16.3	70.7	92	5	Agree	8.4	18.1	67.5	83	5	Not reached
15	WVTT is feasible for patients with IPP >10 mm	13.0	18.5	62.0	92	6	Not reached	14.5	19.3	59.0	83	6	Not reached
16	There is no high-level evidence to support recommendation on WVTT for patients with concomitant bladder stones, and the sequence of WVTT and cystolithotripsy	2.2	21.7	70.0	92	6	Agree	2.4	21.7	68.7	83	6	Not reached
17	There is no high-level evidence to support recommendation on WVTT for patients with LUTS and concomitant prostate cancer	4.3	11.8	78.5	93	5	Agree	4.8	10.8	78.3	83	5	Agree
18	WVTT is feasible for patients whose antithrombotic medications can be stopped perioperatively	1.1	7.6	87.0	92	4	Agree	1.2	8.4	85.5	83	4	Agree
19	For patients whose antithrombotic medications (other than aspirin - acetylsalicylic acid 80 mg daily) cannot be stopped, other options of BPH surgery should be offered	23.9	16.3	54.3	92	5	Not reached	25.3	16.9	51.8	83	5	Not reached
20	For patients with prior BPH surgery, WVTT is feasible for managing BPH-related symptoms or complications (e.g. urinary retention)	13.2	23.1	59.3	91	4	Not reached	14.5	25.3	55.4	83	4	Not reached
Preoperative Preparation
21	Prostate sizing must be performed before WVTT, via transabdominal/transrectal ultrasonography or recent cross-sectional imaging (i.e. computed tomography CT or magnetic resonance imaging MRI)	2.2	2.2	94.5	91	1	Agree	2.4	2.4	94.0	83	1	Agree
22	Flexible cystoscopy before WVTT should be considered, especially if cystoscopy findings (e.g. patency of prostate channel, alternate pathology) may change the management plan	8.8	17.6	72.5	91	1	Agree	9.6	18.1	71.1	83	1	Agree
23	Urine culture must be saved before WVTT	1.1	6.6	91.2	91	1	Agree	1.2	7.2	90.4	83	1	Agree
24	Positive urine culture must be treated before proceeding with WVTT	0.0	1.1	86.8	91	1	Agree	0.0	0.0	98.8	83	1	Agree
25	Prostate-specific antigen (PSA) testing before WVTT should follow recommendations from European Association of urology (EAU) guidelines	0.0	5.4	93.5	92	1	Agree	0.0	4.8	94.0	83	1	Agree
26	Shared decision-making is recommended for preoperative PSA testing in catheter-dependent patients, due to risk of factitious elevation	1.1	7.6	89.1	92	2	Agree	1.2	6.0	90.4	83	2	Agree
27	Digital rectal examination must be performed before WVTT	3.3	4.3	91.3	92	1	Agree	3.6	4.8	90.4	83	1	Agree
28	Aspirin (acetylsalicylic acid) at the dose of 80 mg daily can be continued perioperatively	3.3	16.5	78.0	91	2	Agree	3.6	16.9	77.1	83	2	Agree
29	Antithrombotic medications- other than aspirin 80 mg daily – should be withheld perioperatively	12.0	7.6	77.2	92	3	Agree	13.3	8.4	74.7	83	3	Agree
Patient Counseling
30	Current sexual function and patient's expectation of postoperative sexual function should be discussed before WVTT	1.1	2.2	95.6	90	1	Agree	0.0	2.4	96.4	83	1	Agree
31	The level of current evidence on WVTT, and the lack of head-to-head comparison to transurethral resection of prostate (TURP) in prospective and randomized setting, should be discussed before WVTT	4.4	7.7	86.8	91	1	Agree	4.8	4.8	89.2	83	1	Agree
32	Patient should be informed of the need of indwelling urethral catheters postoperatively	0.0	1.1	96.7	90	2	Agree	0.0	1.2	96.4	83	2	Agree
33	The lack of pathological specimen in WVTT, in contrast to TURP which could detect T1a/1b prostate cancers, should be discussed	6.7	10.0	81.1	90	2	Agree	7.2	9.6	80.7	83	2	Agree
Surgical Procedure
34	WVTT is feasible under general anesthesia	1.1	6.7	90.0	89	2	Agree	1.2	6.0	90.4	83	2	Agree
35	WVTT is feasible under neuraxial anesthesia	3.4	13.5	78.7	89	4	Agree	3.6	14.5	77.1	83	4	Agree
36	WVTT is feasible under local anesthesia	12.4	12.4	71.9	89	3	Agree	4.8	6.0	86.7	83	2	Agree
37	In local anesthesia setting, the combination of transurethral local anesthetic gel and transperineal peri-prostatic block is feasible	6.7	12.4	75.3	89	5	Agree	7.2	12.0	74.7	83	5	Agree
38	In local anesthesia setting, the combination of transurethral local anesthetic gel and intravenous analgesics is feasible	6.7	8.9	76.7	90	7	Agree	7.2	8.4	75.9	83	7	Agree
39	WVTT is feasible in an office-based setting	6.7	13.5	71.9	89	7	Agree	7.2	12.0	72.3	83	7	Agree
40	Intravenous antibiotics – tailored to any positive urine cultures - must be given before operation	0.0	5.6	93.3	89	1	Agree	0.0	6.0	92.8	83	1	Agree
41	If preoperative cystoscopy was not performed, cystoscopic examination (with a flexible or rigid cystoscope) should be performed before introduction of the WVTT device, to rule out alternative pathology	3.4	9.1	86.4	88	1	Agree	2.4	8.4	88.0	83	1	Agree
42	Prostate length should be measured with reference to fields of vision (FOV)	0.0	6.7	91.1	90	2	Agree	0.0	6.0	92.8	83	1	Agree
43	The presence of median lobe must be noted during cystoscopy	0.0	5.7	92.0	88	2	Agree	0.0	4.8	94.0	83	1	Agree
44	The locations of external urethral sphincter and ureteric orifices should be noted, and injections should be avoided at their proximity	0.0	2.2	95.5	89	2	Agree	0.0	2.4	96.4	83	1	Agree
45	Treatment cycles per unit prostate volume (CPV) can be considered to guide the number of treatment cycles	0.0	8.0	86.4	88	5	Agree	0.0	8.4	85.5	83	5	Agree
46	In catheter-dependent patients, a more aggressive approach - with CPV greater than 0.15 – can be considered	1.1	13.3	67.8	90	16	Not reached	1.2	13.3	66.3	83	16	Not reached
47	Bladder washout should be performed till clear effluent is observed before leaving the operating theatre	5.6	21.1	68.9	90	4	Not reached	4.8	10.8	79.5	83	4	Agree
Postoperative Management and Follow-up Schedule
48	Same-day discharge is feasible and encouraged in most cases	2.2	7.9	87.6	89	2	Agree	2.4	8.4	86.7	83	2	Agree
49	Postoperative antibiotics is not routinely required	44.0	14.3	40.7	91	1	Not reached	-	-	-	-	-	-
50	There is no high-level evidence on the use of postoperative antibiotics, and it should depend on local guidelines	-	-	-	-	-	-	0.0	3.6	94.0	83	2	Agree
51	A course of postoperative antibiotics can be considered in those who were catheter-dependent preoperatively	1.1	5.7	88.6	88	4	Agree	1.2	6.0	88.0	83	4	Agree
52	A course of postoperative antibiotics can be considered in those who were NOT catheter-dependent preoperatively	-	-	-	-	-	-	0.0	7.2	88.0	83	4	Agree
53	BPH medications should be continued postoperatively at least till trial without catheter (TWOC)	5.6	4.5	87.6	89	2	Agree	6.0	4.8	86.7	83	2	Agree
54	Date of first TWOC should depend on preoperative catheter dependence	2.3	11.4	80.7	88	5	Agree	2.4	12.0	79.5	83	5	Agree
55	Date of first TWOC should depend on prostate size	5.6	12.4	79.8	89	2	Agree	6.0	12.0	79.5	83	2	Agree
56	Date of first TWOC should depend on patient preference	50.5	16.5	30.8	91	2	Not reached	-	-	-	-	-	-
57	Patients who fail TWOC should be allowed to repeat TWOC until three months, at which further prostate shrinkage is not expected	6.8	12.5	77.3	88	3	Agree	7.3	13.4	75.6	82	3	Agree
58	Flexible cystoscopy should be arranged for patients who fail TWOC at three months	3.4	6.7	88.8	89	1	Agree	3.7	7.3	87.8	82	1	Agree
59	Flexible cystoscopy should be arranged for patients with suboptimal symptom improvement at three months	3.4	11.4	84.1	88	1	Agree	3.7	12.2	82.9	82	1	Agree
60	Flexible cystoscopy should be arranged for patients with suboptimal uroflowmetry results at three months	5.6	13.5	79.8	89	1	Agree	6.0	14.5	78.3	83	1	Agree
61	Urodynamic study should be arranged for patients who fail TWOC at three months	3.4	18.0	77.5	89	1	Agree	3.7	18.3	76.8	82	1	Agree
62	Urodynamic study should be arranged for patients with suboptimal symptom improvement at three months	10.2	22.7	65.9	88	1	Not reached	9.8	23.2	65.9	82	1	Not reached
63	Urodynamic study should be arranged for patients with suboptimal uroflowmetry results at three months	10.0	27.8	61.1	90	1	Not reached	10.8	26.5	61.4	83	1	Not reached
64	International prostate symptom score (IPSS) should be monitored postoperatively	1.1	3.4	94.3	88	1	Agree	1.2	3.7	93.9	82	1	Agree
65	Uroflowmetry should be repeated postoperatively	1.1	1.1	96.7	90	1	Agree	1.2	1.2	96.4	83	1	Agree
66	Erectile function should be assessed postoperatively	2.3	8.0	88.6	88	1	Agree	2.4	7.2	89.2	83	1	Agree
67	Patient should be followed up in three months post WVTT	3.3	4.4	90.0	90	2	Agree	3.6	4.8	89.2	83	2	Agree
68	Patient should be followed up till at least one year post WVTT	3.4	6.8	88.6	88	1	Agree	3.6	6.0	89.2	83	1	Agree
69	PSA testing after WVTT should follow recommendations from EAU guidelines	2.3	4.5	90.9	88	2	Agree	2.4	3.7	91.5	82	2	Agree
Data Reporting and Outcome Measures
70	In studies of WVTT, preoperative catheter dependence must be documented	0.0	2.3	96.6	88	1	Agree	0.0	1.2	97.6	83	1	Agree
71	In studies of WVTT, preoperative prostate size must be documented	0.0	2.3	96.6	88	1	Agree	0.0	2.4	96.4	83	1	Agree
72	In studies of WVTT, preoperative maximal flow rate (Qmax) must be documented	0.0	1.1	97.8	89	1	Agree	0.0	1.2	97.6	83	1	Agree
73	In studies of WVTT, preoperative post void residual urine volume (PVR) must be documented	0.0	2.2	96.6	89	1	Agree	0.0	2.4	96.4	83	1	Agree
74	In studies of WVTT, preoperative international prostate symptom score (IPSS) must be documented	0.0	3.4	95.5	89	1	Agree	0.0	3.6	95.2	83	1	Agree
75	In studies of WVTT, preoperative erectile function should be documented using scores such as international Index of erectile function (IIEF-5)	2.3	10.2	85.2	88	2	Agree	2.4	9.6	85.5	83	2	Agree
76	In studies of WVTT, the operative time is an important outcome measure	20.5	20.5	56.8	88	2	Not reached	21.7	20.5	55.4	83	2	Not reached
77	In studies of WVTT, the need of bladder irrigation is an important outcome measure	13.6	19.3	64.8	88	2	Not reached	14.5	20.5	62.7	83	2	Not reached
78	In studies of WVTT, hospital stay is an important outcome measure	11.4	14.8	72.7	88	1	Agree	12.0	14.5	72.3	83	1	Agree
79	In studies of WVTT, the time to successful TWOC is an important outcome measure	0.0	8.0	90.9	88	1	Agree	0.0	8.4	90.4	83	1	Agree
80	In studies of WVTT, the complication rate is an important outcome measure	1.1	2.2	95.5	89	1	Agree	1.2	2.4	95.2	83	1	Agree
81	In studies of WVTT, the occurrence of urinary tract infection is an important outcome measure	0.0	4.5	94.4	89	1	Agree	0.0	6.0	92.9	84	1	Agree
82	In studies of WVTT, the occurrence of hematuria is an important outcome measure	4.5	11.2	83.1	89	1	Agree	7.1	11.9	79.8	84	1	Agree
83	In studies of WVTT, the occurrence of urinary retention is an important outcome measure	0.0	0.0	98.9	89	1	Agree	0.0	0.0	98.8	83	1	Agree
84	In studies of WVTT, the occurrence of urinary incontinence is an important outcome measure	2.2	7.9	86.5	89	3	Agree	2.4	8.4	85.5	83	3	Agree
85	In studies of WVTT, the 3-month Qmax is an important outcome measure	0.0	2.3	96.6	88	1	Agree	0.0	2.4	96.4	83	1	Agree
86	In studies of WVTT, the 3-month PVR is an important outcome measure	1.1	5.7	92.0	88	1	Agree	2.4	6.0	90.5	84	1	Agree
87	In studies of WVTT, the 3-month IPSS is an important outcome measure	0.0	2.3	96.6	88	1	Agree	0.0	2.4	96.4	83	1	Agree
88	In studies of WVTT, the 3-month IIEF-5 score is an important outcome measure	2.3	9.1	87.5	88	1	Agree	2.4	9.6	86.7	83	1	Agree
89	In studies of WVTT, the prostate volume reduction is an important outcome measure	5.7	11.4	81.8	88	1	Agree	6.0	12.0	80.7	83	1	Agree
90	In studies of WVTT, the use of BPH medication at 1 year is an important outcome measure	2.3	11.4	85.2	88	1	Agree	2.4	10.8	85.5	83	1	Agree
91	In studies of WVTT, the use of BPH medication at 3 years is an important outcome measure	4.5	10.2	83.0	88	2	Agree	4.8	10.8	81.9	83	2	Agree
92	In studies of WVTT, the use of BPH medication at 5 years is an important outcome measure	6.8	17.0	72.7	88	3	Agree	7.2	15.7	73.5	83	3	Agree
93	In studies of WVTT, the 1-year surgical retreatment rate is an important outcome measure	0.0	4.5	92.0	88	3	Agree	0.0	4.8	91.6	83	3	Agree
94	In studies of WVTT, the 3-year surgical retreatment rate is an important outcome measure	2.3	6.8	87.5	88	3	Agree	2.4	8.3	85.7	84	3	Agree
95	In studies of WVTT, the 5-year surgical retreatment rate is an important outcome measure	2.3	10.2	83.0	88	4	Agree	2.4	10.8	81.9	83	4	Agree

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Table 1b.

Panel members of the consensus meeting

Name	Role	Representing Body/Institution
Dr. Lo Ka Lun	Urologist	The Chinese University of Hong Kong, Hong Kong
Dr. Fam Xeng Inn	Urologist	Universiti Kebangsaan Malaysia, Malaysia
Dr. Hsu Yu-Chao	Urologist	Hong Ren Hospital, Taiwan
Prof. Park, Min Gu	Urologist	Korea Univ. Anam Hospital, Korea
Dr. Jung, Jae Hyun	Urologist	Seoul Leaders urology clinic, Korea
Dr. Lau Weida	Urologist	Khoo Teck Puat Hospital, Singapore
Dr. Siu Wai Hei Brian	Urologist	The Chinese University of Hong Kong, Hong Kong
Dr. Adistra Satjakoesoemah	Urologist	Abdi Waluyo Hospital, Indonesia
Dr. Teerapon Amornvesukit	Urologist	Bumrungrad Hospital, Thailand
Dr. Suntchal Wirotsaengthong	Urologist	BNH Hospital, Thailand
Dr. Varat Woranisarakul	Urologist	Siriraj Hospital, Thailand
Dr. Anand Dharaskar	Urologist	Manipal Hospital, Pune, India
Dr. Mallikarjuna C	Urologist	Asian Institute of Nephrology and urology (AINU), India

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Table 3.

Summary of statements discussed and re-voted during the consensus meeting

Domain	Statement No.	Statement	% Disagree	% Equivocal	% Agree	Total n	Consensus Status
Case selection	2	Water vapor thermal therapy (WVTT) is feasible for patients with bothersome LUTS who are not on medical therapy	7.7	0.0	92.3	13	Agree
	3	WVTT is feasible for patients with benign prostatic hyperplasia (BPH)-related gross hematuria	30.8	7.7	61.5	13	Not reached
	4	WVTT is feasible for patients with BPH-related recurrent urinary tract infection (UTI)	7.7	15.4	76.9	13	Agree
	7	WVTT is feasible for patients with acute urinary retention complicated by obstructive uropathy (renal impairment)	23.1	7.7	69.2	13	Not reached
	8	WVTT is feasible for patients with chronic urinary retention	23.1	15.4	61.5	13	Not reached
	10	For patients with prostate size <30 ml, workup (e.g. cystoscopy, urodynamic study) should be considered before WVTT	7.7	0.0	92.3	13	Agree
	12	WVTT is feasible for patients with prostate size >80 ml	0.0	0.0	100.0	13	Agree
	13	WVTT is feasible for patients with median lobes	0.0	0.0	100.0	13	Agree
	14	WVTT is feasible for patients with intravesical protrusion (IPP) < 10 mm	0.0	7.7	92.3	13	Agree
	15	WVTT is feasible for patients with IPP >10 mm	0.0	0.0	100.0	13	Agree
	16	There is no high-level evidence to support recommendation on WVTT for patients with concomitant bladder stones, and the sequence of WVTT and cystolithotripsy	7.7	0.0	92.3	13	Agree
	19	For patients whose antithrombotic medications (other than aspirin 80 mg daily) cannot be stopped, other options of BPH surgery should be offered	46.2	7.7	46.2	13	Not reached
	20	For patients with prior BPH surgery, WVTT is feasible for managing BPH-related symptoms or complications (e.g. urinary retention)	0.0	15.4	84.6	13	Agree
Surgical procedure	46	In catheter-dependent patients, a more aggressive approach - with CPV greater than 0.15 – can be considered	0.0	7.7	92.3	13	Agree
Postoperative management and follow-up Schedule	62	Urodynamic study should be arranged for patients with suboptimal symptom improvement at three months	23.1	0.0	76.9	13	Not reached
Postoperative management and follow-up Schedule	63	Urodynamic study should be arranged for patients with suboptimal uroflowmetry results at three months	23.1	0.0	76.9	13	Not reached
Data reporting and outcome measures	76	In studies of WVTT, the operative time is an important outcome measure	23.1	15.4	61.5	13	Not reached
Data reporting and outcome measures	77	In studies of WVTT, the need of bladder irrigation is an important outcome measure	30.8	15.4	53.8	13	Not reached

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Overall, 84 out of the 93 statements (90.3%) reached a final consensus (Table 4). The principal findings are summarized by the domains below. The key actionable recommendations are summarized in Table 6.

Table 6.

Summary of key actionable recommendations for clinicians

Domain	Key Actionable Recommendations
Patient selection	• Feasible for extended indications, including: - Prostate volume >80 mL - Median lobes (regardless of IPP) - Refractory urinary retention • For prostate volume <30 mL: Perform further workup (cystoscopy/urodynamics) to rule out alternative pathology (i.e. hypocontractile bladder or high riding bladder neck) before proceeding. • Insufficient evidence to recommend routine use in patients with concomitant bladder stones or prostate cancer.
Preoperative preparation	• Mandatory: Digital rectal examination, prostate sizing (US/CT/MRI), and urine culture; treat all cases of asymptomatic bacteriuria before the procedure. • Antithrombotic management: (Weak recommendation based on very low level of evidence) - Continue aspirin (80 mg daily). - Withhold all other antithrombotic medications (clopidogrel, warfarin, DOACs etc.) after multidisciplinary consultation. • Counseling must cover: - Expected postoperative catheter requirement - Current erectile function and expectations - Absence of a pathological specimen (as compared to TURP) - Current evidence level and lack of RCTs vs. TURP
Surgical procedure	• Anesthesia: Feasible under general, neuraxial, or local anesthesia. Suitable for office-based settings and same-day discharge. • Treatment planning: Measure prostate length with reference to fields of vision (FOV). Consider using cycles per unit prostate volume (CPV) as a guide. Consider a more aggressive approach (CPV >0.15) in catheter-dependent patients. • Perform a manual bladder washout until clear effluent is observed before concluding the case.
Postoperative management	• Catheter management: Individualize TWOC timing based on preoperative catheter status and prostate size. If initial TWOC fails, repeat attempts are reasonable for up to three months. • Medication: Continue BPH medications at least until successful TWOC. • Follow-up schedule: - At 3 months: Assess IPSS, Qmax, PVR, and erectile function. - Followed up at least till 1 year • For failed TWOC at 3 months: Perform flexible cystoscopy to evaluate the prostatic channel; perform urodynamic studies to assess bladder contractility

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Abbreviations: BPH, benign prostatic hyperplasia; CPV, cycles per unit prostate volume; CT, computed tomography; DOACs, direct oral anticoagulants; FOV, fields of vision; IPP, intravesical prostatic protrusion; IPSS, International Prostate Symptom Score; MRI, magnetic resonance imaging; PVR, post-void residual urine volume; Qmax, maximum flow rate; RCT, randomized controlled trial; TURP, transurethral resection of the prostate; TWOC, trial without catheter; US, ultrasonography.

3.3. Principal findings of the consensus statements

3.3.1. Case selection

For case selection, WVTT is considered feasible for most classical BPH surgical indications, even for those who are not on medical therapy.²¹ Large prostates (>80 ml), significant (>1 cm) intravesical prostatic protrusion (IPP), prior BPH surgery, or refractory urinary retention should not be considered contraindications. 22, 23, 24, 25 For patients with a prostate volume less than 30 ml, the panel agreed that further workup, such as cystoscopy or urodynamic studies, should be considered before proceeding with WVTT to identify the cause of the poor voiding (e.g. hypocontractile bladder or high-riding bladder neck).

3.3.2. Preoperative preparation

There was strong agreement on several essential preoperative steps. Prostate sizing by ultrasonography or cross-sectional imaging and a digital rectal examination must be performed. A urine culture is mandatory, and any asymptomatic bacteriuria must be treated prior to the procedure. Preoperative flexible cystoscopy was recommended. Prostate-specific antigen (PSA) testing should follow guideline recommendations,²⁶ with shared decision-making advised for catheter-dependent patients due to the risk of factitious elevation (with the alternative option of testing postoperatively without a catheter).

Regarding antithrombotic medication management, the panel agreed that aspirin (acetylsalicylic acid), at 80 mg daily, can be safely continued perioperatively.²⁷ However, all other antithrombotic medications should be withheld. For patients on these agents who discontinue therapy, no consensus was reached on whether alternative surgical options should be offered.

3.3.3. Patient counseling

The consensus emphasized the importance of comprehensive preoperative counseling. Discussions must cover current sexual function and postoperative expectations. Patients should be informed about the expected need for a postoperative indwelling catheter.⁷^,²⁸ Furthermore, the level of current evidence for WVTT, including the lack of robust head-to-head randomized comparisons with procedures like transurethral resection of the prostate (TURP), should be transparently discussed.⁶ Another salient point for counseling is the absence of a pathological specimen with WVTT, in contrast to TURP, which could incidentally detect prostate cancer.²⁹

3.3.4. Surgical procedure

WVTT is considered feasible under a variety of anesthesia modalities, including general, neuraxial, and local anesthesia, and can be performed in an office-based setting.³⁰ When using local anesthesia, combinations involving transurethral anesthetic gel with either transperineal peri-prostatic blocks or intravenous analgesics are supported.²³^,³¹

A cystoscopy examination should be performed before introducing the WVTT device to rule out alternate pathology and to assess anatomy. Critical anatomical landmarks, including the verumontanum, external urethral sphincter, and ureteric orifices, must be identified, and injections should be avoided in their immediate proximity. In addition to the conventional fields-of-vision (FOV) approach, the number of injections can be guided by the number of treatment cycles per unit prostate volume (CPV). For catheter-dependent patients, the panel agreed that a more aggressive approach (with a CPV greater than 0.15) can be considered.³²^,³³ Finally, a bladder washout should be performed until the effluent is clear before concluding the procedure, to minimize the risk of clot retention.

3.3.5. Postoperative management and follow-up

Same-day discharge is feasible and encouraged for most patients. While preoperative treatment of asymptomatic bacteriuria is mandatory, the use of postoperative antibiotics is not routinely required but can be considered based on local guidelines or for specific patient groups, e.g. patients who were catheter-dependent preoperatively.³⁴ The panel members noticed a large heterogeneity in postoperative medication duration across various studies,⁷^,³²^,³⁵^,³⁶ but it came to consensus that BPH medications should be continued at least until the first successful trial without catheter (TWOC).

The timing of the first TWOC should be individualized, depending on preoperative catheter status and prostate size. For patients who fail an initial TWOC, repeat trials should be permitted for up to three months, at which point the literature has demonstrated that minimal prostate shrinkage is expected afterwards.³⁷ In cases of failed TWOC or suboptimal symptomatic or urodynamic improvement at three months, flexible cystoscopy is recommended to assess the prostatic channel. While urodynamic study is advised for patients failing TWOC at three months, its routine use for those with suboptimal symptom or flow rate improvement did not achieve consensus, possibly due to its more invasive and resource-dependent nature.

Patients should be followed up with standardized assessments of the International Prostate Symptom Score - IPSS, uroflowmetry (maximal flow rate (Qmax) and post-void residual urine volume [PVR), and erectile function at three months and for at least one year postoperatively. Postoperative PSA testing should follow guideline recommendations.³⁸

3.3.6. Data reporting and outcome measures

To standardize future research, consensus was reached on a comprehensive set of parameters that must be reported in WVTT studies. These include key preoperative baseline characteristics (catheter dependence, prostate size, Qmax, PVR, IPSS, and erectile function). Important postoperative outcome measures encompass time to successful TWOC, complication rates (including UTI, hematuria, retention, and incontinence), and 3-month outcomes (Qmax, PVR, IPSS, International Index of Erectile Function 5 - IIEF-5), prostate volume reduction, the use of BPH medication and surgical retreatment up to 5 years and beyond.

4. Discussion

The systematic review underpinning this consensus statement reveals that the majority of the final recommendations are supported by very low to low quality evidence according to the GRADE framework. This underscores the relatively nascent state of high-quality research in the field of water vapor thermal therapy. Apart from the seminal sham-controlled RCT by McVary et al and its follow-up publications⁷^,⁸^,²⁸ the literature consists of only one RCT comparing WVTT against bipolar TURP,³⁹ and another comparing it against transperineal laser ablation (TPLA).⁴⁰ Apart from RCTs, the broader literature consists predominantly of single-arm case series, retrospective cohort studies, and heterogeneous observational data. While RCTs are valuable for comparing voiding and sexual outcomes against different treatments, the strict inclusion criteria often enroll younger, healthier, non-catheter-dependent patients (with mostly medium-sized prostates). Consequently, these trial populations may not reflect the broader real-world patient demographic. Importantly, RCTs do not address many practical clinical questions, such as the optimal number of treatment cycles, the duration for continuing BPH medications post-procedure, or the ideal timing for the first trial without catheter (TWOC). This scarcity of high-quality data to inform robust recommendations across various aspects of WVTT underscores the necessity of developing a consensus statement, using an established and reproducible methodology.

4.1. Implications on clinical practice and research

The panel reached a consensus that patients with prostates <30 ml require further investigation, such as cystoscopy or urodynamic studies, before proceeding with WVTT. This is because, analogous to the experience with TURP, the pathology in these patients often does not stem from benign prostatic enlargement alone; symptoms may be due to a high-riding bladder neck or poor bladder contractility, which do not respond optimally to volume-reducing procedures like WVTT or TURP.⁴¹

Conflicting views existed for a few other indications, including BPH-related gross hematuria (primarily due to technical concerns of injecting into a highly vascular prostate), chronic urinary retention, and acute urinary retention with obstructive uropathy (both due to concerns about underlying detrusor underactivity).³² The panel agreed that there was no high-level evidence to support the use of WVTT in patients with concomitant bladder stones or prostate cancer.

The panel agreed that aspirin (acetylsalicylic acid) at a dose of 80 mg daily need not be discontinued. For other more potent antithrombotic medications (e.g., clopidogrel and warfarin), the panel expressed concern despite a published series by Bausch et al⁴² demonstrating no bleeding complications in 38 patients who continued these agents perioperatively. The primary concern is the difficulty in managing a major hemorrhage during the WVTT procedure. Consequently, no consensus was reached on whether WVTT should be offered to patients on potent antithrombotic medications that cannot be stopped (e.g., a patient on warfarin due to a recent stroke). A larger-scale prospective study is warranted to confirm the safety of WVTT without interruption of these agents.

The optimal number of injections, or the ‘aggressiveness’ of treatment, has been a controversial topic. A “less is more” approach was advocated in a single-arm pilot study by Aladesuru et al, where a simplified method of a single vapor injection per prostate lobe provided significant improvements in IPSS, QoL, and Qmax at 12 months.³⁵ Conversely, a high cycles per unit prostate volume (CPV) approach has been advocated, especially for catheter-dependent patients, with a recent publication showing that a CPV >0.15 was associated with superior 1-year IPSS and lower 30-day readmission rates.²⁴ While not formally summarized in a consensus statement, the panel acknowledged that both high-CPV and ‘less is more’ approaches are sound approaches, with the selection depending on individual patient characteristics (e.g. catheter dependence, age) and prostate morphology (e.g. prostate length, anteroposterior diameter). It was agreed that CPV could be used to guide the number of treatment cycles, in addition to the traditional approach based on the field of vision (FOV).

4.2. Strengths and limitations

The principal strength of this consensus statement lies in its foundation upon a well-established and robust methodological framework.⁹^,¹⁷ The process was initiated by a systematic review with a registered protocol¹⁵ to comprehensively identify gaps in the literature, ensuring that the subsequent consensus statements were grounded in the current evidence. Furthermore, the multi-national panel of urologists was purposively selected from across the Asia-Pacific region and verified for substantial personal experience with the WVTT procedure, ensuring that the consensus reflects practical, expert insight. Statements that reached a consensus were based on a two-round Delphi survey and/or a round of anonymous voting from the expert consensus meeting.

However, several limitations must be acknowledged. The evidence base for WVTT is still evolving, and only three published randomized controlled trials were identified; consequently, a quantitative meta-analysis was deemed not meaningful and not performed. All members of the consensus panel were urologists, while this reflects that the surgeon is the primary stakeholder for WVTT, the inclusion of patient representatives or a methodologist could have provided additional valuable perspectives on patient-reported outcomes and process rigor, respectively. Nevertheless, our methodology is consistent with other published urological consensus statements.¹⁰^,¹²^,¹³ While the recommendations are predominantly underpinned by fundamental principles of patient selection, surgical technique, and perioperative care that are universal to the safe and effective delivery of water vapor thermal therapy (e.g. ensuring prostate sizing and digital rectal examination are done before WVTT), clinicians outside the APAC region should exercise judicious adaptation in light of their local practice patterns, regulatory requirements, and patient population characteristics. The response rate was 64.7% in round 1 of the Delphi survey, while this is comparable to previous urology consensus statements¹⁰^,¹² , which ranged from around 60-70%, there exists a risk of non-response bias – non-respondents might be more likely to disagree with the statements. Finally, the nature of consensus statements requires that they are often binary, which may not fully capture more complex, situation-based clinical concepts, such as the nuanced decision between a ‘less is more’ versus a ‘high CPV’ treatment strategy.

5. Conclusion

This APAC collaborative consensus project has developed a set of 84 consensus statements on water vapor thermal therapy (WVTT) for BPH, utilizing an established methodology that incorporated a systematic review, a two-round Delphi survey, and a final consensus meeting. These statements provide comprehensive guidance on case selection, preoperative preparation, surgical technique, postoperative management, and data reporting. This consensus statement will serve as a critical reference for urologists in the Asia-Pacific region and beyond, aiming to standardize and optimize clinical practice and inform the design of future studies until more robust, long-term comparative evidence becomes available.

Availability of data and materials

The data and materials are available upon reasonable requests.

Conflict of interest

The authors have no relevant conflicts of interest to disclose.

Footnotes

^{Appendix A}

Supplementary data to this article can be found online at https://doi.org/10.1016/j.prnil.2026.04.004.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1

mmc1.docx^{(32.8KB, docx)}

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

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Data Availability Statement

The data and materials are available upon reasonable requests.

[bib1] 1.Cosimo De Nunzio W.A., Freedland Stephen J., Edward Giovannucci, Parsons J. Kellogg. The correlation between metabolic syndrome and prostatic diseases. Eur Urol. 2012;61 doi: 10.1016/j.eururo.2011.11.013. [DOI] [PubMed] [Google Scholar]

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PERMALINK

Asia-Pacific collaborative consensus statements on water vapor thermal therapy (Rezūm) incorporating a systematic review, a two-round Delphi survey, and a consensus meeting

Brian Wai Hei Siu

Jeremy Man Hon Ho

Xeng Inn Fam

Yu-Chao Hsu

Min Gu Park

Jae Hyun Jung

Weida Lau

Adistra Satjakoesoemah

Teerapon Amornvesukit

Suntchai Wirotsaengthong

Angus Man Chung Chan

Varat Woranisarakul

Anand Dharaskar

C Mallikarjuna

Chi Fai Ng

Ka Lun Lo

Abstract

Background

Methods

Results

Conclusions

1. Introduction

2. Methodology

Fig. 1a.

2.1. Systematic review

2.2. Two-round Delphi survey

2.3. Consensus meeting

Table 4.

Table 5.

3. Results

3.1. Uncertainties review

Fig. 1c.

Fig. 1d.

3.2. Two-round Delphi survey

Fig. 1b.

Table 1a.

Table 2.

Table 1b.

Table 3.

Table 6.

3.3. Principal findings of the consensus statements

3.3.1. Case selection

3.3.2. Preoperative preparation

3.3.3. Patient counseling

3.3.4. Surgical procedure

3.3.5. Postoperative management and follow-up

3.3.6. Data reporting and outcome measures

4. Discussion

4.1. Implications on clinical practice and research

4.2. Strengths and limitations

5. Conclusion

Availability of data and materials

Conflict of interest

Footnotes

Appendix A. Supplementary data

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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