Intraprostatic injections for lower urinary tract symptoms/benign prostatic enlargement treatment

INTRODUCTION: Endoscopic surgical treatment represents the gold standard in patients with lower urinary tract symptoms (LUTS) when medical treatment fails. In the past years there has been a growing interest in intraprostatic injections which represent a minimally invasive alternative for those patients not suitable for surgery. Aim of our study is to systematically review all the available data on intraprostatic injections for the treatment of LUTS patients with benign prostatic enlargement (BPE). EVIDENCE ACQUISITION: A systematic review of the literature using the Medline, Scopus and Web of Science databases for relevant articles published until June 2018 was performed using both the Medical Subjects Heading and free test protocols. The MeSH search was conducted by combining the following terms: "Intraprostatic Injections," "Botulinum Toxin A," "Onabotulinum," "Ethanol," "Lower Urinary tract Symptoms," "Benign prostatic enlargement," "Benign Prostatic Hyperplasia," "NX1207," "PRX302." Each article's title and abstract were reviewed for their appropriateness and their relevance with regards to the relationship to intraprostatic injections. EVIDENCE SYNTHESIS: Intraprostatic injections for the treatment of LUTS/BPE patients may be performed using different products as: Ethanol, onabotulinum toxin A, NX1207 and PRX 302. Ethanol, the first agent for intraprostatic use, showed promising results in prospective trials, however, the rare but serious adverse events associated with extraprostatic diffusion of ethanol stopped its use. Many studies on onabotulinum toxin A (BotoxR) have been performed, however, two large randomized clinical trials showed no differences in terms of symptoms improvements and flow improvements when compared to placebo. Two new promising drugs NX 1207 and PRX 302 have been developped in the past years. NX 1207 showed lack of efficacy in the two large European phase III RCT. PRX 302 showed promising results in phase I and II studies, however, definitive results from a large phase III randomized controlled trial (RCT) are awaited before drawing any definitive conclusions. CONCLUSIONS: Intraprostatic injections are still to be considered investigational for the minimally invasive management of LUTS/BPE patients. Emerging data suggest a possible role of new agents in the near future when definitive data of ongoing RCTs will be available.