The double-decker technique for transurethral water vapor therapy (Rezūm) in catheter-dependent patients: A step-by-step guide and results from a prospective registry

PURPOSE: Recent work by our group demonstrated that a treatment cycles per unit prostate volume (CPV) ratio >0.15 significantly improves outcomes in transurethral water vapor therapy (Rezūm) for catheter-dependent patients. Prostates have highly variable morphology and the treatment planning approach in Rezūm is not well reported. MATERIALS AND METHODS: The double-decker technique, which conceptually divides the prostate into anterior and posterior 'decks', is detailed step-by-step and illustrated in the supplementary video. The outcomes of double-decker technique versus conventional technique were compared in a prospective registry of men with refractory retention undergoing Rezūm. RESULTS: Among 144 catheter-dependent patients, 102 underwent the conventional technique and 42 were treated with the double-decker technique. Baseline characteristics were comparable. The double-decker technique had a higher mean CPV (0.204 vs. 0.132, p<0.001) with more injections (10.4 vs. 6.7, p<0.001). This was associated with a significantly greater percentage reduction in prostate volume at three months (34.3% vs. 26.1%, p=0.029) and a superior International Prostate Symptom Score (IPSS) at one year (3.70 vs. 8.13, p=0.041). Multivariable regression showed that the double-decker technique was associated with a lower one-year IPSS (coefficient: -4.86, p=0.045). There was no significant difference in 30-day readmission rates (4.8% vs. 12.7%, p=0.145). CONCLUSIONS: The double-decker technique in Rezūm is a systematic and reproducible method to optimize prostate volume shrinkage in catheter-dependent patients. It shows promise with better one-year IPSS and greater prostate volume shrinkage against the conventional technique. Prospective and randomized studies are warranted to confirm its advantage against conventional field-of vision-based technique.