WVTT is a procedure that is feasible in-office under local anesthesia or in other settings with sedation for 30-80 cc prostates which may include a median lobe. Utilizing a procedure-specific cystoscopic delivery system, a needle is deployed from the scope into the peri-urethral prostatic adenoma. Water vapor (steam) is then injected through this needle into the targeted tissue, where it diffuses outward and induces cell death. Over the coming weeks, the treated tissue then regresses via necrosis as it is broken down by the body. Due to tissue edema acutely following treatment, many patients are managed via an indwelling catheter placed at the conclusion of the procedure. The duration of catheterization varies by practice and is often influenced by prostate volume and/or baseline bladder function. Catheter durations have been observed as short as one day for smaller prostates and up to a few weeks for patients with very large prostates or those that have poor bladder function. After one month, WVTT achieved significant improvements in IPSS, quality of life scores, and uroflowmetry without a difference in adverse events compared to sham procedures.255, 353-358 In appropriately selected patients, the IPSS and quality of life score improvements from WVTT remain durable from three months through five years with no significant differences in erectile function or PVR bladder volume.255 Sub-analyses found no differences in IPSS improvements with the presence or absence of a median lobe, or with varying baseline symptom severity (IPSS ≤18 points versus IPSS ≥19 points).354, 356 Recent evidence supported expansion of the FDA-indications for prostates up to 150 cc; however, the Panel recommends this should only be considered in appropriate patients and by clinicians with sufficient procedural experience/expertise.359, 360     Randomized comparison of WVTT to TURP in a group with a mean prostate volume of 73 cc, of which 23% had a median lobe, found no difference in response rates (IPSS decrease of ≥8 points) at 2 years, but statistically greater IPSS and quality of life score improvements with TURP, as well as objective measures of uroflowmetry and PVR bladder volume.361 However, TURP was associated with an 80% rate of retrograde ejaculation compared to 2% in the WVTT group,361 whereas another series similarly showed 82.7% and 3.7%, respectively.362 Another randomized comparison for use in urinary retention showed no differences in IPSS or quality of life scores at 1 year, but a higher risk for UTI in the TURP group.362 An RCT compared WVTT and transperineal laser ablation of the prostate (TPLA) at 3 and 6 months, but found no differences in uroflowmetry, PVR volume, erectile function, or ejaculatory function despite statistically significantly better IPSS with TPLA.363, 364 Retrospective comparisons of WVTT and PUL have shown slight statistical differences in AUA-SS and quality of life scores at early time points, but no significant differences at 1 year.265, 365 Mathematical comparisons of pivotal trial data vary from showing no significant differences in IPSS improvements but significantly better uroflowmetry gains with WVTT through four years, to significantly better IPSS improvements with WVTT than PUL at two and three years.366, 367 Otherwise, these analyses show significantly less risk of EjD but significantly less treatment durability (greater rates of retreatment) in the PUL groups compared to the WVTT groups. Overall reoperation rates for WVTT ranged from 3-4% over 1-5 years.257, 287 Other studies reported retreatment rates of 4.6-9.7% over 1-3 years and cited inadequately treated adenoma and bladder neck obstruction as common etiologies, with the latter suggesting the optimal application of WVTT is in prostates without a higher obstructive bladder neck in the absence of a median lobe.368, 369