Is Rezum or transurethral resection of the prostate (TURP) indicated after failed medical therapy in a male patient with mild prostatomegaly and significant post‑void residual urine (pre‑void volume 401 mL, post‑void residual 207 mL)?

Surgical Intervention is Indicated After Failed Medical Therapy

Given your patient's significant post-void residual (207 mL, representing 52% of bladder capacity) and failed medical therapy, surgical intervention is clearly indicated. For mild prostatomegaly, TURP remains the gold standard, though Rezūm is a reasonable alternative if preserving ejaculatory function is a priority.

Why Surgery is Indicated

Your patient meets clear criteria for surgical intervention:

• Failed medical therapy (absolute indication per guidelines) 1
• Significant post-void residual (207 mL is well above the 150 mL threshold associated with treatment failure and complications) 2
• High bladder retention ratio (52% PVR/total volume indicates poor bladder emptying)

The 2023 EAU guidelines explicitly state that surgery should be offered to "nonresponders to medical treatment" 1. This patient clearly falls into that category.

TURP vs Rezūm: The Decision Algorithm

Choose TURP if:

• Patient prioritizes maximum symptom improvement and durability
• Ejaculatory function is not a primary concern
• Patient accepts 1-2 day hospitalization
• This is the stronger recommendation for your patient 1

The 2023 EAU guidelines give TURP a Strong recommendation for prostates 30-80 mL, while most alternatives receive only Weak recommendations 1. Even with mild prostatomegaly, if the prostate is <30 mL, transurethral incision of the prostate (TUIP) receives a Strong recommendation 1.

Choose Rezūm if:

• Patient strongly desires preservation of ejaculatory function (87.5% preservation vs 50% with TURP) 3
• Patient prefers outpatient procedure (90% done as day case) 3
• Patient accepts higher retreatment rates (20-47% vs 15-16% for TURP) 4, 3, 5
• Prostate volume <80 mL and no obstructive middle lobe 6

Critical Caveat About Your Patient's High PVR

Your patient's 207 mL PVR is a significant concern. Recent evidence identifies elevated baseline PVR as an independent predictor of treatment failure after Rezūm (OR 1.009 per mL increase, p<0.001) 5. This suggests potential underlying detrusor dysfunction, which responds less favorably to any intervention.

However, reassuring data shows:

• TURP remains effective even with very high residual volumes 7
• In catheter-dependent patients (worse than yours), Rezūm achieved 80-88% success rates 4, 8
• Higher prostate volume (not PVR) predicted TURP failure in retention patients 2

Practical Recommendation

For your specific patient, I recommend TURP as first-line because:

1. Stronger guideline support (Strong vs Weak recommendation) 1
2. Better durability with lower retreatment rates 4, 3
3. More predictable outcomes in patients with elevated PVR 2, 7
4. Comparable functional outcomes at 6-12 months between both procedures 4

Consider Rezūm only if the patient is a poor surgical candidate, strongly prioritizes same-day discharge and ejaculatory preservation, and accepts that 1 in 5 patients may need additional intervention 4, 8, 5, 9.

What NOT to Do

• Do not delay surgery waiting for PVR to improve—it won't without intervention
• Do not offer prostatic urethral lift (Urolift) in this patient—it's inferior to TURP and contraindicated if middle lobe present 1, 6
• Do not dismiss Rezūm entirely—recent multicenter data shows 80-90% catheter-free rates even in retention patients 4, 8

Counseling Points

Regardless of procedure chosen, inform the patient:

• TURP: 57% ejaculatory dysfunction rate, 1-2 day hospital stay, 15% retreatment at 5 years 1, 3
• Rezūm: 12.5% ejaculatory dysfunction, outpatient procedure, longer catheter time (5 vs 1.5 days), 20-47% retreatment risk 4, 3, 5, 9
• Both procedures significantly improve symptoms and quality of life 4, 3