Is mild to moderate prostatomegaly with calcification and normal PSA indicated for TURP?

Mild to Moderate Prostatomegaly with Calcification and Normal PSA is Not Indicated for TURP

Transurethral resection of the prostate (TURP) is not indicated for mild to moderate prostatomegaly with calcification and a normal PSA of 0.29 ng/mL in the absence of moderate to severe lower urinary tract symptoms (LUTS). According to current guidelines, surgical intervention should be reserved for patients with significant symptoms that affect quality of life.

Indications for TURP Based on Current Guidelines

The European Association of Urology (EAU) provides clear recommendations for when TURP is appropriate:

1. Primary Indication: Moderate to severe LUTS with prostate size of 30-80 mL 1
2. Symptom Severity: TURP is recommended for patients with significant symptoms affecting quality of life
3. PSA Considerations: Elevated PSA may warrant further investigation but is not itself an indication for TURP

Decision Algorithm for TURP Candidacy

Step 1: Assess Symptom Severity

• Mild symptoms (IPSS <8): Medical therapy or watchful waiting
• Moderate to severe symptoms (IPSS ≥8): Consider surgical options if medical therapy fails

Step 2: Evaluate Prostate Size

• <30 mL: Consider TUIP (Transurethral Incision of the Prostate)
• 30-80 mL: TURP is appropriate if symptoms warrant
• >80 mL: Consider HoLEP, ThuLEP, or open prostatectomy 1, 2

Step 3: Consider Complicating Factors

• Calcifications alone: Not an indication for surgery without significant symptoms
• Normal PSA: Suggests low likelihood of malignancy requiring intervention

Evidence Against TURP in This Case

1. Normal PSA (0.29 ng/mL): Well below the threshold of concern (4 ng/mL), suggesting low risk of malignancy 3

2. Calcifications: Prostatic calcifications are common findings and not themselves an indication for surgical intervention. In fact, calcifications can recur after TURP, as documented in case reports 4

3. Mild to Moderate Prostatomegaly: Without significant symptoms, this finding alone does not warrant surgical intervention according to EAU guidelines 1

Potential Risks of Unnecessary TURP

Performing TURP when not clinically indicated exposes the patient to unnecessary risks:

• Perioperative complications: Bleeding (8%), UTI (6%), bladder neck contracture/stricture (7%) 1
• Sexual dysfunction: Ejaculatory dysfunction (65%), erectile problems (10%) 1
• Potential for recurrent calcifications: As demonstrated in case reports 4

Alternative Approaches

For patients with mild to moderate prostatomegaly and calcifications but minimal symptoms:

1. Watchful waiting: Appropriate for patients with minimal symptoms and normal PSA
2. Medical therapy: Alpha-blockers or 5-alpha reductase inhibitors if mild symptoms develop
3. Regular monitoring: Annual PSA testing and symptom assessment

Special Considerations

If the patient develops significant LUTS in the future, TURP could be reconsidered. Multiple international urological associations agree that TURP should be reserved for patients with moderate to severe symptoms that affect quality of life 1.

Conclusion

Based on current guidelines, a prostate volume of 44 mL with calcifications and a normal PSA of 0.29 ng/mL without significant LUTS does not warrant TURP. The risks of the procedure outweigh potential benefits in the absence of bothersome symptoms.