What are the recommended surgical treatments for patients with Benign Prostatic Hyperplasia (BPH) and total urinary restriction?

Surgical Treatments for BPH with Total Urinary Retention

For patients with BPH and total urinary retention, transurethral resection of the prostate (TURP) is the recommended surgical treatment, as it remains the benchmark for surgical therapies due to its established efficacy from randomized clinical trials with long-term follow-up. 1

Initial Management Algorithm

1. Immediate bladder decompression via urethral catheterization 2
2. Start alpha blocker therapy (preferably non-titratable like tamsulosin or alfuzosin) 2
3. Continue alpha blocker for at least 3 days before attempting catheter removal 2
4. If catheter removal fails after alpha blocker treatment, proceed to surgical intervention 1, 2

Recommended Surgical Options

First-Line Surgical Treatment

• Transurethral Resection of the Prostate (TURP) remains the gold standard surgical treatment for BPH with urinary retention 1
  • Involves surgical removal of the prostate's inner portion via endoscopic approach through the urethra
  • No external skin incision required
  • Uses electrified loop to resect prostatic tissue and cauterize bleeders
  • Typically performed under general or spinal anesthesia
  • Requires hospital stay

Alternative Surgical Options

• Holmium Laser Enucleation of the Prostate (HoLEP) has emerged as an effective alternative 3

  • Shows better postoperative voiding parameters than TURP in terms of peak flow rate and postvoid residual urine volume 4
  • Can be performed on patients with high risk for postoperative bleeding 3
  • Effective for all prostate sizes 3
  • May have longer operative time than TURP 4

• Transurethral Incision of the Prostate (TUIP) 5

  • Effective with minimal adverse effects for patients with prostate not larger than 30g

Surgical Outcomes and Considerations

• TURP demonstrates significant improvement in symptoms with a mean IPSS reduction from 22.5 preoperatively to 6.5 postoperatively 6
• Favorable outcomes reported in 88.6% of patients after 12 weeks following TURP 6
• Complications of TURP include: 1
  • TURP syndrome (dilutional hyponatremia)
  • Sexual dysfunction
  • Irritative voiding symptoms
  • Bladder neck contracture
  • Need for blood transfusion
  • UTI
  • Hematuria

Special Considerations

• For high-risk patients who are not surgical candidates, options include: 1, 2

  • Intermittent catheterization
  • Indwelling catheter
  • Prostatic stent placement (though associated with significant complications such as encrustation, infection, and chronic pain) 1

• Balloon dilation is not recommended as a treatment option for BPH 1

• Finasteride (5α-reductase inhibitor) can reduce the risk of acute urinary retention by 57% and the need for BPH-related surgery by 55%, but is not a primary treatment for established urinary retention 7

Decision-Making Factors

• Selection of surgical approach should be based on: 1

  • Patient's prostate size
  • Individual surgeon's judgment and experience
  • Patient's medical comorbidities
  • Prostatic anatomy

• For patients with moderate-to-severe symptoms or those who have developed acute urinary retention, surgical intervention is the appropriate treatment option 1