What is the recommended treatment approach for a patient considering a urethral lift for benign prostatic hyperplasia (BPH)?

Prostatic Urethral Lift (PUL) for Benign Prostatic Hyperplasia

Primary Recommendation

Prostatic urethral lift should be considered for patients with LUTS/BPH who have prostate volume <80g and no obstructing middle lobe, particularly when preservation of sexual function is a priority, but patients must understand that symptom improvement and flow rates are significantly inferior to TURP. 1

Patient Selection Criteria

Anatomic Requirements (Absolute)

• Prostate volume must be <80g 1
• Verified absence of obstructing middle lobe tissue - this is a cystoscopic exclusion criterion that remains mandatory 1
• Patients with middle lobe obstruction are not candidates for PUL, despite some case series attempting to treat this anatomy 1

Ideal Patient Profile

• Men prioritizing preservation of erectile and ejaculatory function 1
• Patients willing to accept less symptom improvement in exchange for better sexual function outcomes 1
• Those seeking to avoid or delay more invasive procedures 1

Efficacy Compared to TURP (The Gold Standard)

Symptom Improvement

• PUL achieves 73% response rate (≥30% IPSS reduction) at 12 months versus 91% with TURP (p=0.05) 1
• At 24 months, TURP provides 6.1 additional points of IPSS improvement compared to PUL 1
• Average symptom improvement with PUL is meaningful but consistently inferior to TURP at all follow-up intervals 1

Urinary Flow Rates

• Qmax (maximum flow rate) is significantly lower with PUL compared to TURP at all time points 1
• This represents a measurable functional disadvantage that patients should understand preoperatively 1

Sexual Function Preservation (Key Advantage)

Ejaculatory Function

• PUL demonstrates superior ejaculatory function preservation based on Male Sexual Health Questionnaire for Ejaculatory Dysfunction scores 1
• No evidence of de novo ejaculatory dysfunction with PUL 1
• This is the primary advantage over TURP and should guide patient selection 1

Erectile Function

• Erectile function measures are similar between PUL and TURP at all time points 1
• No de novo erectile dysfunction reported with PUL 1

Critical Limitations and Counseling Points

Retreatment Rates

• Evidence of long-term efficacy and retreatment rates remains poorly defined 1
• This uncertainty should be explicitly discussed during informed consent 1
• Older patients (>75 years) show higher incidence of de novo overactive bladder symptoms requiring medical treatment after PUL 2

Age Considerations

• Younger patients (<60 years) may benefit from earlier intervention before prolonged obstruction leads to secondary bladder dysfunction 2
• Older patients have higher rates of new anticholinergic/beta-3 agonist requirements post-PUL 2

Alternative Surgical Options for Comparison

When PUL is Not Appropriate

• Prostate volume ≥80g: Consider HoLEP, ThuLEP, or TURP 1
• Obstructing middle lobe present: PUL is contraindicated; consider TURP, HoLEP, or ThuLEP 1
• Patients prioritizing maximal symptom relief over sexual function: TURP remains gold standard 1, 3
• Urinary retention: TURP is preferred for catheter-dependent patients 3

High-Risk Bleeding Patients

• For patients on anticoagulation, consider HoLEP, PVP, or ThuLEP over TURP due to lower transfusion risk 1
• PUL may be considered in this population given its minimally invasive nature, though specific bleeding risk data is limited 1

Preoperative Evaluation Requirements

Essential Assessments

• Cystoscopy to verify absence of middle lobe obstruction 1
• Prostate volume measurement (transrectal ultrasound or MRI) to confirm <80g 1
• AUA Symptom Index (IPSS) and quality of life assessment 1
• Discussion of patient priorities regarding sexual function versus symptom improvement 1

Medical History Focus

• Current urinary medications and response 1
• Sexual function baseline (erectile and ejaculatory) 1
• Anticoagulation status 1
• History of urinary retention 1

Common Pitfalls to Avoid

• Do not offer PUL to patients with middle lobe obstruction - this anatomic variant predicts failure 1
• Do not oversell symptom improvement - patients must understand PUL provides less relief than TURP 1
• Do not ignore prostate volume limits - volumes ≥80g are outside evidence-based indications 1
• Do not assume long-term durability - retreatment data remains limited and poorly defined 1

Evidence Quality and Strength

The AUA guideline rates PUL as a Moderate Recommendation with Evidence Level Grade C 1, reflecting:

• Limited long-term outcome data 1
• Inferior efficacy compared to established procedures 1
• Specific anatomic limitations that restrict applicability 1

The recommendation strength was maintained in the 2019 amendment despite additional follow-up data, emphasizing the persistent concerns about durability and retreatment rates 1.