Management of BPH with Impaired Renal Function (eGFR 29.8) and Large Prostate (70.4cc)
Surgery is the recommended treatment for this patient with renal insufficiency clearly due to BPH, as this represents a serious complication requiring definitive intervention. 1
Immediate Assessment and Stabilization
- Confirm BPH as the cause of renal impairment by evaluating for hydronephrosis on imaging and excluding other causes of chronic kidney disease (diabetic nephropathy, hypertensive nephrosclerosis). 1
- Check for urinary retention with post-void residual measurement, as retention is strongly associated with renal dysfunction in BPH. 2
- If retention is present, place an indwelling catheter temporarily to decompress the upper tracts and allow renal function stabilization before surgery. 1
Surgical Intervention: The Definitive Treatment
Transurethral resection of the prostate (TURP) remains the benchmark surgical therapy and is specifically indicated for patients with renal insufficiency clearly due to BPH. 1
Key Surgical Considerations:
- Target eGFR >30 mL/min before surgery if possible, as this represents a safer threshold for operative intervention in patients with chronic renal failure. 3
- Open prostatectomy may be preferred given the large prostate size (70.4cc), as prostates >60-80g are often better managed with open rather than endoscopic approaches. 1
- The choice between TURP and open prostatectomy should be based on prostate size, surgeon experience, and patient comorbidities. 1
Critical Pitfall - Realistic Expectations:
Renal function recovery is unpredictable and often incomplete. In patients presenting with renal failure from bladder outflow obstruction, only 21% (3/14) achieved normal renal function post-TURP, while 57% remained dialysis-dependent despite successful relief of obstruction. 4 The duration of obstruction and degree of tubular damage determine reversibility. 5
Medical Therapy is NOT Appropriate Here
Medical management should NOT be offered as primary treatment when renal insufficiency is clearly due to BPH, as this represents a serious complication requiring surgical intervention. 1
However, if surgery must be delayed:
- Alpha-blockers (tamsulosin, alfuzosin) can be used to facilitate catheter removal attempts in retention, but are not definitive treatment. 1
- 5-alpha reductase inhibitors are contraindicated as primary therapy given the urgency of the situation and their slow onset of action (3-6 months). 1
- Combination therapy (alpha-blocker + 5-ARI) would only be considered if the patient refuses surgery AND has prostate >30cc (which this patient does), but this delays definitive treatment. 1
Pre-operative Optimization
- Correct hypoproteinemia if present, as this significantly increases risk of severe gastrointestinal ulceration post-operatively in renal failure patients. 3
- Treat any urinary tract infection aggressively before surgery to reduce infectious complications. 3
- Nephrology consultation for perioperative renal management and potential need for dialysis support. 4
- No dosage adjustment of finasteride is needed for renal impairment if 5-ARI therapy is considered post-operatively. 6
Post-operative Management
- Monitor for failure to void after catheter removal (occurs in 14% of cases), which may require clean intermittent self-catheterization or indwelling catheter. 4
- Serial creatinine monitoring to assess renal function trajectory, recognizing that improvement may be limited. 4
- Avoid prolonged indwelling catheterization if possible, as this causes uninhibited detrusor contractions, gross hematuria, urethral pain, and recurrent pyelonephritis. 3
The Bottom Line
This patient requires surgical decompression, not medical management. The renal insufficiency at eGFR 29.8 represents a clear indication for surgery per AUA guidelines. 1 While TURP or open prostatectomy will likely restore normal voiding, complete renal recovery is uncertain and depends on the chronicity of obstruction. 4 The large prostate size (70.4cc) favors open prostatectomy in experienced hands. 1