Indications for Surgery in Benign Prostatic Hyperplasia
Surgery is recommended for patients with BPH who have renal insufficiency, refractory urinary retention (after failed catheter removal following at least 3 days of alpha-blocker therapy), recurrent urinary tract infections, recurrent bladder stones, gross hematuria refractory to medical management, or moderate-to-severe LUTS that are refractory to or unwilling to use medical therapies. 1, 2
Absolute Indications for Surgery
These represent scenarios where surgery should be the initial intervention, assuming no prohibitive medical comorbidities:
Renal insufficiency secondary to BPH-related obstruction requires surgical intervention to prevent irreversible kidney damage 1, 2
Refractory urinary retention after failed catheter removal trial following at least 3 days of alpha-blocker therapy (preferably non-titratable agents like tamsulosin or alfuzoin) 2, 3
Recurrent urinary tract infections clearly attributable to BPH 1, 2
Recurrent gross hematuria refractory to medical management with 5-alpha reductase inhibitors after adequate trial (note: cystoscopy is essential to rule out bladder cancer before attributing hematuria to BPH) 1, 2
Relative Indications for Surgery
Moderate-to-severe LUTS (typically International Prostate Symptom Score ≥15) with bothersome symptoms that have failed medical therapy are appropriate candidates for surgery 2, 3
Patients may appropriately select surgery as initial treatment if symptoms are particularly bothersome, even without attempting medical therapy first, based on shared decision-making 2
LUTS/BPH in patients unwilling to use other therapies represents a valid indication for surgical intervention 1
Important Caveats
Do NOT perform surgery solely for asymptomatic bladder diverticulum, though evaluation for bladder outlet obstruction should be considered in these cases 1
Counsel all patients about sexual side effects before surgery, as surgical treatment can cause ejaculatory dysfunction and may worsen erectile dysfunction—this is particularly important given the strong relationship between ED and LUTS/BPH 1
Surgical Options Based on Clinical Scenario
TURP remains the gold standard against which all other interventions are measured, with the most robust long-term efficacy data 2, 3. Both monopolar and bipolar approaches are acceptable depending on surgeon expertise, though bipolar TURP has reduced risk of TUR syndrome and allows for longer resection times on larger glands 1
For large prostates, consider open, laparoscopic, or robotic-assisted prostatectomy depending on surgeon expertise (though "large" is relative, as some providers achieve excellent results with bipolar TURP or HoLEP on prostates >60g) 1
For high-risk surgical candidates with urinary retention who cannot undergo standard surgery, options include intermittent catheterization, indwelling catheter, or prostatic stent placement, though stents carry significant complications including encrustation, infection, and chronic pain 2, 3