What is the best approach for an elderly male patient with Benign Prostatic Hyperplasia (BPH) and severe Lower Urinary Tract Symptoms (LUTS) who has a significantly elevated Prostate-Specific Antigen (PSA) level, considering Transurethral Resection of the Prostate (TURP) with bilateral orchiectomy?

Management of Elderly Male with PSA >100, BPH, and Severe LUTS

Critical First Step: Rule Out Prostate Cancer Before Any Intervention

A PSA level exceeding 100 ng/mL is highly suspicious for metastatic prostate cancer, not benign prostatic hyperplasia, and requires immediate urologic evaluation with prostate biopsy before proceeding with any surgical intervention including TURP or bilateral orchiectomy. 1, 2

Why This Changes Everything

• PSA >100 ng/mL is virtually never seen in BPH alone - even large prostates with severe obstruction typically have PSA levels well below 20-30 ng/mL 1
• Bilateral orchiectomy is a treatment for metastatic prostate cancer (androgen deprivation therapy), not BPH - this surgical plan suggests the clinical suspicion is actually for advanced prostate cancer, not benign disease 2
• TURP in the setting of undiagnosed prostate cancer can upstage disease and complicate subsequent cancer treatment 1

Mandatory Pre-Operative Workup

Immediate Diagnostic Steps

• Digital rectal examination to assess for locally advanced cancer - palpate for nodularity, asymmetry, or extension beyond the prostate capsule that would indicate malignancy 1, 2
• Transrectal ultrasound-guided prostate biopsy - this is mandatory to establish tissue diagnosis before any surgical intervention when PSA is this elevated 1
• Staging imaging if cancer is confirmed - bone scan and CT or MRI of abdomen/pelvis to assess for metastatic disease, as PSA >100 suggests high likelihood of metastases 2

Additional Required Testing

• Serum creatinine and renal ultrasound - to evaluate for obstructive uropathy and hydronephrosis, which would indicate absolute indication for urgent decompression 1, 2
• Post-void residual volume measurement - to quantify degree of urinary retention 1, 2
• Urinalysis and urine culture - to exclude infection before any instrumentation 1

Treatment Algorithm Based on Biopsy Results

If Biopsy Confirms Prostate Cancer

Bilateral orchiectomy becomes appropriate as androgen deprivation therapy for metastatic disease, NOT as treatment for BPH. 2

• TURP may still be indicated for bladder outlet obstruction relief - but timing should be coordinated with oncology, as medical androgen deprivation (LHRH agonist/antagonist) may shrink the prostate sufficiently to avoid surgery 2
• Consider channel TURP - a limited resection to relieve obstruction without extensive tissue removal, preserving cancer tissue for staging if needed 1
• Urethral catheter drainage as bridge - initiate alpha-blocker therapy (tamsulosin 0.4 mg daily) and consider trial of voiding after 2-4 weeks while cancer staging proceeds 2, 3

If Biopsy Shows Only BPH (Unlikely with PSA >100)

Proceed with TURP alone - bilateral orchiectomy has NO role in BPH management. 1, 4

• TURP remains the gold standard surgical treatment for severe LUTS/BPH with absolute indications including refractory urinary retention, recurrent UTIs, bladder stones, gross hematuria, or renal insufficiency secondary to BPH 1, 4, 5
• Counsel regarding sexual side effects - TURP causes retrograde ejaculation in the majority of patients and new-onset erectile dysfunction in approximately 14% (range 0-32.5%) 1, 6
• Bilateral orchiectomy would cause permanent hypogonadism with severe sexual dysfunction, osteoporosis, metabolic syndrome, and has no therapeutic benefit for BPH 6

Critical Pitfalls to Avoid

• Never proceed with TURP without tissue diagnosis when PSA is this elevated - you risk upstaging occult cancer and missing the opportunity for curative treatment 1, 2
• Never perform bilateral orchiectomy for BPH - this is surgical castration and is only indicated for metastatic prostate cancer or as part of gender-affirming surgery 2
• Do not delay biopsy while attempting medical management - with PSA >100, cancer risk is extremely high and delays diagnosis of potentially life-threatening disease 2, 7
• Do not assume elevated PSA is solely from BPH - even with large prostates and severe obstruction, PSA >100 mandates cancer exclusion 1, 7

Bridging Management While Awaiting Biopsy

• Place urethral catheter if in acute retention - provides immediate symptom relief and prevents renal damage 2, 8
• Initiate alpha-blocker therapy (tamsulosin 0.4 mg daily) at time of catheter placement to increase chances of successful voiding trial 2, 3
• Avoid 5-alpha reductase inhibitors before biopsy - finasteride/dutasteride reduce PSA by 50% and can interfere with cancer detection and staging 1, 3