What are the surgical options for an adult male with a history of Benign Prostatic Hyperplasia (BPH)?

Surgical Options for Benign Prostatic Hyperplasia

Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH and should be offered as the primary surgical option for most men with moderate-to-severe LUTS or BPH-related complications. 1, 2

Primary Surgical Options

Transurethral Resection of the Prostate (TURP)

• TURP is the benchmark surgical therapy with the strongest long-term efficacy data from randomized controlled trials. 1
• The procedure involves endoscopic removal of the prostate's inner portion through the urethra using an electrified loop to resect tissue and cauterize bleeding vessels. 1, 2
• No external skin incision is required. 2
• Both monopolar and bipolar approaches can be used based on surgeon expertise. 1
• Bipolar TURP has reduced risk of TUR syndrome (dilutional hyponatremia) and allows for longer resection times, making it preferable for larger glands. 1
• The procedure typically requires general or spinal anesthesia and hospital admission. 1, 2

Common complications include sexual dysfunction (particularly ejaculatory dysfunction), irritative voiding symptoms, bladder neck contracture, need for blood transfusion, urinary tract infection, and hematuria. 1, 2

Simple Prostatectomy (Open, Laparoscopic, or Robotic)

• Should be considered for large prostates, typically >80-100g depending on surgical expertise. 1, 3
• Open simple prostatectomy has been the traditional approach for very large glands. 1
• Laparoscopic and robot-assisted approaches are newer alternatives that may offer benefits in select patients. 1
• The choice between open, laparoscopic, or robotic approach depends on surgeon expertise and available technology. 1

Transurethral Incision of the Prostate (TUIP)

• Should be offered as an option for smaller prostates (typically <30g). 1, 4
• This is an effective therapy with minimal adverse effects in appropriately selected patients. 4

Alternative Surgical Technologies

Laser Procedures

• Various laser modalities exist (including holmium laser enucleation - HoLEP) that can be used for different prostate sizes. 1
• Selection should be based on surgeon experience, prostate size, and patient comorbidities. 1, 3
• The Panel emphasizes that new surgical technologies have not demonstrated better outcomes than TURP in comparative trials to date. 1

Transurethral Electrovaporization

• This is an adaptation of roller ball electrocautery technology. 1
• Can be performed as an alternative to TURP in select cases. 1

Absolute Indications for Surgery

Surgery is recommended (not just optional) for patients with: 1, 3, 5

• Renal insufficiency secondary to BPH
• Refractory urinary retention (especially after failed catheter removal trial following at least 3 days of alpha-blocker therapy)
• Recurrent urinary tract infections clearly attributable to BPH
• Recurrent bladder stones due to BPH
• Recurrent gross hematuria due to BPH that cannot be controlled medically

Relative Indications for Surgery

• Patients with moderate-to-severe LUTS (AUA Symptom Score >8) who have failed or cannot tolerate medical therapy should be offered surgical intervention. 3
• Patients may appropriately select surgery as initial treatment if symptoms are particularly bothersome, even without trying medical therapy first. 1, 5
• Intolerable medication side effects (orthostatic hypotension, sexual dysfunction, ejaculatory dysfunction) warrant consideration of surgery. 3

Special Considerations for High-Risk Patients

For high-risk patients with urinary retention who cannot undergo standard surgery:

• Intermittent catheterization is an option. 2
• Indwelling catheter placement may be necessary. 2
• Prostatic stent placement should only be considered as a last resort due to significant complications including encrustation, infection, and chronic pain. 1, 3, 5

Critical Decision-Making Algorithm

The selection of surgical approach should follow this hierarchy: 1, 3

1. For prostates <30g: Consider TUIP as a minimally invasive option
2. For prostates 30-80g: TURP (monopolar or bipolar) is the standard approach
3. For prostates >80-100g: Consider simple prostatectomy (open, laparoscopic, or robotic) or bipolar TURP/HoLEP if surgeon has expertise
4. Technical decisions regarding energy source and instrumentation should be based on surgeon experience, patient's prostatic anatomy, and medical comorbidities

Essential Preoperative Counseling

All patients must be counseled about sexual side effects before any surgical intervention: 1, 3

• Ejaculatory dysfunction is common with most BPH surgeries
• Erectile dysfunction may worsen after surgery
• The risk of urinary incontinence is approximately 1% with TURP 1

Common Pitfalls to Avoid

• Do not perform surgery solely for asymptomatic bladder diverticulum; evaluate for bladder outlet obstruction first. 1
• Avoid prolonged resection times with monopolar TURP to reduce risk of TUR syndrome. 1
• Do not offer prostatic stents to patients who are candidates for other forms of treatment. 1
• Ensure proper evaluation including ruling out bladder cancer in patients with hematuria through cystoscopy before attributing symptoms solely to BPH. 5