What are the indications for Transurethral Resection of the Prostate (TURP) in a male patient with Benign Prostatic Hyperplasia (BPH) and a history of hematuria, who has failed medical management with tamsulosin (alpha-blocker) and possibly a 5-alpha reductase inhibitor?

Indications for TURP in BPH

TURP is indicated for patients with moderate-to-severe BPH symptoms who have failed medical management, and is specifically recommended for those with absolute indications including refractory urinary retention, recurrent gross hematuria due to BPH, renal insufficiency secondary to BPH, recurrent urinary tract infections, or bladder stones clearly attributable to BPH. 1, 2

Absolute Indications for TURP

These represent complications of BPH where surgical intervention is the preferred treatment:

• Refractory urinary retention in patients who have failed at least one attempt at catheter removal 1
• Recurrent gross hematuria due to BPH that is refractory to medical therapy (including 5-alpha reductase inhibitors) 1, 3
• Renal insufficiency clearly secondary to BPH 1, 2
• Recurrent urinary tract infections attributable to BPH 1, 2
• Bladder stones clearly due to BPH and refractory to other therapies 1, 2

Relative Indications for TURP

Patients with moderate-to-severe lower urinary tract symptoms (LUTS) who have failed medical therapy with alpha-blockers (such as tamsulosin) and/or 5-alpha reductase inhibitors are appropriate candidates for TURP. 4, 2 This applies when:

• Symptoms are bothersome enough that the patient requests intervention 2
• Medical therapy has been inadequate or the patient is unwilling to continue medical management 2
• The patient prefers definitive treatment over ongoing medical therapy 5

Pre-Surgical Evaluation Considerations

Before proceeding with TURP, certain evaluations help optimize patient selection:

• Urethrocystoscopy is appropriate in patients with a history of microscopic or gross hematuria to rule out other pathology 6
• Pressure-flow urodynamic studies should be considered in patients with Qmax >10 ml/sec when surgery is being considered, as higher flow rates suggest less obstruction and lower likelihood of benefit from surgery 6
• Prostate size assessment via ultrasound helps guide surgical approach (TURP vs. TUIP for prostates <30g, or open prostatectomy for very large prostates) 6, 1

TURP as the Benchmark Procedure

TURP remains the gold standard surgical treatment for BPH due to published evidence of efficacy from randomized clinical trials with long-term follow-up. 6, 4, 1 While newer minimally invasive procedures exist, they generally fall between TURP and medical therapy in effectiveness 7, 5.

Important Caveats

• Complications occur in >5% of patients and include sexual dysfunction, irritative voiding symptoms, bladder neck contracture, need for blood transfusion, UTI, and hematuria 6, 1, 2
• Risk of urinary incontinence is approximately 1% 6, 2
• TURP syndrome (dilutional hyponatremia from irrigant absorption) is a unique complication, though bipolar TURP has reduced this risk compared to monopolar TURP 6, 2
• For your specific patient with hematuria who has failed tamsulosin, hematuria secondary to BPH represents an absolute indication for surgical intervention if it is recurrent and refractory to medical management including 5-alpha reductase inhibitors 1, 3