Can minimally invasive surgical therapy be considered for a 68‑year‑old man with acute urinary obstruction who is Foley catheter‑dependent and has a 68‑g prostate with central intravesical prostatic protrusion?

MIST for Acute Urinary Retention with 68g Prostate and Intravesical Protrusion

Yes, minimally invasive surgical therapy (MIST) can be considered for this 68-year-old catheter-dependent patient, but traditional surgical options (TURP, HoLEP, or PVP) are strongly preferred given the acute retention, significant prostate size (68g), and central intravesical prostatic protrusion. 1, 2

Why Traditional Surgery is Preferred Over MIST

• Acute urinary retention with catheter dependence is a serious complication of BPH that warrants definitive surgical intervention rather than MIST, as surgery remains the treatment of choice for refractory retention 1
• The 68g prostate size exceeds optimal parameters for several MIST options: UroLift is contraindicated (requires <70-80g prostate), and water vapor therapy (Rezūm) is limited to prostates <80g 1, 2
• Central intravesical prostatic protrusion (median lobe) is an absolute contraindication to UroLift, the most commonly offered MIST 1, 2
• Traditional TURP, HoLEP, or photoselective vaporization (PVP) provide superior long-term outcomes with proven efficacy for this clinical scenario 1, 2

Pre-Operative Evaluation Required

Before any intervention, the following assessments are essential:

• Attempt catheter removal with concomitant alpha-blocker therapy (tamsulosin or alfuzosin) if the patient has not already failed this approach 1
• Measure post-void residual and assess for detrusor underactivity: Some catheter-dependent patients have compromised detrusor function and may not benefit from outlet procedures 1
• Pressure-flow urodynamic studies are NOT required in this case since the patient is catheter-dependent with presumed severe obstruction (equivalent to Qmax <10 mL/s), making obstruction highly likely 1
• Check PSA level: If PSA >1.5 ng/mL, consider transrectal ultrasound to rule out prostate cancer before proceeding 1
• Assess for upper urinary tract complications: Obtain renal function tests and consider upper tract imaging if there is concern for hydronephrosis, renal insufficiency, or recurrent UTIs 1

Recommended Surgical Approach

For this patient's clinical presentation, the following hierarchy applies:

1. Holmium laser enucleation of the prostate (HoLEP) is ideal for 68g prostate with median lobe, offering excellent long-term outcomes, lower transfusion risk, and suitability for larger prostates 1

2. Photoselective vaporization (PVP) with 120W or 180W platforms provides similar symptomatic improvement to TURP with lower bleeding risk, particularly advantageous if the patient is anticoagulated 1

3. Traditional monopolar or bipolar TURP remains the gold standard with proven durability, though it carries higher transfusion risk (>5%) 1, 2

4. Thulium laser enucleation (ThuLEP) is another option with lower bleeding risk for patients on anticoagulation 1

If MIST is Still Considered Despite Limitations

If the patient is a poor surgical candidate or refuses traditional surgery, the only potentially viable MIST option is:

• Water vapor thermal therapy (Rezūm) could be considered since the prostate is 68g (just under the 80g cutoff), though outcomes are less predictable with median lobe involvement 1, 2
• Patients must be counseled that MIST has higher failure rates (7-22% requiring retreatment by 2 years for UroLift; 13.6% retreatment rate at 5 years) and provides less symptom improvement than TURP (73% vs 91% treatment response) 2
• UroLift is absolutely contraindicated due to the central intravesical prostatic protrusion 1, 2

Critical Pitfalls to Avoid

• Do not offer balloon dilation: This has significant long-term failure rates and is not recommended 1, 2
• Do not proceed with MIST without discussing realistic expectations: Symptom reduction and flow rate improvement are significantly less than with TURP 1, 2
• Do not skip the trial of catheter removal with alpha-blocker: Some patients with acute retention can void successfully after medical optimization 1
• Do not assume all catheter-dependent patients will benefit from surgery: Those with detrusor underactivity may have poor outcomes even after outlet reduction 1

Special Considerations for High-Risk Patients

• If the patient is on anticoagulation or at high bleeding risk, prioritize HoLEP, PVP, or ThuLEP over traditional TURP 1
• Prostatic stents should only be considered as a last resort in extremely high-risk patients who cannot tolerate any other intervention, given significant complications including encrustation, infection, and chronic pain 2
• If the patient has compromised detrusor function on urodynamics, counsel that surgical success rates are lower, though most patients with retention and documented detrusor underactivity can still benefit from outlet procedures 1