Indications for Surgery in Benign Prostatic Hyperplasia
Surgery is recommended for patients with absolute indications including renal insufficiency secondary to BPH, refractory urinary retention, recurrent urinary tract infections, recurrent bladder stones, or gross hematuria due to BPH, as well as for patients with LUTS/BPH refractory to or unwilling to use medical therapies. 1
Absolute Indications for Surgical Intervention
These represent scenarios where surgery should be the initial intervention, assuming no prohibitive medical comorbidities exist:
- Renal insufficiency secondary to BPH requires urgent surgical decompression due to bladder outlet obstruction causing kidney damage 2, 3
- Refractory urinary retention secondary to BPH when patients cannot void despite catheter trials and medical management 1, 2, 3
- Recurrent urinary tract infections attributable to prostatic obstruction and incomplete bladder emptying 1, 2, 3
- Recurrent bladder stones due to chronic urinary stasis from obstruction 1, 2, 3
- Gross hematuria due to BPH that is refractory to medical management 1, 2
Relative Indications for Surgical Intervention
Surgery should be offered when medical therapy has failed or is not desired:
- Moderate-to-severe LUTS/BPH that have not responded adequately to medical therapy (alpha-blockers and/or 5-alpha-reductase inhibitors) 1, 2
- Patients unwilling to use medical therapies who have bothersome symptoms significantly affecting quality of life 1, 2
The AUA emphasizes that although LUTS/BPH is not often life-threatening, its impact on quality of life can be significant and should not be underestimated 1. Men with moderate-to-severe LUTS experience substantial quality of life impairment, and effective surgical treatments should be offered promptly 4.
Important Clinical Caveats
Do not perform surgery solely for asymptomatic bladder diverticulum; however, evaluation for bladder outlet obstruction should be considered and treated if clinically indicated 1, 2. This is a common pitfall where anatomic findings may prompt unnecessary intervention without functional impairment.
Preoperative Evaluation Requirements
Before proceeding with surgery, the following assessment is mandatory:
- Medical history and AUA-Symptom Index (AUA-SI) scoring 1, 2
- Urinalysis 1, 2
- Post-void residual (PVR) measurement in select patients 1, 2
- Imaging with sufficient resolution to calculate prostate volume and assess for intravesical lobe when surgery is being discussed 1
Surgical Options Based on Prostate Size
The choice of surgical approach depends heavily on prostate volume:
- Prostates ≤30 grams: Transurethral incision of the prostate (TUIP) is preferred, offering lower rates of retrograde ejaculation and reduced transfusion requirements 2
- Prostates 30-80 grams: TURP (monopolar or bipolar) remains the gold standard 1, 5, 6
- Prostates >80 grams: Open, laparoscopic, or robotic-assisted simple prostatectomy should be considered, depending on surgeon expertise 1
TURP remains the single best standard against which to measure efficacy, effectiveness, and safety of other interventions for LUTS/BPH 1, 5, 6. Bipolar TURP has a reduced risk of hyponatremia and TUR syndrome compared to monopolar TURP, allowing for longer resection times and surgery on larger glands 1, 2.
Special Considerations for High-Risk Patients
In patients with renal impairment, bipolar TURP is preferred over monopolar TURP due to reduced risk of TUR syndrome and hyponatremia, which are particularly dangerous in patients with compromised renal function 2.
Shared Decision-Making
Patients must be counseled about sexual side effects of any surgical intervention, particularly that surgery can cause ejaculatory dysfunction and may worsen erectile dysfunction 1. The risk/benefit profile for all treatment options should be provided to allow informed decisions 1.