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Guidelines Summary

The American Urological Association (AUA) updated its guideline on surgical management of lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia BPH) in 2020. Recommendations are listed below; unless otherwise specified, recommendations are based on clinical principles.^[1]

Evaluation and Preoperative Testing

The initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH should include the following:

Medical history, utilizing the AUA Symptom Index (AUA-SI)
Physical examination
Urinalysis

Prior to surgical intervention for LUTS attributed to BPH, clinicians should do the following:

Consider assessment of prostate size and shape via abdominal or transrectal ultrasound, cystoscopy, or by preexisting cross-sectional imaging (ie, magnetic resonance imaging [MRI]/ computed tomography [CT])
Assess post-void residual (PVR)
Consider uroflowmetry
Consider pressure flow studies when diagnostic uncertainty exists

Surgical Therapy

Surgery is recommended for patients with any of the following resulting from BPH:

Kidney insufficiency
Refractory urinary retention
Recurrent urinary tract infections (UTIs)
Recurrent bladder stones or gross hematuria
LUTS, in patients unresponsive to, or unwilling to use, other therapies

Clinicians should not perform surgery solely for an asymptomatic bladder diverticulum. However, consider evaluation for bladder outlet obstruction.

Surgical approaches for men with LUTS attributed to BPH are listed below.

Transurethral resection of the prostate (TURP):

Offer TURP as a treatment option.
Use a monopolar or bipolar approach to TURP, depending on clinician expertise with these techniques.

Simple prostatectomy:

In patients with large prostates, consider open, laparoscopic or robotic assisted prostatectomy, depending on clinician expertise with these techniques.

Transurethral incision of the prostate (TUIP):

Offer TUIP as an option for patients with prostates ≤30 g.

Transurethral vaporization of the prostate (TUVP):

Bipolar TUVP may be offered.

Photoselective vaporization of the prostate (PVP):

Consider PVP as an option using 120W or 180W platforms.

Prostatic urethral lift (PUL):

Consider PUL as an option in patients with prostate volume < 80 g and verified absence of an obstructive middle lobe.
PUL may be offered to eligible patients concerned with erectile and ejaculatory function.

Transurethral microwave therapy (TUMT):

TUMT may be offered, but patients should be informed that surgical retreatment rates are higher with TUMT than with TURP.

Water vapor thermal therapy:

Water vapor thermal therapy may be offered if prostate volume is < 80 g; however, patients should be informed that evidence of efficacy, including longer-term retreatment rates, remains limited.
Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function.

Transurethral needle ablation (TUNA):

TUNA is not recommended.

Laser enucleation:

Consider holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP), depending on clinician expertise with either technique, as prostate size–independent treatment options.

Aquablation:

Aquablation may be offered, provided prostate volume is between 30 and 80 g.

Prostate artery embolization (PAE):

PAE is not recommended outside the context of a clinical trial.

Medically Complicated Patients

HoLEP, PVP, and ThuLEP should be considered in patients who are at higher risk of bleeding, such as those on anticoagulant drugs.

Medication

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Media Gallery

Benign prostatic hyperplasia. Normal prostate anatomy is shown. The prostate is located at the apex of the bladder and surrounds the proximal urethra.
Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.
Benign prostatic hyperplasia. Basic management of lower urinary tract symptoms (LUTS) in men.

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Author

Levi A Deters, MD Attending Physician, Spokane Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond A Costabile, MD Jay Y Gillenwater Professor of Urology and Vice Chairman, Senior Associate Dean for Clinical Strategy, University of Virginia Health System

Raymond A Costabile, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Andrology, American Urological Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Raymond J Leveillee, MD, FRCS(Glasg) Professor of Clinical Urology, Radiology and Biomedical Engineering, Department of Urology, University of Miami Miller School of Medicine; Chief, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, Department of Urology, Jackson Memorial Hospital

Raymond J Leveillee, MD, FRCS(Glasg) is a member of the following medical societies: American Urological Association, Endourological Society, Sigma Xi, The Scientific Research Honor Society, Society of Laparoscopic and Robotic Surgeons

Disclosure: Received honoraria from ACMI/Gyrus for speaking and teaching; Received honoraria from Boston Scientific for speaking and teaching; Received honoraria from Applied Medical for speaking and teaching; Received honoraria from Intuitive Surgical for speaking and teaching; Received grant/research funds from Intio for other.

Charles R Moore, MD Endourology Fellow, Department of Urology, University of Miami School of Medicine

Charles R Moore, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association

Disclosure: Nothing to disclose.

Vipul R Patel, MD Consulting Surgeon, Global Robotics Institute, Florida Hospital Celebration Health

Vipul R Patel, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society, Ohio State Medical Association, Society of Laparoscopic and Robotic Surgeons

Disclosure: Received honoraria from Intuitive Surgical for speaking and teaching; Received honoraria from Pfizer for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Vincent G Bird, MD, to the development and writing of the source article.

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