Benign Prostatic Hyperplasia (BPH) Guidelines

Updated: Feb 19, 2021
  • Author: Levi A Deters, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines

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:

  • Renal 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.