Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms

Publication Date: June 26, 2020
Last Updated: July 21, 2023

Guideline Statements

Evaluation

Initial Evaluation

1. In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should obtain a medical history, conduct a physical examination, utilize the International Prostate Symptom Score (IPSS), and perform a urinalysis. (Clinical Principle, )
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2. Patients should be counselled on options for intervention, which can include behavioral/lifestyle modifications, medical therapy and/or referral for discussion of procedural options. (Expert Opinion , )
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Follow-up Evaluation

3. Patients should be evaluated by their providers 4-12 weeks after initiating treatment (provided adverse events do not require earlier consultation) to assess response to therapy. Revaluation should include the IPSS. Further evaluation may include a post-void residual (PVR) and uroflowmetry. (Clinical Principle, )
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4. Patients with bothersome LUTS/BPH who elect initial medical management and do not have symptom improvement and/or experience intolerable side effects should undergo further evaluation and consideration of change in medical management or surgical intervention (Expert Opinion , )
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Preoperative Testing

5. Clinicians should consider assessment of prostate size and shape via transrectal or abdominal ultrasound, cystoscopy, or cross-sectional imaging (i.e., magnetic resonance imaging [MRI]/ computed tomography [CT]) if such studies are available, prior to intervention for LUTS/BPH. (Clinical Principle, )
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6. Clinicians should perform a PVR assessment prior to intervention for LUTS/BPH. (Clinical Principle, )
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7. Clinicians should consider uroflowmetry prior to intervention for LUTS/BPH. (Clinical Principle, )
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8. Clinicians should consider pressure flow studies prior to intervention for LUTS/BPH when diagnostic uncertainty exists. (Expert Opinion , )
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9. Clinicians should inform patients of the possibility9. of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS/BPH. (Clinical Principle, )
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Medical Therapy

Alpha Blockers

10. Clinicians should offer one of the following alpha blockers as a treatment option for patients with bothersome, moderate to severe LUTS/BPH: alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin. (Moderate, A)
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11. When prescribing an alpha blocker for the treatment of LUTS/BPH, the choice of alpha blocker should be based on patient age and comorbidities, and different adverse event profiles (e.g., ejaculatory dysfunction [EjD], changes in blood pressure). (Moderate, A)
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Alpha Blockers and Intraoperative Floppy Iris Syndrome (IFIS)

12. When initiating alpha blocker therapy, patients with planned cataract surgery should be informed of the associated risks and be advised to discuss these risks with their ophthalmologists. (Expert Opinion , )
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5- Alpha Reductase inhibitor (5-ARI)

13. For the purpose of symptom improvement, 5-ARI monotherapy should be used as a treatment option in patients with LUTS/BPH with prostatic enlargement as judged by a prostate volume of >30cc on imaging, a prostate specific antigen (PSA) >1.5ng/dL, or palpable prostate enlargement on digital rectal exam (DRE). (Moderate, B)
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14. 5-ARIs alone or in combination with alpha blockers are recommended as a treatment option to prevent progression of LUTS/BPH and/or reduce the risks of urinary retention and need for future prostate-related surgery. (Strong, A)
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15. Before starting a 5-ARI, clinicians should inform patients of the risks of sexual side effects, certain uncommon physical side effects, and the low risk of prostate cancer. (Moderate, C)
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16. Clinicians may consider 5-ARIs as a treatment option to reduce intraoperative bleeding and peri- or postoperative need for blood transfusion after transurethral resection of the prostate (TURP) or other surgical intervention for BPH. (Expert Opinion , )
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Phosphodiesterase-5 Inhibitor (PDE5)

17. For patients with LUTS/BPH irrespective of comorbid erectile dysfunction (ED), 5mg daily tadalafil should be discussed as a treatment option. (Moderate, B)
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Combination Therapy

18. 5-ARI in combination with an alpha blocker should be offered as a treatment option only to patients with LUTS associated with demonstrable prostatic enlargement as judged by a prostate volume of >30cc on imaging, a PSA >1.5ng/dL, or palpable prostate enlargement on DRE. (Strong, A)
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19. Anticholinergic agents, alone or in combination with an alpha blocker, may be offered as a treatment option to patients with moderate to severe predominant storage LUTS. (Conditional, C)
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20. Beta-3-agonists in combination with an alpha blocker may be offered as a treatment option to patients with moderate to severe predominate storage LUTS. (Conditional, C)
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21. Clinicians should not offer the combination of low-dose daily 5mg tadalafil with alpha blockers for the treatment of LUTS/BPH as it offers no advantages in symptom improvement over either agent alone. (Moderate, C)
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Acute Urinary Retention (AUR) Outcomes

22. Physicians should prescribe an oral alpha blocker prior to a voiding trial to treat patients with AUR related to BPH. (Moderate, B)
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23. Patients newly treated for AUR with alpha blockers should complete at least three days of medical therapy prior to attempting trial without a catheter (TWOC). (Expert Opinion , )
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24. Clinicians should inform patients who pass a successful TWOC for AUR from BPH that they remain at increased risk for recurrent urinary retention. (Moderate, C)
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Surgical Therapy

25. Surgery is recommended for patients who have renal insufficiency secondary to BPH, refractory urinary retention secondary to BPH, recurrent urinary tract infections (UTIs), recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS/BPH refractory to or unwilling to use other therapies. (Clinical Principle, )
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26. Clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum; however, evaluation for the presence of bladder outlet obstruction (BOO) should be considered. (Clinical Principle, )
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Transurethral Resection of the Prostate (TURP)

27. TURP should be offered as a treatment option for patients with LUTS/BPH. (Moderate, B)
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28. Clinicians may use a monopolar or bipolar approach to TURP as a treatment option, depending on their expertise with these techniques. (Expert Opinion , )
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Simple Prostatectomy

29. Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options by clinicians, depending on their expertise with these techniques, only in patients with large to very large prostates. (Moderate, C)
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Transurethral Incision of the Prostate (TUIP)

30. TUIP should be offered as an option for patients with prostates ≤30cc for the surgical treatment of LUTS/BPH. (Moderate, B)
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Transurethral Vaporization of the Prostate (TUVP)

31. Bipolar TUVP may be offered as an option to patients for the treatment of LUTS/BPH. (Conditional, B)
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Photoselective Vaporization of the Prostate (PVP)

32. PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH. (Moderate, B)
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Prostatic Urethral Lift (PUL)

33. PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe. (Moderate, C)
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34. PUL may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional, C)
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Transurethral Microwave Therapy (TUMT)

35. TUMT may be offered as a treatment option to patients with LUTS/BPH. (Conditional, C)
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Water Vapor Thermal Therapy (WVTT)

36. WVTT should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80cc. (Moderate, C)
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37. WVTT may be offered as a treatment option to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional, C)
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Transurethral Needle Ablation (TUNA)

38. TUNA is not recommended for the treatment of LUTS/BPH. (Expert Opinion , )
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Laser Enucleation

39. Holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP) should be considered as an option, depending on the clinician’s expertise with these techniques, as prostate size-independent options for the treatment of LUTS/BPH. (Moderate, B)
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Robotic Waterjet Treatment (RWT)

40. Robotic waterjet treatment (RWT) may be offered as a treatment option to patients with LUTS/BPH provided prostate volume 30-80cc. (Conditional, C)
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Prostate Artery Embolization (PAE)

41. PAE for the routine treatment of LUTS/BPH is not supported by current data, and benefit over risk remains unclear; therefore, PAE is not recommended outside the context of clinical trials. (Expert Opinion , )
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Hematuria

42. After exclusion of other causes of hematuria, 5-ARIs may be an appropriate and effective treatment alternative in men with refractory hematuria presumably due to prostatic bleeding. (Expert Opinion , )
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Medically Complicated Patients

43. HoLEP, PVP, and ThuLEP should be considered as treatment options in patients who are at higher risk of bleeding. (Expert Opinion , )
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Recommendation Grading

Overview

Title

Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms

Authoring Organization

Publication Month/Year

June 26, 2020

Last Updated Month/Year

February 8, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Provide a useful reference on the effective evidence-based surgical management of male LUTS secondary to BPH (LUTS/BPH).

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings

Ambulatory, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D011470 - Prostatic Hyperplasia

Keywords

benign prostate hyperplasia, BPH, Lower Urinary Tract

Supplemental Methodology Resources

Methodology Supplement

Methodology

Number of Source Documents
373
Literature Search Start Date
January 1, 2007
Literature Search End Date
September 1, 2017