Surgical intervention remains the gold standard for the treatment of benign prostatic hyperplasia (BPH) in patients with moderate to severe lower urinary tract symptoms (LUTS) who have failed or are intolerant to medical therapy, as well as for those who present with complications of BPH. The primary goal of surgery is to relieve bladder outlet obstruction (BOO) by removing the obstructing prostatic adenoma, thereby improving urinary symptoms and quality of life, and preventing the long-term sequelae of chronic obstruction.
The indications for surgical intervention in BPH can be absolute or relative. Absolute indications include:
- Refractory urinary retention (failure to void after at least one trial of catheter removal)
- Recurrent urinary tract infections
- Recurrent gross hematuria due to BPH
- Bladder stones secondary to BPH
- Renal insufficiency secondary to BPH
Relative indications include moderate to severe LUTS (IPSS ≥ 8) that are bothersome to the patient and have not responded adequately to medical therapy, or patient preference for definitive treatment over long-term medication.
The surgical options for BPH have evolved significantly over the past few decades, with a trend towards less invasive techniques that offer comparable efficacy to traditional methods but with reduced morbidity. The choice of surgical procedure depends on several factors, including prostate size and anatomy, patient comorbidities, surgeon experience and preference, and patient values. The main categories of surgical treatment for BPH are summarized in the table below.
| Surgical Category | Description | Examples |
|---|---|---|
| Transurethral Resection | The endoscopic removal of prostatic tissue in small chips using an electrocautery loop. | Monopolar TURP, Bipolar TURP |
| Endoscopic Enucleation | The anatomical dissection and removal of the entire prostatic adenoma from the surgical capsule, followed by morcellation. | Holmium Laser Enucleation of the Prostate (HoLEP), Bipolar Enucleation of the Prostate (TUEB) |
| Laser Vaporization | The use of laser energy to ablate and vaporize prostatic tissue, creating an open channel for urine flow. | Photoselective Vaporization of the Prostate (PVP) with GreenLight Laser, Thulium Laser Vaporization |
| Minimally Invasive Surgical Therapies (MIST) | A diverse group of less invasive procedures that aim to relieve obstruction with minimal tissue removal or disruption. | Prostatic Urethral Lift (UroLift), Convective Water Vapor Thermal Therapy (Rezum), Prostatic Artery Embolization (PAE) |
| Prostatic Stents | The placement of a temporary or permanent device within the prostatic urethra to maintain its patency. | Allium Stent, Spanner Stent |
| Simple Prostatectomy | The surgical removal of the prostatic adenoma through an open, laparoscopic, or robot-assisted approach. Reserved for very large prostates. | Open Simple Prostatectomy, Laparoscopic Simple Prostatectomy, Robot-Assisted Simple Prostatectomy (RASP) |
The subsequent chapters will delve into the technical details, outcomes, and complications of each of these surgical modalities, providing a comprehensive guide for the modern management of BPH.