Benign prostatic hyperplasia: what are the benefits and harms of various surgical management options?

Benign prostatic hyperplasia (BPH) is characterised by stromal and epithelial prostatic cell hyperplasia. The enlarged prostate may be associated with voiding and storage lower urinary tract symptoms (LUTS).

These have been predominantly attributed to bladder outlet obstruction (BOO), assumed to be due to the increased size of the prostate (benign prostatic obstruction; BPO), although recently this assumption has been reconsidered. These troublesome symptoms progress with age and adversely affect the quality of life (QoL), warranting adequate treatment options.

LUTS secondary to BPO (LUTS / BPO) range from mild to severe. Treatment is required for every man with bothersome symptoms and / or impaired QoL. Some patients may require immediate surgical treatment; however conservative options present a feasible option for some patients with LUTS / BPO. All men should receive reassurance, behavioural and dietary advice, as well as optimisation of other related co-morbid conditions. Management with pharmacological agents is applicable if treatment is sought for moderate-to-severe LUTS (International Prostate Symptom Score; IPSS: 8-35) [1].

For many patients the symptoms of LUTS / BPO can remain stable for years either by watchful waiting or with medical management. However, some patients experience progression of their symptoms or develop complications. Complications may include recurrent episodes of haematuria, recurrent urinary tract infections or recurrent episodes of urinary retention, bladder stones, large bladder diverticula or renal impairment secondary to BPO and these will necessitate further treatment when they occur. Surgical treatment is indicated for patients requiring active treatment but who are unwilling to have medical treatment, for non-responders to medical treatment, or for patients with absolute surgical indications (i.e. presenting with the complications mentioned above). In this review we have summarised surgical treatments for LUTS / BPO.