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BackTable / Urology / Article
UroLift: Bridging the Gap From BPH Medications to Minimally Invasive Treatment
Kaitlin Sheppard • Updated Sep 24, 2025 • 38 hits
Benign prostatic hyperplasia (BPH) is highly prevalent among aging men. Approximately 45% of men over age 45 develop BPH, and by age 70, prevalence surges to about 80%– with roughly 94 million cases worldwide as of 2019 [1]. On a population level, BPH-related lower urinary tract symptoms (LUTS) – including storage complaints such as frequency, urgency, and nocturia– rise with age, from 2.7% in men aged 45-49 to nearly 24% by age 80 [2].
Despite this burden, many patients remain on long-term medical therapy even as their symptoms persist or progress. Reliance on medications alone can mask symptom severity, as patients may normalize their symptoms or hesitate to report dissatisfaction. Objective tools such as the International Prostate Symptom Score (IPSS) and post-void residual testing are essential to uncovering true disease impact and determining when pharmacologic treatments are no longer sufficient. At that point attention shifts to diagnostic evaluation to differentiate urinary tract obstruction from bladder dysfunction and guide individualized treatment planning. With anatomy and function assessed, minimally invasive therapies such as UroLift can be personalized for each patient – balancing candidacy criteria, procedural setting, and communication strategies that improve patient acceptance. This article explores the evolving approach to BPH management, highlighting how to recognize inadequate control on medications, incorporate diagnostics into decision-making and optimize patient selection for minimally invasive treatment.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Many men remain on alpha-blockers or other pharmacologic agents despite persistent LUTS.
• Tools such as the International Prostate Symptom Score (IPSS) and post-void residual testing help uncover hidden disease burden and guide next steps.
• Office-based tools–cystoscopy, transrectal ultrasound, and selective UroCuff testing–clarify anatomy, distinguish obstruction from bladder dysfunction, and determine candidacy for minimally invasive therapies.
• Procedural success depends on prostate size and anatomy: outcomes are limited in men with a fixed floor, absent sulcus, or markedly elevated bladder neck, while median lobes can often be managed successfully using advanced cystoscopic assessment and latest UroLift delivery devices.
UroLift is particularly valuable in men with prior prostate radiation, avoiding higher risks associated with ablative surgery.
Table of Contents
(1) Recognizing the Limits of BPH Medications
(2) Using Office-Based Diagnostics to Personalize BPH Care
(3) Patient Selection & Practical Considerations for UroLift
Recognizing the Limits of BPH Medications
Medical therapy remains the first-line management for many men with BPH, but a substantial proportion experience persistent LUTS despite pharmacologic treatment. Identifying when a patient is no longer adequately controlled on medications is critical to preventing further morbidity and improving quality of life. Structured tools like the IPSS allow clinicians to quantify symptom burden, which may reveal significant issues patients downplay in conversation. By pairing IPSS with post-void residual measurements, clinicians can move beyond routine refills and begin a meaningful discussion about diagnostic testing and minimally invasive procedural options to preserve bladder function.
[Dr. Jose Silva]:
Shawn, walk us through that initial visit, that patient that comes with BPH, urinary symptoms. What do you do on that initial visit? Has it changed? You mentioned being more proactive.
[Dr. Shawn West]:
Absolutely.
[Dr. Jose Silva]:
What have you done different to change that?
[Dr. Shawn West]:
The thing that NeoTract and UroLift did that I think a lot of the other types of interventions have followed suit is they really hammered IPSS, or the Symptom Score Index. They felt like that was important to really search for the patients. I think that was manifested in my practice too. I was not consistent with IPSS. I was not consistent with really asking the patients about their avoiding dysfunction. This made this very efficient.
The fact that when you walk into the room and you have this IPSS Symptom Score, you know what's going on, because there is a phenomenon of not wanting to disappoint the physician. You go to the doctor, you've had BPH, and, "Okay. Mr. Smith, how are you doing?" "Oh, I'm doing fine, doctor." Come to find out, you've had him on Flomax for 10 years, and he's up four times a night, and he's bathroom hunting everywhere he's outside, and he's not happy.
He's not comfortable in telling you in every situation that, "Hey, this is failing for me." "What is failing? Is this okay? Is this just me getting old? Am I expected? Everyone says when you get old, this happens. I guess this is just part of aging, so I'll just live with it." I think that IPSS Score was somewhat liberating for patients to write down what they're really dealing with. Whether they felt like that was good or bad was not really the point.
The point is you know that that's bad. You know as a provider that you have-- They've been on Tamsulosin from their primary care doctor, they come to your office and they have an IPSS symptom score of 24, they're up three times a night, that's their bladder crying for help. One of the most important things that NeoTract and Teleflex brought into the arena was asking your patients to be honest with you about their symptoms.
I saw that in my own practice. When I really adopted that, I was amazed and embarrassed that the number of patients that I had had on medical management, "Okay. Everything looks good. Your PSA is 2.1. I'll refill your Flomax. We'll see you next year," they weren't doing well." I think the first several months of really adopting that, it was eye-opening. It really was. That's a long-winded way of saying any male patient that comes to my office-- I'm in a large urology group, we've got I think about 18, 17, or 18 partners, fortunately we've adopted that across the board.
If you're a male and you're over the age of 40, whether you're here to talk to me about a vasectomy, or you've got a kidney stone, or ED, or whatever your problem is, we're going to get an IPSS symptom score, because that lets us know where you are. In our community, a lot of the primary care doctors initiate treatment with medications, and so you'll see a wide range of guys who are either on Tamsulosin or their primary doctor starts them on Tadalafil, we have some that put them on combination therapy.
Oftentimes the patient that comes to my office is someone who has already been on medications, who has already found that this was not helping them, and so they come to my doorstep, I do the IPSS symptom score, I also like to do a post-void residual. When I walk into the room and I know that patient's already been on medications and their IPSS Score is bothersome or their quality of life is not satisfied, then that's an easy conversation for me to take that time with them and not talk about asking them 10 questions about their symptoms, but taking that time and talking to them about what are some of the other options.
More importantly, what are the options in diagnostics? What are you a candidate for? We can do better than we are right now. That's the initial step is the IPSS, a post-void residual, obviously reviewing the meds and having the conversation about where they are and what it means. That gets back to the, you and I talked about bladder health. Urinary symptoms are bladder-related, whether they're a result of prostate enlargement, or whether they are bladder-initiated, or a combination of both. That's our job to really unearth that, and it's definitely the bladder waving the white flag.
I use this analogy on occasion to some patients, especially some of my younger patients. If you went to a cardiologist, and he said, "Hey, listen, you've got some blockage on your coronary. You're doing okay now, but we'll just hold tight until you have a myocardial infarction, and then we'll talk about dealing with the blockage. I think cardiac muscle, bladder muscle, similar in certain senses that they can't be rehabilitated. Throwing that analogy out there that, "You don't need to do this for another 20, 30 years of your life, let's deal with this obstruction and save the bladder."
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Using Office-Based Diagnostics to Personalize BPH Care
After establishing when pharmacologic treatments alone are falling short, the next challenge is guiding patients who hope for a “better pill.” As Dr. West explains, additional agents such as finasteride may offer only modest improvements in IPSS scores while introducing new risks like decreased libido or possible cognitive effects from long-term tamsulosin. For medication-naive patients with mild LUTS, pharmacotherapy remains reasonable, but escalating therapy often requires shifting the focus to diagnostics. Office-based tools like cystoscopy, transrectal ultrasound, and selective UroCuff testing clarify anatomy, differentiate obstruction from overactive bladder, and determine candidacy for minimally invasive procedures. By presenting diagnostics as the pathway to customized therapy, clinicians can move the conversation beyond polypharmacy and toward durable, anatomy-based solutions.
[Dr. Jose Silva]:
Exactly. I think that analogy of the heart is very on point. I talked to Wayne Kwan, he has the man versus prostate propaganda, bladder health, protecting the detrusor. Definitely that analogy of the heart I think is something easy that all the patients can understand, "Hey, your bladder is very important. There's nothing else afterwards. If you damage it, that's it. It's a permanent catheter." It's very important to talk to them. Shawn, let me ask you this, there's always a guy, a patient that thinks that you're going to offer the magical pill that the primary didn't know about, but you do. What do you tell that guy?
[Dr. Shawn West]:
I've had patients that, they've been on Flomax and they say, "Well, I did some research. What about adding Avodart or Finasteride?" I say, "Okay. Well, that's fine. Let's see what some of the literature shows." I said, "Here's where you are symptom-wise. Your IPSS symptom score is a 22. If I put you on Finasteride or Avodart, let's say that drops you down to an 18 or 17," which is what the ENTOPS data showed, "that you're going to get about another three-point improvement from that medication."
Yet there is now a black box warning on Finasteride, the post-Finasteride syndrome, where you can have permanent suppression of your testosterone, decreased libido, some of those things. I said, "Maybe adding another pill is not worth the risk, especially since we may only improve these symptoms." I'll show them their score. I'll show them those numbers and what the scale means. "Does adding another medication get you, do you think that's going to get you to a point where you really are confident that you're happy from a urinary standpoint?"
That's the conversation I had. Listen, I'm not anti-medication at all. I don't want to come across like everybody gets surgery with me. A patient who's medication-naive, who their symptom score is not miserable, I think it's clearly reasonable to offer that first line as an option. That's what the AUA Guidelines suggest. Now, I obviously bring those patients back in a few weeks just to see how they're doing. Are they having side effects? How do they feel with the medications?
I'm not anti-medication, but I also think that there are some risks with medications. I think those conversations, we talk about the risk of surgery, but we're a little hesitant sometimes to talk about the risk of polypharmacy and adding another medication. We talked about the post-Finasteride syndrome. There is some data, I don't know how strong it is, but there clearly is data that talk about long-term Tamsulosin with dementia. I think we need to have those conversations.
[Dr. Jose Silva]:
Exactly. Like you mentioned, either the IPSS or the AUSS, essentially that patient, if you don't do that, you do a pill, they're going to feel a little bit better. Like you mentioned, most of the time they think that it's a normal aging process. You're improving what they think is normal for them, so you're making them a little bit better. There's other ways that they can be actually better without taking pharma pills or anything like that. Usually my practice, what I do, if they're naive or they've been Flomax, I try Tadalafil for a month, but I'll bring them back to do a cystoscopy, do the ultrasound of the prostate.
[Dr. Shawn West]:
Sure.
[Dr. Jose Silva]:
Then, in that time, see how they do it and continue to talk about something else. Shawn, go through what type of work you do with those patients?
[Dr. Shawn West]:
Yes, absolutely. I have the conversation with the patient and I can tell you the last time that I've had someone that I said, "Hey, I think this is important. I don't like your symptoms. I think this is important." That's part of what, getting off track just a bit, but I think as urologists, we need to come in that room with some conviction about what we're seeing on the IPSS Score and what we know ultimately lies for them in the future. A lot of these guys think it's age-related. We talked about that. I think it's important because if your physician feels that it's important for you, then you're going to do it. You're going to say, "Yes, well, this must be important. We need to take a look at this." Sometimes it's, "Well, we can do this if you want to," or, "We can try this if you want to." They're there for you to give them some guidance.
I think when we get to that point that we feel like we need to talk about some diagnostics, we need to have a little bit of conviction about it. I think that's real important. Patient comes in and we agree that the next step is a further diagnostic discussion. I talked to them about what the diagnostics entail. This is a quick office-based procedure where we're just taking a look inside the bladder, allows me to see your prostate anatomy, and it makes you feel like you really need to urinate for about 10 or 15 seconds. That's how I'll describe the cystoscopy.
You hear it in our office, we will then roll them over on their side right after the cystoscopy, and we'll do a transrectal ultrasound. That gives me a good size measurement. I like the transrectal ultrasound. Obviously, it's a little more invasive, but I also think that it is a little more accurate. I think it does a great job of outlining the median lobe, and it's just how large is the median lobe, and does this thing have any intravascular protrusion? I like doing the transrectal ultrasound, and again, describing that as just a quick prostate exam with an ultrasound probe instead of my finger. That's the next step is those diagnostics.
Now, I will add that if I've got a patient who has predominant overactive bladder symptoms, and maybe doesn't complain as much about the obstructive symptoms, I'll go ahead and do a UroCuff on those patients. I don't UroCuff all of mine, but I will do a UroCuff in those patients. If that shows high bladder pressures, then I feel more confident that this clearly is a prostate-related etiology, or at worst, this is mixed.
This is obstruction and OAB. If the UroCuff does not show any degree of obstruction, I'll still consider an anatomic workup, or maybe instead of the anatomic workup, maybe I consider an anticholinergic, or maybe we talk about one of the beta-3 agonists, as a trial, before we go through the diagnostic part. That's my workup for those patients. Before they leave my office, so we have the conversation, I'll say, that we need to do the diagnostics, I will go ahead and give them some paperwork on several modalities.
I'm very clear with them that, "This isn't a choose the one that's got the glossiest picture," but I tell them, "I want you to educate yourself on these options. The diagnostic test will tell us what's going to be the best for you, what you're the best candidate for, and what your success will be long-term with these options." These are more educational tools, so that when they come back and you do the diagnostic testing, you can then have a conversation that, "Hey. Here's what I'm seeing. I think these two are your best options," or, "Hey, based upon your anatomy, I feel strongly that this is your best option moving forward."
As you're well aware, size, their anatomy is going to select out some of this. Some of this, "Which one do you choose, which one do you--?" Their workup is going to tell the story, so to speak. When you talk about customizing a treatment for a patient, as a consumer, that sounds appeasing, that this person is really trying to customize this for me based upon my anatomy, based upon my prostate size, and what's going to give me the best chance of success.
Patient Selection & Practical Considerations for UroLift
With anatomic and functional findings already established, attention shifts to tailoring procedural choices– often beginning with an assessment of UroLift candidacy. Suitability depends on more than prostate size. Patients with a fixed prostate floor, absent sulcus, or significantly raised bladder neck are less likely to benefit, while many with median lobe hyperplasia remain good candidates when anatomy is carefully assessed with cystoscopy and ultrasound. Advances in implant delivery systems have further improved management of challenging median lobe anatomy.
UroLift is also a valuable consideration in men with prior prostate radiation, offering relief of obstruction without the higher risks of stricture, contracture, or poor healing associated with traditional ablative surgery in this cohort. Practical considerations further shape the approach: procedural setting may vary between office, ambulatory surgery center and hospital, depending on gland size, implant requirements and reimbursement logistics. Finally, communication plays a critical role in patient acceptance. Framing UroLift as a brief outpatient procedure under propofol– similar to a colonoscopy– helps reduce anxiety and distinguishes it from more invasive surgical interventions.
[Dr. Jose Silva]:
Shawn, so let's go specifically into UroLift or minimally invasive techniques. Other than size, what else do you see? Let's say, you do a cystoscopy in the office, what will tell you, "Hey, you might not be a candidate for UroLift?
[Dr. Shawn West]:
Yes, I tell you, one of the things is, you talked about median lobes as far as what does that look like? Is that patient a patient that you take off the table? That's where ultrasound comes into advantage for me because I've had a lot of success with treating median lobes with UroLift. Those are the guys that you de-obstruct so quickly that on their post-op visit, they're bringing you bottles of alcohol and wine, [chuckles] and things like that.
I do not shy away from a median lobe, as long as it's not a pedunculated, ball-valving, large gland. The ones that I always look at that I say, "This isn't going to work," is the one that looks like the entire floor of the prostate is raised. If I can get to the bladder neck and I can see a sulcus on either side of the prostate, I have a pretty good chance of pinning that tissue up and out of the way.
Now, oftentimes a median lobe will auto select these patients out from UroLift. I do preceptor ships and everybody wants to see a median lobe, "Well, let's see a median lobe." Oftentimes if you have a large median lobe or a median lobe, the other lobes of your prostate are large too. Sometimes that kicks them out of that a hundred milliliter range. I think if someone does not have a sulcus, that they have a fixed floor of the prostate, that's one that's not going to do well with a UroLift.
The most challenging ones in my opinion are the patient who has a raised bladder neck. They have interior tissue and oftentimes they'll have a short prosthetic urethra. Those can be very challenging. Fortunately, some of the technique has evolved to where we're obviously moving more interior with those initial bladder neck implants. That's raising the roof, so to speak, of the prosthetic urethra. Those are ones that I'm always looking at what degree of angle they have. Am I going to be able to negotiate this? Those are the big ones. I do not exclude someone who's had radiation. I think that's still a very viable option for UroLift.
You and I know, at least I know early in my training, the patient had radiation or had seeds, but they have adenoma around the prosthetic urethra. They're miserable and doing a TURP or any intervention on them is very, very challenging just from their prosthetic, the lack of vascularity, and how that tissue doesn't heal. I think UroLift in that cohort of patients is a great option to try to deal with some of the obstruction without worrying about prosthetic calcification, bladder neck contracture, urethral stricture, bulbar stricture, all of those things that, we associate with doing any type of ablative intervention for someone who's had radiation to their prostate.
[Dr. Jose Silva]:
You mentioned the medial lobe. For me, this also happened when I started doing UroLift, I did a lot of GreenLight at that time. I did a cystoscopy in the office, but then when I went to the OR, the medial lobe didn't seem that big. Then, "Well, this could have been a candidate for UroLift."
[Dr. Shawn West]:
Right.
[Dr. Jose Silva]:
Also knowing that discrepancy and knowing that it maybe it's not as big as it seems, that's where the ultrasound plays a role.
[Dr. Shawn West]:
That's exactly right. I've had patients where I put on my HNP, slight median lobe but no intravascular protrusion. Then when you put those initial two bladder neck implants, it stretches that out and there's essentially no median lobe tissue at all. It's completely flattened out. You're exactly right. What often we think is a median lobe, that ultrasound, especially the transverse ultrasound, that'll help you out. If you don't see a large volume of tissue in that bladder space, then that oftentimes will flatten out.
The other thing with UroLift is now with that advanced tissue control device. Essentially it's almost like a tennis racket and it really allows you some control over that median lobe tissue to pin that infralaterally. That, to me, has made that technique a lot easier in managing the median lobes. You're exactly right. I think some of this is that we think's a median lobe, you get in there, you pin those lateral lobes away at the bladder neck, and a lot of that median lobe tissue flattens out real nicely.
[Dr. Jose Silva]:
Shawn, are you doing these cases in the OR, or in the office, ASC?
[Dr. Shawn West]:
Most of them I'm doing in ASC. We were doing a fair number under nitrous in the office and those actually went fairly well. I think you can tell how a patient tolerates a cystoscopy, how well they're going to do from a nitrous standpoint. Obviously sometimes an older patient is a little easier to relax than a younger patient. If I've got a guy with a high bladder neck and he's 52-years-old, I'm going to have to apply a fair amount of pressure to really open that up. He may not be the best office candidate.
From a logistical standpoint, to be honest with you, it was just carrying the device, and purchasing that amount and holding that month to month to do them in the office setting. For me, I do them in the ASC. They obviously purchased the implants. We're working on some things now to where we can get some of these back in the office. We are working towards that. I should be shifting some of that back into the office. The ones in the hospital, I'll tell you, I'll typically do the larger glands in the office. Because the coding and billing from an ASC is a little different than an inpatient, remember, we can place seven implants.
I've not done that often, but you're allowed seven implants at one setting. I clearly don't want to do that at an ambulatory surgery center. That would obviously upset them. They would lose a significant amount of money. If I've got a patient with a bigger gland or someone, I know I'm going to definitely need at least six implants on them. They've got a long prosthetic urethra or I know they have a large median lobe and we're going to need to use an extra implant on that. Sometimes I'll do those in the hospital just from a reimbursement standpoint for the surgery center.
[Dr. Jose Silva]:
Yes. I will say when I started doing the UroLift, my delivery in terms of the patient saying, "Hey--" I do them in the OR because I don't have an ASC close to where the office is. The patients got scared when you say OR. Some of them, they don't want to go to the OR. It's more expensive or also they think they're going to go on the general anesthesia.
[Dr. Shawn West]:
Sure.
[Dr. Jose Silva]:
I started changing the delivery. I also talking to anesthesia, "Hey, these patients that get UroLift, they're going to go on their sedation, deep sedation, and it's going to be a 5, 10 minute case."
[Dr. Shawn West]:
Right.
[Dr. Jose Silva]:
When you start having that process, definitely the patient, "Okay, that's fine. You're going to put me to sleep a little bit, but then I can go home."
[Dr. Shawn West]:
Right.
[Dr. Jose Silva]:
The patient is more willing to do that because then they will say, "Well, if you're going to take me to the OR, let's do something more aggressive. If you're already going to--"
[Dr. Shawn West]:
You bring up a great point. I think that's part of the delivery part where all of the patients that we do in the surgery center, we ask the anesthesia, "Hey, let's try to do this under Propofol." If there's an airway issue or someone that has bad OS, sleep apnea, sometimes I'll do an LMA. The majority of mine, we do them under Propofol. It's clean. They wake up, they feel, they don't feel like they've been knocked out.
Those patients also have a better chance of passing a voiding trial if you don't want to leave a catheter in place. If you give them general anesthetic, it just takes a little bit longer, I think for them to wake up from that. The ones that you're going to leave a catheter out, I think the Propofol is the right way to go, for sure. You're right. Hey, this is just a quick outpatient procedure. We'll put you under just almost like a colonoscopy, and those kinds of word associations evoke more of a sense of calm about what you're doing as opposed to we're doing surgery.
Additional resources:
External Resources
[1] Jiang, H., et al. (2025). Comprehensive analysis of the global, regional and national burden of benign prostatic hyperplasia, 1990–2019: results from the Global Burden of Disease Study 2019. Scientific Reports, 15(1), 1234. https://www.nature.com/articles/s41598-025-90229-3
[2] Zhu, Y., et al. (2024). Global burden of benign prostatic hyperplasia: a systematic analysis for the Global Burden of Disease Study 2019. BMC Urology, 24(1), 1582. https://bmcurol.biomedcentral.com/articles/10.1186/s12894-024-01582-w
Podcast Contributors
Dr. Shawn West
Dr. Shawn West is a urologist at McIver Clinic in Jacksonville, Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, December 10). Ep. 205 – Optimizing Bladder Health in BPH Treatment Strategies [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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