Contemporary Surgical Management of BPH

In this episode of BackTable Urology, Dr. Claus Roehrborn, chairman and professor of UT Southwestern Urology department, joins our host Dr. Aditya Bagrodia to discuss surgical and post-operative management of benign prostate hyperplasia (BPH).

First, Dr. Roehrborn summarizes the different BPH surgical options based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches. UroLift and the Rezum procedures are the most common minimally invasive options, while the monopolar/bipolar TURP, prostatectomies, the Greenlight (KTP) laser, and different enucleation techniques are the most common surgical options.

Next, Dr. Roehrborn discusses how patient characteristics and prostate size can help guide surgical options. He cites frailty and old age as push factors for minimally invasive techniques and greenlight lasers. To study prostate size, he recommends the point-of-care ultrasound (POCUS) because it is inexpensive and gives all the needed measurements before surgery. For large prostates (over 80 g), he proposes enucleation, simple prostatectomy, and minimally invasive treatments. For small or average-sized prostates (30-80 g), he considers all surgical options to be viable, but favors TURP or enucleation if the median lobe is substantially enlarged. He also assesses the risk of anejaculation for each approach: Urolift has no risk, Rezum and aquablation have minimal risks, other techniques depend on individual skill of the surgeon.

Dr. Roehrborn suggests a follow up visit at 1 month to evaluate urination and to stop all medication. However, he notes that some patients resume anticholinergics or beta-3-adrenergics because their storage symptoms persist. He also notes that 5-alpha-reductase inhibitors prevent prostate re-growth in genetically predisposed patients. In general, he encourages urologists to have a specific plan of action for every post-operative drug they prescribe to patients.