044IC:

AUA BPH Guidelines: How to Best Diagnose & How to

Most Effectively & Safely Treat

Saturday, May 4, 2019

4:00 – 6:00p.m.

Faculty
Steven Abraham Kaplan, MD, FACS – Course Director
Claus Georg Roehrborn, MD
Alexis Edwin Te, MD
Kevin T. McVary, MD
AUA Guidelines 2018: Lower Urinary Tract
Symptoms Associated with Benign Prostatic
Hyperplasia
AUA Guidelines 2019: Lower Urinary Tract
Symptoms Associated with Benign
Prostatic Hyperplasia
Course Director and Faculty

Steven A. Kaplan, MD, FACS

Icahn School of Medicine at Mount Sinai
Claus G. Roehrborn, MD
UT Southwestern Medical Center
Alexis E. Te, MD
Weill Cornell Medical
 Agenda
Introduction and Do
Kaplan​ 20 min
Guidelines Work?

​Diagnostic evaluation - focus

​Roehrborn ​20 min
on what is new

​Ablative 25 min
Te

​Surgical ​Roehrborn ​25 min

​Future ​Kaplan 10 min

​Closeout / Q&A / Discussion

​All ​20 min
/ what will the future hold
 Learning Objectives
1. Analyze the latest evidence on the medical and surgical management of lower
urinary tract symptoms associated with benign prostatic hyperplasia or
BPH/LUTS as outlined in the AUA guidelines.

2. Improve the diagnostic and therapeutic decision making processes by

illustrating the application of these guidelines in urological practice.

3. Acquire in-depth knowledge on the process by which evidence is used to

develop scientifically rigorous, yet actionable, guidelines.
AUA Benign Prostatic Hyperplasia Panel Members

Harris E. Foster, MD (Chair)

Kevin T. McVary, MD (Vice-Chair)
Michael J. Barry, MD
Steven A. Kaplan, MD
Claus G. Roehrborn, MD
J. Kellogg Parsons, MD
Tobias Kohler, MD
Lori B. Lerner, MD
Charles Welliver, MD
Deborah J. Lightner, MD (PGC Rep)
Manhar Gandhi, MD (Patient Advocate)

Methodologist: Timothy J. Wilt, MD, MPH, Philipp Dahm, MD, MHSc

 Background

• 2018 version is 4th iteration

• 1994
• 2003
• 2010
• Reflects evolutionary changes in both minimally invasive and
surgical therapies for BPH
• Reevaluating diagnostic algorithm
• Urodynamics
• Prostate volume
 Why Now?
To understand and implement evidence-based surgical management for
men with lower urinary tract symptoms (LUTS) attributed to benign
prostatic hyperplasia (BPH)

• Goals:
• Maximize
• Patient quality of life
• Minimize
• Adverse events
• Patient burden
 Why Now?
• Numerous new technologies have been developed since last Guidelines
• Benign prostatic hyperplasia (BPH) is a histologic diagnosis that refers to the
proliferation of smooth muscle and epithelial cells within the prostatic transition
zone.
• While several hypotheses exist, BPH is likely the result of a multifactorial process, the
exact etiology of which is unknown.
• The prevalence and the severity of lower urinary tract symptoms (LUTS) in the aging
male can be progressive and is an important diagnosis in the healthcare of patients and
the welfare of society.
 Why Only Surgical?
• There was insufficient time to comprehensively evaluate new surgical data and
simultaneously update medical management

• AUA will be updating the medical information in the coming months

• Release integrated all encompassing guideline in 2019 purpose of this revised

guideline is to provide a useful reference on the management of BPH
 Clinical Practice Guidelines
How Can It Be Better Utilized?

• Goal of Clinical Practice Guidelines (CPG)

• Collating most up to date information into a single document
• Aid HCP in providing best proactive methods
• Data suggests those who use CPG deliver better outcomes
• Internal Barriers
• Awareness
• Familiarity
• Agreement
 Clinical Practice Guidelines
How Can It Be Better Utilized?

• Need to overcome inertia of “normal practice”

• Change is difficult
• Goals of patients and clinicians are not always in sync (or the
guidelines)
 Clinical Practice Guidelines
How Can It Be Better Utilized?

• External Barriers
• Equipment
• Space
• Educational materials
• Time
• Staff
• Financial resources
 Clinical Practice Guidelines
Do Guidelines Improve Care?

• Conflicting Data
• Yes
• 55/59 showed improvement 1 (only RCT’s analyzed)
• Nebulous
• Holland: (CPG embedded into proactive 2)
• 30 studies reviewed
‒ 6 showed significant improvement
‒ 4 showed modest improvement
‒ 3 showed no effect
1Grimshaw Lancet, 1993, 2Lugtenberg M, QSFH 2009
 Clinical Practice Guidelines
Do Guidelines Improve Care?

• < 50% of patients with CML are monitored using published CPG
• Anonymous survey to 515
• The Good
• 96 (19%) responded
• 84% said they used CPG’s
• The Bad
• 46% found them hard to follow
• > 50% found resource barriers
• Physician resources limited use in 25%
1Goldberg et al J Onc Prac, 2017
 Clinical Practice Guidelines
Do Guidelines Improve Care?

• > 90% said additional CPG would not change practice

or encourage use
• Conclusions
• Significant resource barriers exist
• Lack of familiarity / lack of agreement
• Efforts to facilitate use are NOT desired

1Goldberg et al J Onc Prac, 2017

 Clinical Practice Guidelines
Do Physicians Follow Guidelines?

• Non compliance as high as 70% 1

• True for many disciplines
• ? Age dependent
• Older tend to practice based on experience / knowledge
• Younger practice in a more collaborative team – based medicine strongly
influenced by protocols and guidelines

1 Lomas J, NEJM 1989

 Clinical Practice Guidelines Barriers
Identified by Clinicians
• Dutch primary care study
• 90% believe CPG would lead to better outcomes
• 35% won’t change routines to adopt
European primary care
• 89% found CPG useful
• 55% are not compliant
 Clinical Practice Guidelines
Other Barriers
• CPG’s vary in detail
• Some brief with clear instructions; many complex
• Others may conflict with other CPG
• UK study found that CPG less likely to be followed if
they contained vague or controversial statements
 Background

• Benign prostatic hyperplasia (BPH) is a histologic diagnosis that refers to the

proliferation of smooth muscle and epithelial cells within the prostatic transition zone.

• While several hypotheses exist, BPH is likely the result of a multifactorial process, the
exact etiology of which is unknown.

• The prevalence and the severity of lower urinary tract symptoms (LUTS) in the aging
male can be progressive and is an important diagnosis in the healthcare of patients and
the welfare of society.
 Purpose

• The purpose of this revised guideline is to provide a useful reference on the effective
evidence-based surgical management of male LUTS secondary to BPH (LUTS/BPH).

• The strategies recommended in this document were derived from evidence-base

processes and a multi-disciplinary panel (general urology, surgical urology, primary
care, patient advocacy).

• The most effective approach for a particular patient is best determined by shared
decision making by the individual clinician and patient in the context of that patient’s
history, values, and goals for treatment.
 Minnesota Evidence-based Decision and
Implementation Center (MEDIC)
Group Effort Timothy J. Wilt, MD, MPH
Philipp Dahm, MD, MSC
Members
Lauren McKenzie, MPH
Harris Foster, MD Yale University Chair
Christina Rosebush, MPH
Kevin T. McVary, MD-FACS, SIU Vice-Chair
Rod MacDonald, MPH
Charles Welliver, MD, Albany Medical College
Michael Risk, MD
Claus Roehrborn, MD, UT-Southwestern University
Jae Jung, MD
Kellogg Parsons, MD, University California - San Diego
Nancy Greer PhD
Lori Lerner, MD, VA Boston Healthcare System
AUA Staff
Michael Barry, MD , Harvard University/MGH
Heddy Hubbard, PhD, MPH
Steven Kaplan, MD, Icahn School of Medicine/Mt Sinai
Abid Khan, MHS, MPP
Tobias Kohler, MD, Mayo Clinic
Erin Kirkby, MS
Nenellia Bronson, MA :
Deb Lightner, MD - PGC Rep
Leila Rahimi, MHS
Manhar Gandhi, MD - Patient Advocate
Brooke Bixler, MPH
Shalini Selvarajah, MD, MPH
Complex Dynamics
Prevalence and the severity of LUT can be progressive

Prostate Urethra

Central
Bladder
nervous
neck
system

Bladder LUTS/BPH Lifestyles

•It is important for healthcare of our patients and society

•~ 90% of men between 45-80y suffer some type of LUTS
 Methodology
In preparation for the 2018 BPH Clinical Guideline, the Panel
provided the Minnesota Evidence Review Team with key
questions, interventions, comparators, and outcomes to be
addressed.
The review team worked closely with the Panel to refine:
Scope of inquiry
Key questions
Inclusion/exclusion criteria
Methodology
26 Key Questions Identified by the Panel !
Preoperative
parameters that
are necessary
before surgery
These key
questions were
divided 3 topics
Surgical
Acute managemen
urinary t of BOO/
BPH
retenti
on
 Key Questions
What is the comparative efficacy and effectiveness of pre-operative PFS on surgical outcomes?

What is the comparative efficacy and effectiveness of pre-operative Qmax on surgical

outcomes?

What is the comparative efficacy and effectiveness of various open surgical and MIST therapies
compared to TURP or sham procedures on outcomes?

Do these outcomes vary by age, obesity, diabetes, pre-operative PFS/Qmax

In the index patient, what is the risk of recurrent AUR and the need for definitive surgical
treatment at 6 and 12 months?
 Methodology
Searches and Article Selection
Ovid MEDLINE
Cochrane Library
Agency for Healthcare Research and Quality (AHRQ) database
Identified:
Randomized controlled trials (RCTs)
Clinical controlled trials (CCTs)
Systematic reviews/meta-analyses
Observational studies
Published: January 2007 and September 2017.
Methods
Overarching key questions
for surgical therapies Risk of recurrent
AUR/need for
definitive surgical
Comparative
Tx at
Comparative 6 + 12 mo?
efficacy and
efficacy effectiveness
effectiveness of of open
pre-operative surgical and
PFS or Qmax on MIST
Do
surgical compared to
outcomes
outcomes? TURP or sham
vary by age,
procedures on
obesity,
outcomes?
diabetes,
pre-
operative
•Risk of recurrent
PFS/Qmax
AUR and the need
for definitive
surgical treatment
 Methods
Relevant citations: January 2007 and
September 2017

Study inclusion and exclusion criteria were determined by the

Panel chairman, co-chairman, and the methodologists

All titles and abstracts “dual-reviewed” by MEDIC

Relevant articles were selected and then the full-text dual-

reviewed for inclusion

•Ovid Medline®
•Defined the scope to achieve a reproducible and
explicit process
 Methods
Relevant citations: 1/1/2007 and
9/1/2017
Medline and Cochrane N = 2821
Records after duplicates removed, N = 2236
Citations screened: N = 2236 Records excluded:
N = 1896
Full-text assessed for eligibility N = 340. Full text
excluded,Included
N=243 studies: N = 67
KQ 1 or KQ 2= 0 KQ 3= 65 KQ 4 or 5
=2
•Defined the scope to achieve a reproducible and explicit process
Methods
Narrative synthesis and tables
Quatitative analysis of
summarizing important study
evidence was performed on all
and population characteristics,
interventions and outcomes
outcomes, and adverse events

RIGOR
Studies were stratified by study Focus on RCT
design, comparator, follow-up Active comparators:
interval, and intensity of TURP, shams, pharmaRx
intervention
Outcomes at 6, 12 mos
Methods - Population

Inclusion criteria
Men ≥ 45y without significant
risk of non-BPH causes of LUTS
May or may not be associated
w/ BPE, BOO or histologic BPH

Exclusion criteria
Polyuria, neurologic disease, or prior
LUT disease
<45y with voiding dysfunction
 Guideline Development: Strong Recommendation
•Based on the outcomes data
•Tempered by the Panel’s expert opinion

Net
benefit or Evidence
Strength C
harm (LOW Certainty

Evidence SUBSTANT Benefits >

Risks/Burdens
Strength A IAL
Evidence Strength Rarely used to support
(HIGH B a Strong
Certainty) (MODERATE Recommendation
Benefits > Certainty)
Risks/Burdens
Applies to most patients in most Benefits > Applies to most patients in
circumstances Risks/Burdens most circumstances
Future research is unlikely to change Better evidence could
confidence change confidence
 Guideline Development: Moderate Recommendation
•Based on the outcomes data
•Tempered by the Panel’s expert opinion
Net
benefit Evidence
or harm Strength C
(LOW Certainty
Evidence MODER Benefits >
Strength A ATE StrengthRisks/Burdens
Evidence
(HIGH B Rarely used to support
Certainty) a Strong
(MODERATE
Recommendation
Benefits > Certainty)
Risks/Burdens Benefits >
Applies to most patients in most Applies to most patients in
Risks/Burdens most circumstances
circumstances
Future research is unlikely to change Better evidence could
confidence change confidence
 Guideline Development: Conditional Recommendation
No
apparen Evidence Strength C

t net (LOW Certainty)

Balance between
benefit Benefits Risks
Unclear
Evidence
Strength A or
Evidence Strength
(HIGH harm) B Alternative strategies
may be equally
reasonable
Certainty) (MODERATE Better evidence likely
to change confidence
Benefits = Certainty)
Risks/Burdens
Applies to most patients in most Benefits =
circumstances Risks/Burdens Best action appears to depend on individual
patient circumstances
Future research is unlikely to change Better evidence could change
confidence
 Balance be

Guideline Development: Clinical Principle

Widely agreed upon by

urologists or other clinicians
for which there may or may
not be evidence in
the medical literature
 Balance be

Guideline Development: Expert Opinion

A statement, achieved by consensus

of the Panel, that is based on
members clinical training,
experience, knowledge,
and judgment for which
there is no evidence
WARNING!!

• The statements represent the combined input of the entire panel.

• Course presenters are not solely responsible for the statements
presented.
Preoperative Testing
Key Question 1: What is the comparative efficacy and effectiveness of
pre-operative pressure flow studies on surgical outcomes?

Key Question 2: What is the comparative efficacy and effectiveness of

pre-operative uroflowmetry in relation to surgical outcomes?
 Preoperative Testing
Key Question 1: What is the comparative efficacy and effectiveness of
pre-operative pressure flow studies on surgical outcomes?
Topic Total Anticipated
Total Trials
(# Articles/ # Trials) Articles Deliverable Date
Pre-operative pressure flow
10/6/17
study 0 0
TOTAL 0 0
 Preoperative Testing
Key Question 2: What is the comparative efficacy and effectiveness of
pre-operative uroflowmetry in relation to surgical outcomes?
Topic Total Anticipated
Total Trials
(# Articles/ # Trials) Articles Deliverable Date
Pre-operative uroflowmetry
10/6/17
0 0
TOTAL 0 0
Preoperative Testing
1. Prior to surgical intervention for LUTS/BPH, clinicians
should consider assessment of prostate size and shape.
(Clinical Principle)

Options include:
TRUS or abdominal ultrasound
Cystoscopy
Previous performed cross sectional imaging (i.e. MRI/CT).
Preoperative Testing
1994
• Guidelines recommended against any imaging (upper,
lower, prostate) by cysto or U/S as part of any initial
evaluation

• Optional when planning invasive surgical

treatments

2004/2010
• Imaging remained a low priority optional test
• 2010 adopted the evaluation algorithm from the ICUD
 Preoperative Testing - What Changed?
• Differential treatment for LUTS/BPH became more sophisticated.
• AUA and International guidelines recommend AB/5ARI with
enlarged prostates (TPV >30-40g)
• Intra-vesical protrusion predicts poor outcomes from AS, many
medical Tx, and the presence of urodynamic obstruction.
• MIST (water thermotherapy/PUL) indicated for TPV: 30-80g
• Very large prostates should be treated with open, laparoscopic or
robotic enucleation.
 Preoperative Testing - REMEMBER
• DRE is unreliable in estimating prostate size
• PSA is only an indicator of prostate size provided no CaP or other intrinsic
differences.
• Reasonable and necessary to recommend prostate imaging prior to surgical
interventions.
• Prostate size may direct the clinician as to which intervention to consider
• Many have had such imaging (PSA rise and/or biopsy)
• Prostate growth rates are 1.6% per year
• Imaging w/in 12 mo of intervention utilized for size/shape assessment
• Should provide cross-sectional sagittal imaging of sufficient resolution to
calculate TPV and assess presence of an intravesical lobe.
• An assessment of TPV is a reasonable clinical principle.
Preoperative Testing
2. Prior to surgical intervention for LUTS/BPH, clinicians
should perform a post void residual (PVR).
(Clinical Principle)

• Evidence base is limited

• Multiple organizations/guidelines include PVR measurement for LUTS
evaluation
• Useful in determining a baseline ability of the bladder to empty
• Differentiate from significant obstruction that may not be amenable
to medical therapy
• Indicates detrusor dysfunction.
Preoperative Testing - REMEMBER
• There is no accepted definition of a “significant” PVR volume
• Trend is the best way to use this tool.
• A rising PVR can indicate medication failure and surgical
intervention or further workup is needed.
• To fully determine the etiology of an elevated PVR, formal
urodynamics testing with a PFS is needed.
• A clinically useful test that may drive management choices
• PVR is not a strong predictor of acute urinary retention
Preoperative Testing
3. Clinicians should consider Qmax prior to intervention
(Clinical Principle)

• Uroflowmetry is a low risk procedure that can be an important

adjunct
• Qmax <10 mL/s
Specificity of 70%, PPV of 70%, Sensitivity of 47% for BOO
• Threshold voided volume for adequate interpretation: 150 cc
• Useful in counseling patients regarding surgical outcomes
• Catheter-dependent retention who may have underactive
detrusor function, PFS is advised
Preoperative Testing
4. PFS should be considered prior to intervention when
diagnostic uncertainty exists.
(Expert Opinion)

• PFS: most complete means to determine the presence of BOO

• A large PVR may indicate poor detrusor contractility, but
correlation with obstruction is weak
• Most can likely be managed and treated surgically without PFS
• Certain circumstances dictate more complex evaluation.
Preoperative Testing - Certain circumstances?
• Overactive bladder symptoms and incontinence can be sequelae
of obstruction or secondary to non-obstructive etiologies
• Catheter-dependent urinary retention may mean compromised
detrusor function

• Surgery may not lead to meaningful improvement

• May risk unnecessary surgery
• Carry increased risk for incontinence and exacerbated LUTS.
Diagnostics
• Relevant medical history
• Previous surgical procedures
• General health for surgical or other Tx
• Sexual function history
• Medications
• Assessment of Symptoms and Bother
• Physical Examination and Digital Rectal Exam
• Urinalysis
• PSA
• Frequency Volume Charts*
 Guideline Statements
Evaluation and Preoperative Testing
1. Clinicians should take a medical history and utilize the AUA-Symptom Index (AUA-SI)
and urinalysis in the initial evaluation of patients presenting with bothersome LUTS
possibly attributed to BPH; select patients may also require post-void residual (PVR),
uroflowmetry, or pressure flow studies. (Clinical Principle)
2. Clinicians should consider assessment of prostate size and shape via abdominal or
transrectal ultrasound, or cystoscopy, or by preexisting cross-sectional imaging (i.e.
magnetic resonance imaging [MRI]/ computed tomography [CT]) prior to surgical
intervention for LUTS attributed to BPH. (Clinical Principle)
3. Clinicians should perform a PVR assessment prior to surgical intervention for LUTS
attributed to BPH. (Clinical Principle)
4. Clinicians should consider uroflowmetry prior to surgical intervention for LUTS
attributed to BPH. (Clinical Principle)
 Guideline Statements
Evaluation and Preoperative Testing
5. Clinicians should consider pressure flow studies prior to surgical intervention for
LUTS attributed to BPH when diagnostic uncertainty exists. (Expert Opinion)
Surgical Therapy
6. 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
attributed to BPH refractory to and/or unwilling to use other therapies. (Clinical
Principle)
7. Clinicians should not perform surgery solely for the presence of an asymptomatic
bladder diverticulum; however, evaluation for the presence of BOO should be
considered. (Clinical Principle)
 Guideline Statements
Transurethral Resection of the Prostate (TURP)
8. TURP should be offered as a treatment option for men with LUTS attributed to BPH.
(Moderate Recommendation; Evidence Level: Grade B)
9. Clinicians may use a monopolar or bipolar approach to TURP, depending on their
expertise with these techniques. (Expert Opinion)
Simple Prostatectomy
10. Clinicians should consider open, laparoscopic or robotic assisted prostatectomy,
depending on their expertise with these techniques, for patients with large prostates.
(Moderate Recommendation; Evidence Level: Grade C)
 Guideline Statements
Transurethral Incision of the Prostate (TUIP)
11. TUIP should be offered as an option for patients with prostates ≤30g for the surgical
treatment of LUTS attributed to BPH. (Moderate Recommendation; Evidence Level:
Grade B)
Transurethral Vaporization of the Prostate (TUVP)
12. Bipolar TUVP may be offered to patients for the treatment of LUTS attributed to BPH.
(Conditional Recommendation; Evidence Level: Grade B)
Photoselective Vaporization of the Prostate (PVP)
13. Clinicians should consider PVP as an option using 120W or 180W platforms for
patients for the treatment of LUTS attributed to BPH. (Moderate Recommendation;
Evidence Level: Grade B)
 Guideline Statements
Prostatic Urethral Lift (PUL)
14. Clinicians should consider PUL as an option for patients with LUTS attributed to BPH
provided prostate volume <80g and verified absence of an obstructive middle lobe;
however, patients should be informed that symptom reduction and flow rate
improvement is less significant compared to TURP. (Moderate Recommendation;
Evidence Level: Grade C)
15. PUL may be offered to eligible patients concerned with erectile and ejaculatory
function for the treatment of with LUTS attributed to BPH. (Conditional
Recommendation; Evidence Level: Grade C)
 Guideline Statements
Transurethral Microwave Therapy (TUMT)
16. TUMT may be offered to patients with LUTS attributed to BPH; however, patients
should be informed that surgical retreatment rates are higher compared to TURP.
(Conditional Recommendation; Evidence Level: Grade C)
Water Vapor Thermal Therapy
17. Water vapor thermal therapy may be offered to patients with LUTS attributed to BPH
provided prostate volume <80g; however, patients should be informed that evidence
of efficacy, including longer-term retreatment rates, remains limited. (Conditional
Recommendation; Evidence Level: Grade C)
18. Water vapor thermal therapy may be offered to eligible patients who desire
preservation of erectile and ejaculatory function. (Conditional Recommendation;
Evidence Level: Grade C)
 Guideline Statements
Transurethral Needle Ablation (TUNA)
19. TUNA is not recommended for the treatment of LUTS attributed to BPH. (Expert
Opinion)
Laser Enucleation
20. Clinicians should consider holmium laser enucleation of the prostate (HoLEP) or
thulium laser enucleation of the prostate (ThuLEP), depending on their expertise
with either technique, as prostate size-independent suitable options for the
treatment of LUTS attributed to BPH. (Moderate Recommendation; Evidence Level:
Grade B)
 Guideline Statements
Prostate Artery Embolization (PAE)
21. PAE is not recommended for the treatment of LUTS attributed to BPH outside the
context of a clinical trial. (Expert Opinion)
Medically Complicated Patients
22. HoLEP, PVP, and ThuLEP should be considered in patients who are at higher risk of
bleeding, such as those on anti-coagulation drugs. (Expert Opinion)
Evaluation and Preoperative Testing
 AUA-Symptom Index
1. Clinicians should take a medical history and utilize the AUA-
Symptom Index (AUA-SI) and urinalysis in the initial evaluation of
patients presenting with bothersome LUTS possibly attributed to
BPH; select patients may also require post-void residual (PVR),
uroflowmetry, or pressure flow studies. (Clinical Principle)
• AUA-SI is a validated self-administered questionnaire, can provide
information regarding the symptom burden
• Urinalysis can help to rule out other causes of LUTS
• Shared decision making approach should be used to guide the need for
further evaluation and possible treatment
 Prostate Imaging
2. Clinicians should consider assessment of prostate size and shape
via abdominal or transrectal ultrasound, or cystoscopy, or by
preexisting cross-sectional imaging (i.e. magnetic resonance
imaging [MRI]/ computed tomography [CT]) prior to surgical
intervention for LUTS attributed to BPH. (Clinical Principle)
• Prostate size and morphology is important in the decision making process
‒ eg, Intravesical lobe and ball-valving middle lobe predict poor outcomes
• DRE and PSA are rough indicators of prostate size
‒ Reasonable to recommend imaging
 Abdominal or transrectal ultrasonography or cystoscopy
 Cross-sectional imaging using CT or MRI
 PVR Assessment
3. Clinicians should perform a PVR assessment prior to surgical
intervention for LUTS attributed to BPH. (Clinical Principle)
• Multiple organizations include PVR measurement as part of the basic
evaluation of LUTS
• Rising PVR can indicate medication failure and need for surgical intervention
• PVR does not seem to be a strong predictor of acute urinary retention
‒ Clinically useful test that may drive management choices
 Uroflowmetry
4. Clinicians should consider uroflowmetry prior to surgical
intervention for LUTS attributed to BPH. (Clinical Principle)
• Generally accepted minimum threshold voided volume for adequate
interpretation is 150 cc
‒ Flow rate, shape of curve of voiding, duration
• Underactive detrusor function
‒ Bladder diverticulum
 Pressure Flow Studies
5. Clinicians should consider pressure flow studies prior to surgical
intervention for LUTS attributed to BPH when diagnostic
uncertainty exists. (Expert Opinion)
• Most complete means to determine the presence of bladder outlet
obstruction (BOO)
• Likelihood of obstruction is greatly increased in patients with a Qmax <10mL/s
• Large volume PVR weakly correlated with obstruction
• OAB symptoms and incontinence can be sequelae of obstruction or secondary
to non-obstructive etiologies
‒ Surgery in these individuals may not lead to meaningful improvement
Surgical Therapy
 Surgery
6. 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 attributed to BPH refractory to and/or unwilling to use
other therapies. (Clinical Principle)
• Rates of surgical interventions dropping
‒ Those patients receiving surgery are generally older and have more medical
comorbidities
‒ Surgery is mainstay in men with refractory urinary retention thought
secondary to BPH
 Bladder Diverticulum
7. Clinicians should not perform surgery solely for the presence of
an asymptomatic bladder diverticulum; however, evaluation for
the presence of BOO should be considered. (Clinical Principle)
• Indications for surgical intervention: recurrent UTI, recurrent bladder stones,
progressive bladder dysfunction, and renal insufficiency secondary to
progressive bladder dysfunction
• Prior to surgery for bladder diverticulum, clinicians should perform
assessment for BOO and treat as clinically indicated
 Transurethral Resection of the Prostate (TURP)
8. TURP should be offered as a treatment option for men with LUTS
attributed to BPH. (Moderate Recommendation; Evidence Level: Grade B)
• TURP is gold standard
• TURP helps to reduce urinary symptoms associated with BPH:
‒ Frequent/urgent need to urinate
‒ Difficulty initiating urination
‒ Prolonged urination
‒ Nocturia
‒ Non-continuous urination
‒ Feeling of incomplete bladder emptying
‒ UTIs
 Approach to TURP
9. Clinicians may use a monopolar or bipolar approach to TURP,
depending on their expertise with these techniques. (Expert
Opinion)
• No significant differences in efficacy or effectiveness between monopolar and
bipolar approaches
• Safety differences:
‒ Bipolar TURP reduces
 Incidence of TUR syndrome
 Catheterization time
 Length of stay
 Dilution hyponatremia
 Simple Prostatectomy
10. Clinicians should consider open, laparoscopic or robotic
assisted prostatectomy, depending on their expertise with these
techniques, for patients with large prostates. (Moderate
Recommendation; Evidence Level: Grade C)
• Complications increase with increasing resection time and increasing resected
tissue volume following monopolar TURP
‒ Bipolar TURP extends safe duration of TURP and use for larger glands
• Open simple prostatectomy (OSP) compared to TURP
‒ OSP: Greater maximum flow rate at 12 months
Lower reoperation
‒ No difference in blood transfusion needs
 Transurethral Incision of the Prostate (TUIP)
11. TUIP should be offered as an option for patients with prostates
≤30g for the surgical treatment of LUTS attributed to BPH.
(Moderate Recommendation; Evidence Level: Grade B)
• Used to treat small prostates (usually defined as ≤30g)
• TUIP has lower rate of retrograde ejaculation, need for blood transfusion,
compared to TURP
• ED in 8% with TUIP, 20% with TURP1

1. Abd-El Kader O, et al. Afr J Urol 2012; 18: 29.

 Transurethral Vaporization of the Prostate (TUVP)
12. Bipolar TUVP may be offered to patients for the treatment of LUTS
attributed to BPH. (Conditional Recommendation; Evidence Level: Grade
B)
• Multiple electrode types
• Metaanalysis outcomes were similar in both groups
‒ Long-term response to treatment based on varying definitions using the
International Prostate Symptom Score (IPSS)
‒ Mean change in IPSS through 7 years
‒ Need for reoperation
‒ Urinary incontinence
‒ However, need for blood transfusion was lower for TUVP compared with TURP
 Photoselective Vaporization of the Prostate (PVP)
13. Clinicians should consider PVP as an option using 120W or
180W platforms for patients for the treatment of LUTS attributed
to BPH. (Moderate Recommendation; Evidence Level: Grade B)
• Generally similar outcomes with regards to symptomatic, urinary
improvement in LUTS/BPH and complication rates between TURP and PVP
‒ Need continuous irrigation due to high temperatures that may develop
• PVP may be more efficacious for smaller volume prostates
‒ Increased probability of intraoperative conversion to TURP for prostate
volumes > 60 cc to 80 cc
• Other laser technologies are either investigational or had results that were
not considered sufficient or safe to recommend them for routine use
 Prostatic Urethral Lift (PUL)
14. Clinicians should consider PUL as an option for patients with
LUTS attributed to BPH provided prostate volume <80g and verified
absence of an obstructive middle lobe; however, patients should
be informed that symptom reduction and flow rate improvement is
less significant compared to TURP. (Moderate Recommendation;
Evidence Level: Grade C)
• Response and safety favors TURP vs PUL
‒ 91% reached I-PSS goal with TURP vs 73% with PUL
‒ Relative risk = 2.7, for serious and non-serious treatment-related harms
• Incontinence favors PUL vs TURP
‒ 1.7% vs 17.1%
 PUL Preservation of Sexual Function
15. PUL may be offered to eligible patients concerned with erectile
and ejaculatory function for the treatment of with LUTS attributed
to BPH. (Conditional Recommendation; Evidence Level: Grade C)
• Sexual function of men with normal or moderate ED at baseline was
unaffected, and those with severe ED reported modest improvement
 Transurethral Microwave Therapy (TUMT)
16. TUMT may be offered to patients with LUTS attributed to BPH;
however, patients should be informed that surgical retreatment
rates are higher compared to TURP. (Conditional Recommendation;
Evidence Level: Grade C)
 Water Vapor Thermal Therapy
17. Water vapor thermal therapy may be offered to patients with
LUTS attributed to BPH provided prostate volume <80g; however,
patients should be informed that evidence of efficacy, including
longer-term retreatment rates, remains limited. (Conditional
Recommendation; Evidence Level: Grade C)
• Improvement in I-PSS was 74% with water vapor thermal therapy vs 31% with
sham treatment
• Serious AEs were similar between therapy and sham groups
‒ Incidence of non-serious transient adverse eventswas significantly higher in
the water vapor thermal therapy group (dysuria, hematuria, frequency and
urgency, and UTI)
Water Vapor Theramal Therapy and Sexual Function
18. Water vapor thermal therapy may be offered to eligible
patients who desire preservation of erectile and ejaculatory
function. (Conditional Recommendation; Evidence Level: Grade C)
• Short teram: few harms occurred in the water vapor thermal therapy group
between months 3 and 12
‒ 2% experienced a decrease in ejaculatory volume
• Long-term:
‒ No de novo ED was reported
‒ No significant changes in IIEF-EF scores or ejaculatory functions
‒ Bother associated with ejaculation was assessed was significantly improved
at 12 and 24 months following treatment
 Transurethral Needle Ablation (TUNA)
19. TUNA is not recommended for the treatment of LUTS
attributed to BPH. (Expert Opinion)
• TUNA reduces prostatic volume less than initially anticipated
‒ BPH histologic architecture is likely replaced in part with scar
• Lack of peer-reviewed publications
‒ Decreasing clinical relevance
• Attempts to identify favorable candidates for TUNA have been unsuccessful
 Laser Enucleation
20. Clinicians should consider holmium laser enucleation of the
prostate (HoLEP) or thulium laser enucleation of the prostate
(ThuLEP), depending on their expertise with either technique, as
prostate size-independent suitable options for the treatment of
LUTS attributed to BPH. (Moderate Recommendation; Evidence
Level: Grade B)
• Superficial penetration, excellent coagulative properties
• Outcomes measures generally similar to TURP
‒ Qmax, reoperation, safety, post-surgical complications
‒ Less need for blood transfusion with HoLEP or ThuLEP
 Prostate Artery Embolization (PAE)
21. PAE is not recommended for the treatment of LUTS attributed
to BPH outside the context of a clinical trial. (Expert Opinion)
• Newer, largely untested MIST for BPH
• Available trial results present conflicting picture, relative to TURP
‒ Small trials
‒ No difference in outcomes, or TURP superiority.
Medically Complicated Patients
 Patients Receiving Anti-Coagulant Therapy
22. HoLEP, PVP, and ThuLEP should be considered in patients who
are at higher risk of bleeding, such as those on anti-coagulation
drugs. (Expert Opinion)
• Need for a blood transfusion (either peri- or post-operatively) was
significantly less likely with HoLEP and ThuLEP, as compared to TURP
• Superficial penetration, shallow coagulation zones
• PVP is safe and effective for patients who continue their
anticoagulant/antiplatelet therapy
Future Directions
 Future Directions
Disease Etiology
• No good animal models available
Management of Nocturia
• unique symptom complex requiring special concern and judicious evaluation
Urodynamic Evaluation and Imaging
New Therapeutic Options
• Many new, promising options
Treatment Failure
Treatment Comparative Efficacy