This protocol addresses the management of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in patients whose initial medical therapy has not produced adequate symptom relief — and who require a structured next step.
The prior treatment line — an alpha blocker (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin), or tadalafil, or tadalafil combined with an alpha blocker — did not achieve a decrease of more than 3 points in the International Prostate Symptom Score (IPSS) from baseline within 4–12 weeks. Failure to reach this symptom-relief threshold is the indication for escalation to this protocol.
The next step involves surgical intervention. Multiple evidence-based procedural options are available, and the selection depends on factors such as prostate volume and individual clinical context. The complete procedural algorithm and full criteria for each option are in the protocol below.
DOI: 10.1097/JU.0000000000003698
TURP should be offered as a treatment option for patients with LUTS/BPH.
Clinicians may use a monopolar or bipolar approach to TURP as a treatment option, depending on their expertise with these techniques.
TUIP should be offered as an option for patients with prostates ≤30g for the surgical treatment of LUTS/BPH.
PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH.
Holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP) should be considered as an option, depending on the clinician's expertise with these techniques, as prostate size-independent options for the treatment of LUTS/BPH.
Bipolar TUVP may be offered as an option to patients for the treatment of LUTS/BPH.
PUL should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80g and verified absence of an obstructive middle lobe.
WVTT should be considered as a treatment option for patients with LUTS/BPH provided prostate volume 30-80g.
Robotic waterjet treatment (RWT) may be offered as a treatment option to patients with LUTS/BPH provided prostate volume 30-80g.
Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options by clinicians, depending on their expertise with these techniques, only in patients with large to very large prostates.
PAE may be offered for the treatment of LUTS/BPH.
TIPD may be offered as a treatment option for patients with LUTS/BPH provided prostate volume is between 25 and 75g and lack of obstructive median lobe.
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