**Question:** 60 yrs old male with poor stream of urine, post void residual urine is 400ml, b/1 hydronephrosis and prostate weighing 70g. His urea is 120 and creatinine 3.5. Ideal "next immediate" step:

A. Urethral dilatation
B. Ureteric stenting
C. Antispasmodic medication
D. Transurethral resection of prostate (TURP)

**Core Concept:** In patients with obstructive uropathy due to large prostate gland causing hydronephrosis, an immediate management step aims to relieve urinary obstruction and prevent further kidney damage.

**Why the Correct Answer is Right:**

D. Transurethral resection of prostate (TURP) is the correct answer as it directly addresses the underlying cause of the patient's symptoms - an enlarged prostate (prostate gland). By removing part of the prostate, TURP relieves the obstruction and improves urine flow, preventing further kidney damage.

**Why Each Wrong Option is Incorrect:**

A. Urethral dilatation is a temporary measure to relieve obstruction, but does not address the underlying cause of the patient's symptoms, which is an enlarged prostate. It might provide some symptomatic relief but does not resolve the issue.

B. Ureteric stenting is a temporary measure to prevent kidney damage but does not directly address the cause of the patient's symptoms. While stenting relieves the obstruction, it doesn't improve the patient's urinary flow or resolve the enlarged prostate.

C. Antispasmodic medication (e.g., alpha-blockers) is a symptomatic treatment to relax the smooth muscle around the prostate and improve urine flow, but it does not directly address the underlying cause of the patient's symptoms - an enlarged prostate. Antispasmodic medication is helpful but not sufficient in this scenario.

**Clinical Pearl:** In cases of obstructive uropathy due to large prostate (benign prostatic hyperplasia), the immediate management should aim to relieve the obstruction and prevent kidney damage. TURP (transurethral resection of prostate) is the most appropriate management option as it directly addresses the cause of the symptoms (enlarged prostate) and improves urinary flow. Temporary management options like ureteric stenting or alpha-blockers can provide symptomatic relief but do not resolve the enlarged prostate. Urethral dilatation may provide relief but does not address the root cause.