Surgery should be recommended for patients who continue to be bothered by their symptoms or who experience urinary retention despite medical therapy. Surgery should also be recommended for patients with upper tract dilation, renal insufficiency secondary to BPH, or bladder stones."- Schwaz 8/e p1530 About other options: Prostate Size: Treatment of BPH is primarily dictated by patient's symptoms and not by the prostate size. However the size of prostate can decide whether to go for endoscopic method of treatment or open surgical procedure. Open surgery is more effective than endoscopic methods for prostates weighing >100gm UTI: Recurrent episodes of UTI (and not a single episode) are an absolute indication for surgery of prostate. Hypeension: Alpha blockers which are first line medical therapy for BPH lower the blood pressure and thus are helpful in hypeensive persons. Management of BPH Management is primarily directed by symptoms. Mild symptoms can be managed with watchful waiting. More severe symptomatic patients are treated with medicines (alpha blockers, 5-alpha reductase inhibitors or combination of both). Surgery is recommended if the patient is having problems despite medical therapy. Absolute indications for surgery as listed in Smith's Urology is given below. Absolute indications for surgical treatment of BPH Refractory urine retention (failing at least one attempt at catheter removal) Recurrent UTI from BPH Bladder stones d/t BPH Renal insufficiency d/t BPH Large bladder diveicula secondary to BPH Recurrent gross hematuria from BPH Upper tract dilatation is an indication for surgery according to Schwaz. Medical therapy Alpha-blockers (terazosin, doxazosin, and tamsulosin) Alpha-blockers help is reducing the symptoms of BPH by blocking the alpha 1 adrenoreceptors present in human prostate and bladder base. 5-Alpha-reductase inhibitors (Finasteride, Dutasteride) - 5-alpha-reductase inhibitors block the conversion of testosterone to dihydrotestosterone. This thus results in reduction in the size of the gland and improvement in symptoms (after several months of use). Surgery Surgery for BPH is most commonly performed endoscopically; however, if the prostate gland is quite large (approx >100 g), an open prostatectomy should be performed. The standard endoscopic procedure for BPH is a transurethral resection (TUR) of the prostate. Conventional surgical methods: Transurethral resection of the prostate (most commonly used method) Transurethral incision of the prostate (TUIP) Open simple prostatectomy (simple suprapubic prostatectomy, simple retropubic prostatectomy) - When the prostate is too large to be removed endoscopically, an open enucleation is necessary. What constitutes "too large" is subjective and varies depending upon the surgeon's experience with TURP. Glands >100 g are usually considered for open enucleation. Open prostatectomy may also be initiated when concomitant bladder diveiculum or a bladder stone is present or if dorsal lithotomy positioning is not possible. Open prostatectomies can be done with either a suprapubic or retropubic approach. A simple suprapubic prostatectomy is performed transvesically and is the operation of choice in dealing with concomitant bladder pathology. Minimally invasive methods: Laser therapy (Nd:YAG and holmium:YAG ) Transurethral electro vaporization of the prostate Microwave Hypehermia Transurethral needle ablation of the prostate- High-intensity focused ultrasound for thermal tissue ablation Intraurethral stents--stents are endoscopically placed in the prostatic fossa and are designed to keep the prostatic urethra patent. They are usually covered by urothelium within 4-6 months after inseion. These devices are typically used for patients with limited life expectancy who are not deemed to be appropriate candidates for surgery or anesthesia. Ref : Schwaz 8/e p1528-31