Editing CUA: Male LUTS & BPH (2018) (section)

===== '''UrologySchool.com summary of size considerations:''' =====

* '''TURP: 30-80g'''
* '''Plasma button: <60g'''
* '''Open simple: >80g'''
* '''TUIP: <30g'''
* '''Urolift, aquablation: <80g'''
** Urolift cannot be done with median lobe, aquablation can
* '''HOLEP/PVP: not explicitly stated'''
* Ejaculatory preserving: TUIP, urolift, aquablation

** '''TURP'''
*** '''Monopolar TURP (M-TURP)'''
**** '''Standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with prostate volume of 30–80 cc'''
**** '''Potential complications:''' bleeding (2–9%), capsule perforation with significant extravasation (2%), TUR syndrome (0.8%), urinary retention (4.5–13%), infection (3–4%; sepsis 1.5%), incontinence (<1%), bladder neck contracture (3–5%), retrograde ejaculation (65%), erectile dysfunction (6.5%), and surgical retreatment (2%/year).
*** '''Bipolar TURP (B-TURP)'''
**** '''Standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with prostate volume of 30–80 cc;''' has evolved as an equivalent alternative to the monopolar technique
**** '''Advantages (3):'''
****# '''Reduction in the risk of dilutional hyponatremia (TUR syndrome)'''
****# '''Improvements in intraoperative visibility'''
****# '''May result in shorter catheterization times'''
*** '''Bipolar plasma kinetic vaporization/plasma button TURP'''
**** '''An alternative first-line surgical therapy for men with moderate to severe MLUTS/BPH and prostate volume <60 cc'''

** '''Open simple prostatectomy'''
*** '''First-line surgical therapy for men with moderate to severe MLUTS/BPH and prostate volume >80 cc'''
*** '''Other indications for OSP include (2):'''
***# '''Plans for concurrent bladder procedure, such as diverticulectomy or cystolithotomy'''
***# '''Men who are unable to be placed in dorsal lithotomy position due to severe hip disease'''
** '''Laser prostatectomy'''
*** '''Can be used to treat men on anti-coagulation and those with bleeding dyscrasia'''
*** '''Holmium laser enucleation of the prostate (HoLEP)'''
**** The procedure requires a steep learning curve (estimated >20–50 cases) often requiring fellowship training.
**** '''We recommend HoLEP as an alternative to TURP or OSP in men with moderate to severe LUTS if performed by a HoLEP-trained surgeon [no size cut-off]'''
*** '''Photoselective vaporization of the prostate (PVP)'''
**** '''We recommend PVP as an alternative to TURP in men with moderate to severe LUTS [no size cut-off]'''
**** '''We suggest Greenlight PVP therapy as an alternate surgical approach in men on anti-coagulation''' or with a high cardiovascular risk
*** '''Diode laser vaporization of the prostate'''
**** '''We suggest diode laser vaporization of the prostate as an alternative to TURP in men with moderate to severe LUTS'''
**** We suggest diode laser vaporization of the prostate as an alternate surgical approach in men on antic-oagulation
*** '''Thulium laser'''
**** '''We suggest Tm:YAG vaporization of the prostate as an alternative to TURP in men with moderate to severe LUTS with prostate volume <60 cc.'''
**** '''Thulium enucleation may be an alternative to OSP and HoLEP in men with moderate to severe LUTS with prostate volume >80 cc'''
** '''Transurethral incision of the prostate (TUIP)'''
*** '''We recommend TUIP to treat moderate to severe LUTS in men with prostate volume <30 cc without a middle lobe.''' '''These patients should experience symptom improvements similar to TURP with a lower incidence of retrograde ejaculation.'''
** '''Minimally invasive surgical therapies'''
*** '''Transurethral microwave therapy (TUMT): an option for elderly patients with significant comorbidities or greater anaesthesia risks as long-term durability is limited'''
*** '''Transurethral needle ablation (TUNA): should not be offered as a consideration for treatment of BPH/LUTS'''
*** '''Prostatic stents should only be used as an alternative to catheterization in men unfit for surgery with a functional detrusor for those medically unfit for surgery'''
** '''New and emerging therapies'''
*** '''Prostatic urethral lift (Urolift):'''
**** '''Provides less effective, but adequate and durable improvements in IPSS and Qmax compared to TURP'''
**** '''Preserves sexual function, no reported case of retrograde ejaculation'''.
**** '''May be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function, with prostates <80 cc and no middle lobe'''
*** '''Rezum system of convective water vapour energy ablation:'''
**** '''May be considered an alternative treatment for men with LUTS interested in preserving ejaculatory function, with prostates <80 cc, with or without middle lobe'''
*** '''Image-guided robotic waterjet ablation:'''
**** '''Offered to men with LUTS interested in preserving ejaculatory function, with prostates <80 cc, with or without middle lobe'''
*** '''Temporary implantable nitinol device (iTIND):''' We recommend that iTIND (a mechanical, stent-like device designed to remodel the bladder neck and the prostatic urethra through pressure necrosis) '''should not be offered at this time for the treatment of LUTS due to BPH'''
*** '''Prostatic artery embolization (PAE): should not be offered at this time for the treatment of LUTS due to BPH'''