Gerard Pregenzer, MD

An expert discusses how he has integrated minimally invasive therapies into his practice workflow through a mutual evolution with his patients, noting that as these procedures became more amenable to office-based treatment, they lowered the bar for patient acceptance and allowed many who would have stayed on medications too long to undergo procedural intervention much earlier. The vast majority of his benign prostatic hyperplasia (BPH) work is now done in-office rather than in hospitals through advanced patient comfort techniques, including specialized lidocaine applications, bladder alkalinization with sodium bicarbonate, prostate nerve blocks, and nitrous oxide that allow about one-third of patients to fall asleep during procedures.

An expert discusses how comparing the durability and treatment effects of newer minimally invasive therapies to gold standard transurethral resection of the prostate (TURP) or holmium laser enucleation depends heavily on surgeon skill. He notes that while an excellent TURP taken to the capsule or excellent holmium laser enucleation would generally be more durable and potentially lifelong, the reality is that surgical quality varies significantly between practices, making direct comparisons difficult as outcomes are largely surgeon dependent.

An expert discusses how the most common complications with minimally invasive benign prostatic hyperplasia (BPH) therapies are extremely mild (typically irritative voiding symptoms for a few days and some blood in urine) and how he counsels patients about trade-offs by explaining that every procedure has re-treatment and complication rates. He asks patients which “flavor of risk” they prefer while emphasizing that minimally invasive procedures “burn no bridges” and allow stepwise treatment progression because you can try something less invasive first and escalate later if needed.

An expert discusses how the proposed Centers for Medicare & Medicaid Services (CMS) rule represents an unusual circumstance that benefits smaller private practices by reducing work relative value units (RVUs) while increasing practice expense and malpractice RVUs. This could potentially result in substantial reimbursement increases for prostatic urethral lift and water vapor therapy, which may enable earlier intervention in younger men who want to avoid more invasive surgeries and preserve bladder function long-term rather than relying on α-blockers that don’t prevent disease progression.

An expert discusses how the greatest unmet need in minimally invasive benign prostatic hyperplasia (BPH) treatments is achieving durability and retreatment rates that match those of surgical options such as transurethral resection of the prostate (TURP) while maintaining sexual function preservation. He also discusses how barriers to broader adoption include inadequate technical training in office-based procedures, ongoing reimbursement challenges, and poor patient awareness because many patients and even well-meaning primary care physicians are unaware of options beyond medications or TURP.

An expert discusses how the prostatic urethral lift procedural kit has transformed his practice economics from nearly having to stop offering the procedure due to low margins and Centers for Medicare & Medicaid Services (CMS) cuts to achieving the best margins seen in years. This has created what he calls a “rare triple win” that benefits urologists by maintaining procedure viability, patients by ensuring continued access to minimally invasive therapy with potentially more implants, and hospital systems through fewer re-treatments.

An expert discusses how his diagnostic treatment workflow for a new patient with benign prostatic hyperplasia (BPH) progresses from initial α-blocker therapy through noninvasive systematic testing with nurse practitioner review, followed by multichannel urodynamics, transrectal ultrasound, and cystoscopy if improvement is insufficient. He emphasizes that he pushes for a thorough evaluation even when symptoms seem mild because “the bladder is a notoriously unreliable witness,” and he wants to prevent emergency urinary retention by identifying underlying obstruction early.

An expert discusses how decision-making for minimally invasive benign prostatic hyperplasia (BPH) therapies has evolved over the past decade to position these treatments earlier in the algorithm (sometimes before long-term medication), emphasizing shared decision-making that considers patient factors such as age, desire to preserve sexual function, medication adherence, and lifestyle preferences rather than following a rigid treatment sequence.

An expert discusses how the current benign prostatic hyperplasia (BPH) treatment landscape is dominated by traditional approaches such as watchful waiting and medical therapy (particularly α-blockers as first-line treatment). However, minimally invasive therapies such as prostatic urethral lift, water vapor therapy, and temporary stents have emerged over the past decade as office-based options that bridge the gap between lifelong medications and more invasive surgeries while preserving sexual function.