AUA updates guideline for surgical management of BPH-related lower urinary tract symptoms

Urology Times JournalVol 48 No 8
Volume 48
Issue 08

The guidelines are an evidence-based clinical reference for the treatment of patients with lower urinary tract symptoms secondary to BPH.

The American Urological Association (AUA) has updated its clinical guideline for the surgical management of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH).1,2

LUTS comprises a group of urinary symptoms resulting from prostate, bladder, bladder neck, urethra, and/or urinary sphincter complications. BPH frequently leads to LUTS, which include having to frequently urinate, weak urine stream, sudden urges to urinate, nocturia, and the inability to feel empty after urination.

"BPH is extremely common. It affects about half of all men between ages 51 and 60 years, and up to 90% of men over age 80 years," J. Kellogg Parsons, MD, MHS, chair of the BPH Guideline Panel, stated in a press release. "We believe this revised guideline will provide a useful, evidence-based clinical reference for the surgical management of male LUTS secondary to BPH."

The guidelines were initially published in 2018. The following are the core components of the updates:

  • A physical examination, along with a medical history should be conducted as part of the initial assessment of patients with “bothersome” LUTS potentially caused by BPH. The AUA Symptom Index should be used. The physician should perform a urinalysis.

  • The decision-making process on surgical and minimally-invasive treatments for BPH-related LUTS should include a physician-patient dialogue on the potential that the procedure could fail, requiring additional treatments.

  • Eligible patients who prioritize the preservation of ejaculatory and erectile function maybe offered prostate urethral lift (PUL) as a treatment option.

  • Water vapor thermal therapy is indicated for eligible individuals seeking to maintain ejaculatory and erectile function.

  • Prostate size–independent options considered for the treatment of patients with BPH-associated LUTS should include thulium laser enucleation of the prostate (ThuLEP) or thulium laser enucleation of the prostate (HoLEP). (Limited to clinicians with familiarity with either technique.)

  • The use of prostate artery embolization (PAE) to treat patients with BPH-related LUTS is not recommended outside of clinical trials. The benefit-risk profile is unclear based on the available clinical evidence.

The complete guidelines are accessible on the AUA’s website. Overall, the guidelines comprise 24 statements divided into 15 categories. The categories include Evaluation and Preoperative Testing; Surgical Therapy; Transurethral Resection of the Prostate (TURP); Simple Prostatectomy; Transurethral Incision of the Prostate (TUIP); Transurethral Vaporization of the Prostate (TUVP); Photoselective Vaporization of the Prostate (PVP); (PUL); Transurethral Microwave Therapy (TUMT); Water Vapor Thermal Therapy; Transurethral Needle Ablation (TUNA); Laser enucleation; Aquablation; PAE; and Medically Complicated Patients.

The statement on medically complicated patients stipulates that “HoLEP, PVP, and ThuLEP should be considered in patients who are at higher risk of bleeding, such as those on anti-coagulation drugs.”


1. AUA Announces Updates to Clinical Guidance for Surgical Management of LUTS Attributed to BPH. Posted June 25, 2020. Accessed June 25, 2020.

2. Parsons JK, Barry MJ, Gandhi MC, et al. Benign Prostatic Hyperplasia: Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms (2018, amended 2019, 2020). American Urological Association. Updated June 25, 2020. Accessed June 25, 2020.

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