Factors Guiding Decision-Making for BPH

BPH Decision-Making Factors Summary

Decision-making for minimally invasive BPH therapies has evolved significantly over the past decade, with these treatments now positioned earlier in the treatment algorithm. They are increasingly considered before or instead of long-term medication, particularly in younger men seeking to preserve sexual function, patients with poor medication adherence or intolerance, and those desiring outpatient solutions with quick recovery. The approach has shifted from rigid treatment sequences to shared decision-making that emphasizes symptom relief, favorable adverse effect profiles, retreatment risk, and lifestyle impact.

The selection of specific minimally invasive therapies depends primarily on prostate size and morphology. For prostatic urethral lift, ideal candidates have prostates between 30 and 80 g with lateral lobe obstruction and collapsible tissue, though some median lobes can be treated if there is a deep sulcus. Water vapor therapy works well for similar-sized prostates and is particularly effective for broad obstructing middle lobes but cannot be performed in patients with inflatable penile implants. The temporary nitinol stent is best suited for smaller to medium prostates without obstructing middle lobes and is especially effective for anterior obstruction or high, tight bladder necks. Larger procedures such as TURP, HoLEP, or robotic waterjet therapy are reserved for larger glands with severe obstruction.

Managing complicating factors requires individualized assessment and nuanced decision-making. For median lobe enlargement, treatment feasibility depends on the specific morphology, size, and presence of lateral sulci, with real-time cystoscopic evaluation guiding treatment planning. High postvoid residuals require urodynamic evaluation to differentiate between obstruction-related and detrusor dysfunction causes, as patients may have combined problems requiring discussion of realistic outcomes. For patients with significant comorbidities, particularly bleeding risks from conditions such as hepatic dysfunction or anticoagulation therapy, physical deformation procedures are preferred over thermal or electrocautery modalities to minimize bleeding complications.