Nicole L. Miller, MD, FACS, on assessing patients after BPH treatment failure

In the following video, recorded at the 2026 American Urological Association Annual Meeting, Nicole L. Miller, MD, FACS, discusses her approach to evaluating and managing patients who experience persistent or recurrent lower urinary tract symptoms after treatment for benign prostatic hyperplasia (BPH). She particularly emphasizes the importance of identifying the underlying reason for treatment failure before pursuing additional intervention.

Miller is a professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

When assessing a patient after a failed BPH treatment, Miller stressed that a thorough medical history is the most critical first step. Clinicians must understand which treatment was performed, whether any postoperative complications occurred, and, most importantly, why the patient considers the treatment unsuccessful. Determining the symptoms that are most bothersome to the patient, while also accounting for coexisting medical conditions that may contribute to lower urinary tract symptoms, helps guide subsequent evaluation. She noted that obtaining a validated symptom assessment, such as the International Prostate Symptom Score (IPSS), is essential for distinguishing whether symptoms are primarily related to bladder dysfunction or persistent outlet obstruction.

Miller also highlighted the value of basic office-based testing in the initial workup. Urinalysis can help rule out infection as a contributor to symptoms, while uroflowmetry and bladder scanning provide insight into urinary flow patterns and bladder emptying. These assessments can identify patients with significant urinary retention or other concerning findings that may influence retreatment decisions. According to Miller, 2 of the most common reasons BPH therapies fail are inappropriate patient selection and technical issues related to the procedure itself.

Beyond these preliminary evaluations, Miller emphasized that retreatment requires a detailed understanding of both prostate anatomy and bladder function. Prostate size remains a key factor in selecting subsequent therapies, while anatomical features such as a median lobe may explain why an earlier intervention was unsuccessful. She noted that prior treatments can also alter prostate anatomy, making additional diagnostic testing particularly important. In her practice, cross-sectional imaging combined with cystoscopy often provides valuable information to help determine the most appropriate next step for management.