Sophisticated surgical management of distinctive patients with benign prostatic hyperplasia (BPH)

Herein we describe four clinical scenarios. For thestandard patient(prostate volume 30-80ml, life expectancy >10-years) transurethral resection of the prostate (TURP) remains the standard of care, while endoscopic enucleation is a valuable alternative.Patients with a relevant middle lobeprofit most from TURP, endourological enucleation procedures, or laser vaporization. In the case of the absence or a moderate-sized middle lobe and the absence of severe bladder outlet obstruction (BOO), minimally invasive procedures such as Rezum (R), UroLift (R) or prostate artery embolization (PAE) can be offered. Patients have to be informed that long-term data on this specific indication are lacking. Particularly younger men requiring BPH surgery are interested inpreserving ejaculatory function. In the presence of severe BOO, ejaculatory-protective TURP or endoscopic enucleation by preserving the pericollicular region or aquablation are the methods of choice providing an antegrade ejaculation in 60-90% of cases. Rezum (R), AquaBeam (R), and UroLift (R) enable preservation of ejaculation in almost 100%; data on PAE with this respect are more controversial.For patients with a small prostate and significant post void residual, a thorough preoperative work-up, including urodynamics and bladder/detrusor wall thickness measurement, is of great importance. Desobstructive surgery provides satisfactory short- and midterm outcome, yet the long-term outcome is disappointing and remains to be determined in greater detail. The broad spectrum of therapeutic options enables today an individualized minimally invasive or surgical management of BPH considering patient wishes, anatomical factors or urodynamic factors. The time of a "one therapy fits all" strategy is definitely history.