AUA BPH guideline amendment explained
Many of the guideline changes focus on newer techniques and technologies that were unavailable or had little evidence in prior years.
The management of benign prostatic hyperplasia (BPH) is evolving. Legacy technologies are out. Newer, less invasive approaches that are potentially more sparing of ejaculation are in.
Jaspreet S. Sandhu, MD, urological surgeon at Memorial Sloan Kettering Cancer Center in New York, discussed key changes made to the 2021 AUA guideline on the management of lower urinary tract symptoms attributed to BPH that were released in 2023. He also focused on what has not changed.
“The initial evaluation and approach remain the same,” Dr. Sandhu said in his presentation on the current BPH guideline amendment during the Saturday morning Plenary. “That every patient should be counseled as an individual is extremely important. Patients should be counseled on options for intervention, including behavioral and lifestyle modifications.”
Many of the changes focus on newer techniques and technologies that were unavailable or had little evidence in prior years, but pharmacotherapy remains an early option.
Alpha blockers and alpha reductase inhibitors remain mainstay medications. New evidence supports the combination of daily low-dose tadalafil with alpha blockers. The 2021 guideline had advised against the combination for lack of clinical benefit.
Low-dose daily tadalafil plus finasteride is a second new combination therapy.
Transurethral resection of the prostate (TURP) remains the leading surgical intervention. Either the familiar monopolar procedure or the newer bipolar approach is appropriate, depending on the surgeon’s experience. Transurethral incision of the prostate and transurethral vaporization of the prostate are also acceptable.
Transurethral microwave therapy and transurethral needle ablation are now considered legacy technologies and are no longer recommended.
Laser procedures are recommended; both holmium laser enucleation of the prostate or thulium laser enucleation of the prostate should both be considered. Functional results are as good as or better than simple TURP or simple prostatectomy.
Prostate urethral lift, permanent implants placed every centimeter along each lobe to retract tissue and open the urethra, can also be considered in appropriate patients.
Two water-based techniques, water vapor thermal therapy and robotic waterjet, may also be offered to patients.
Prostate artery embolism (PAE), a technique based on interventional radiology, is now an allowable alternative surgical approach, but is not recommended. The prior 2021 guideline recommended against PAE due to lack of evidence.
Dr. Sandhu said the panel was unable to find substantial evidence to recommend PAE over minimally invasive surgical techniques, but there is evidence of at least a short-term benefit compared to observation in select patient populations.
“We have seen that multiple techniques are now available, some of which are less invasive and have variable preservation of ejaculation,” Dr. Sandhu said. “All of the guideline recommendations are available at auanet.org.”
