A 55-year-old man with symptomatic BPH (IPSS 22, Qmax 8 mL/s, prostate volume 75 mL) fails medical therapy with an alpha-1 blocker and 5-alpha reductase inhibitor combination after 12 months. He has no urinary retention history and PSA is 2.4 ng/mL (biopsy negative). The most appropriate surgical intervention given the prostate size and desire for minimal sexual side effects is:

• A Monopolar transurethral resection of the prostate (M-TURP)
• B Transurethral needle ablation (TUNA)
• C Open simple prostatectomy (Millin's retropubic prostatectomy)
• D Holmium laser enucleation of the prostate (HoLEP) ✓

Explanation

For prostate volumes >80 mL (some guidelines >60 mL), HoLEP is the preferred surgical option as it is size-independent, offers equivalent or superior outcomes to open prostatectomy with significantly lower morbidity (less bleeding, shorter catheterization and hospital stay). For volumes >80 mL, traditional TURP is technically challenging with higher risk of dilutional hyponatremia (TUR syndrome) from monopolar TURP. Open prostatectomy (Millin) is effective but more invasive. HoLEP preserves antegrade ejaculation in ~80% of cases. TUNA is a minimally invasive option but less durable. The EAU 2024 guidelines recommend HoLEP or bipolar TURP as the gold standard for large glands.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.