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Benign prostatic enlargement with persistent severe voiding LUTS after combination medical therapy — MSRA MCQ

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HardBPHBenign prostatic enlargement with persistent severe voiding LUTS after combination medical therapyMSRA

A 61-year-old man is reviewed in urology for persistent voiding LUTS attributed to benign prostatic enlargement. He has severe hesitancy, weak stream, intermittency and incomplete emptying despite 9 months of tamsulosin MR 400 micrograms once daily and finasteride 5 mg once daily. His IPSS is 23. Urine culture is negative. He has no visible haematuria, recurrent UTI, urinary retention, renal impairment, neurological disease or suspicion of prostate cancer. DRE is benign. Specialist assessment shows a maximum flow rate of 8 mL/second, post-void residual volume of 90 mL, and prostate volume of 58 mL. He is fit for an intervention but strongly wishes to minimise risk to sexual function and prefers a day-case procedure if clinically appropriate. Which is the most appropriate procedure to consider?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Consider UroLift

Explanation lettering: D = shown as A · A = shown as B · E = shown as C · B = shown as D · C = shown as E

D is correct. He has severe, persistent voiding LUTS despite appropriately prolonged combination drug treatment, so an intervention is reasonable. His objectively measured prostate volume is 58 mL, which falls within NICE’s recommended 30–80 mL range for UroLift. UroLift should be considered as an alternative to TURP or HoLEP because it can be performed as a day-case or outpatient procedure and NICE identifies avoidance of risk to sexual function as a key benefit. These features directly match his priorities. A is inappropriate because transurethral incision of the prostate is the surgical alternative recommended for prostates smaller than 30 g. B and C are established effective operations for severe voiding LUTS after failed medical treatment, but neither best addresses his stated preference to minimise sexual adverse effects when an eligible minimally invasive alternative is available. They would be reasonable if UroLift were anatomically unsuitable, locally unavailable, or if he prioritised maximal conventional debulking over sexual-function preservation. E is inappropriate because open prostatectomy is reserved for prostates larger than 80 g.

Reference: UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia: Recommendations (2021) — https://www.nice.org.uk/guidance/htg578/chapter/1-Recommendations Lower urinary tract symptoms in men: management: Surgery for voiding symptoms (2010, current NICE guidance page checked 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations