Modern approaches to BPH management: expert insights and the latest evidence from the 2024 International Functional and Reconstructive Urology Update

Introduction

Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary tract symptoms (LUTS) and represents a growing burden on healthcare systems. ¹ While historically viewed as a prostate-centered disease, LUTS may also be caused by other urologic, neurologic, or systemic conditions. Current approaches to BPH/LUTS tailor care based on symptoms, anatomy, and patient preferences.

The International Functional and Reconstructive Urology Update (IFRUU) 2024 BPH session reviewed advances in diagnostics and therapeutic interventions. By highlighting key insights in assessments and management of BPH/LUTS, this proceedings article supports a personalized, evidence-based approach to BPH.

Methods

These proceedings summarize expert-led presentations:

1. Dr. David A. Hadley—BPH Office Evaluation and Non-Operative Management

2. Dr. Kevin C. Zorn—Minimally Invasive Surgical Therapies (MIST) for BPH: Rezu-m and Prostatic Stents

3. Dr. Matthew C. Ercolani—The Prostatic Urethral Lift (UroLift): Back to Basics

4. Dr. Garrett D. Pohlman—Drug-Coated Balloon Catheter System for BPH Management (Optilume^® BPH Catheter System)

5. Dr. Gregg R. Eure—GreenLight Photoselective Vaporization of the Prostate (PVP)

6. Dr. Granville L. Lloyd—Transurethral Resection of the Prostate (TURP) in 2024

7. Dr. Kevin C. Zorn—Robotic Ultrasound-Guided Aquablation of the Prostate: BPH and Beyond

8. Dr. Lori B. Lerner—HoLEP: Nuanced and Informed Enucleation Techniques

9. Dr. Amy E. Krambeck—Morcellation and Complications Following HoLEP

10. Dr. Pierluigi Bove—Laser Selection Strategies for HoLEP Procedures

Results

Nonoperative management

Dr. Hadley presented nonoperative approaches to LUTS, which can stem from BPH, pelvic pain syndrome, neurogenic bladder, or nocturnal polyuria. The LURN SI-10 and ICIQ bladder diary capture urgency, incontinence, and polyuria, offering broader insight than the American Urologic Association Symptom Score alone. ² Daily Tadalafil has similar efficacy to tamsulosin while treating comorbid erectile dysfunction, which affects up to 70% of BPH patients. ³ Prostates >30 g or Prostate Specific Antigen (PSA) ⩾ 1.5 are associated with worse outcomes, reinforcing the need for comprehensive, symptom-driven approaches. ⁴

Minimally invasive surgical therapies

Temporary implantable nitinol devices

Dr. Zorn discussed Temporary Implantable Nitinol Devices (iTind^®, Olympus Corporation, Tokyo, Japan), which are placed and removed cystoscopically. This causes pressure necrosis at the prostatic urethra with reduced International Prostate Symptom (IPSS) scores, increased urine flow rate, and a 9% 3-year reintervention rate. Notably, these devices preserve erectile and ejaculatory function and have a low adverse event rate (Figure 1). ⁵

Figure 1.

Rates of postoperative ejaculatory dysfunction among patients undergoing MIST or surgical resection for BPH.

Water vapor thermal therapy

Dr. Zorn also highlighted water vapor thermal therapy (Rezum^®, Boston Scientific Corporation, Marlborough, MA, USA), which shrinks prostate tissue by delivering water vapor into the prostatic transition zone. This treatment recently received approval for >80 g prostates (previously approved only for 30–80 g prostates) and results in increased urine flow rate and durable reductions in postvoid residual (PVR), prostate volume, and IPSS scores.^6,7

Prostatic urethral lifts

Dr. Ercoloni discussed Prostatic Urethral Lifts (Urolift^®, Teleflex Incorporated, Wayne, PA, USA), which are the only MISTs approved for prostates <30 g and are indicated for prostates 0–100 g. Clinical trials showed few adverse events and a 14% 5-year reintervention rate. ⁸ Avoiding clip placement at the bladder neck prevents migration and stone formation. Relative to medical therapies, these devices are the only procedural intervention for BPH delivering greater symptomatic benefit with fewer sexual side effects in randomized trials (Figure 1).

Drug-coated balloon catheter

Dr. Pohlman introduced drug-coated balloon catheter devices (Optilume^®, Laborie Medical Technologies, Portsmouth, NH, USA), which combine mechanical dilation with localized delivery of paclitaxel. These devices employ a double-lobe balloon to achieve an anterior commissurotomy (split) that releases constricting lateral prostatic lobes, while paclitaxel prevents re-fusion of the lateral lobes and maintains an open channel. The EVEREST and PINNACLE trials, which included men ⩾50 years old with 20–80 prostates and without intravesical protrusion >1 cm, demonstrated durable improvements in IPSS, urine flow rates with Qmax improvements of 113% at 2 years (PINNACLE study), and PVR.^9,10

Surgical interventions

Photoselective vaporization of the prostate

Photoselective vaporization of the prostate (Greenlight PVP) utilizes a laser that is optimally absorbed by hemoglobin present in living tissue, resulting in vaporization and coagulation. Patients who underwent PVP reported a median 14.4-point reduction in IPSS scores. A 2024 meta-analysis of 13 also demonstrated that, relative to TURP, patients undergoing PVP experienced shorter hospital stays, fewer bleeding-related complications, and shorter periods of postoperative catheterization. ¹¹

Transurethral resection of the prostate

Dr. Lloyd highlighted the continued utility of TURP, even with the proliferation of MISTs. TURP utilizes ubiquitous equipment and familiar techniques and, relative to medical management, demonstrates a median 14-point reduction in IPSS scores. Preserving tissue proximal to the verumontanum preserves ejaculatory function and bipolar resectoscopes reduce bleeding and adverse events (Figure 1). ¹² Postoperatively, prostatic tissue can be examined for cancer, although only 2.2% of patients are diagnosed and only ~50% of patients require treatment. ¹³

Waterjet ablation

Dr. Zorn introduced Waterjet Ablation (Aquablation^®, PROCEPT BioRobotics, San Jose, CA, USA), a novel robotically executed technique that utilizes a high-velocity waterjet coupled with real-time ultrasound imaging to precisely resect the median and lateral prostate lobes while preserving apical tissues in the bladder neck and external sphincter. Accordingly, antegrade ejaculation was preserved in 85–90% of male patients and 72–99% of patients reported significant improvements in IPSS scores with preserved ejaculatory function at 5 years postoperatively (Figure 1).^14–16 These outcomes were validated in both randomized and prospective multicenter studies, including the WATER and WATER II trials, supporting waterjet ablation as an effective, durable, and function-preserving option for patients with small to large prostate volumes.^14–16 Furthermore, outpatient waterjet ablation can be performed with standardized protocols for postoperative hematuria. The figure presented by Dr. Zorn at the IFRUU 2024 meeting was adapted from these original publications.^14–16

Holmium laser enucleation of the prostate—Overview of technique, complications, and laser selection

HoLEP uses a laser to separate obstructing tissue from the prostatic capsule. Preoperatively, Dr. Lerner recommended imaging to characterize each prostate’s size and specific anatomy. Intraoperatively, Dr. Lerner emphasized the use of anatomical landmarks as reference points and discussed en-bloc enucleation. Dr. Bove discussed laser selection in HoLEP, highlighting that pulse modulation may improve hemostasis. ¹⁷

Dr. Krambeck discussed morcellation during HoLEP, emphasizing the importance of bladder distention and avoidance of the mucosa. Intraoperative complications (capsule perforation, bladder injury, and ureteral orifice injury) occur at rates of 0.1–9.6% but rarely require additional management. ¹⁶ Patients should be counseled on long-term complications such as urinary incontinence, bladder neck contracture, and urethral stricture, which occur in 0–2% of patients. ¹⁸

Discussion

A central theme across each session was the need to individualize therapy based on patient anatomy, comorbidities, and treatment goals. MISTs such as water vapor thermal therapy, temporary implantable nitinol devices, prostatic urethral lift, and paclitaxel-coated balloon dilation can be completed in the outpatient clinic setting and offer faster recovery and preservation of sexual function. Water vapor thermal therapy can now include patients with prostates >80 g, prostatic urethral lift remains well suited for smaller glands (<80 g) without obstructive median lobes, and drug-coated balloon dilation introduces a novel drug-delivery mechanism. In contrast, TURP and HoLEP continue to provide durable outcomes, albeit with higher perioperative risks and a greater likelihood of ejaculatory dysfunction, but advancements in preoperative optimization and resection/enucleation techniques have improved ejaculatory outcomes. One of the newest surgical modalities, waterjet resection, supported by multiyear outcomes in both moderate- and large-volume prostates, represents a new paradigm by combining resection efficacy with high rates of functional preservation.

Despite these advances, controversies remain regarding treatment selection for BPH. The relative abundance of BPH treatments means that urologists must carefully consider each option in their armamentarium. Concerns still remain regarding the durability of MISTs, the role of prostate size thresholds in guiding therapy, and whether earlier adoption of procedural interventions should replace long-term pharmacologic management. Shifting paradigms include the move toward robotic techniques such as waterjet ablation and the refinement of laser enucleation strategies. Future directions will depend on head-to-head comparative trials, registry-based practical data, and long-term outcomes to establish evidence-based treatment algorithms that balance efficacy, safety, durability, and quality of life.

Finally, these proceedings are based on expert presentations from the IFRUU 2024 meeting rather than original trial data. While references to published studies are included, the content reflects meeting highlights and the interpretation of the presenting experts. Readers should be mindful when applying the findings to clinical practice.

Conclusion

BPH management continues to evolve, especially with advancements in surgical optimization and the proliferation of MISTs. Future research will refine techniques, optimize patient selection, and drive innovation toward less invasive procedures with shorter recovery.