Rethinking the term “gold standard” in benign prostate surgery: Reflections from the EAU Endourology Research Group

Abstract

The term “gold standard” is widely used in benign prostatic obstruction (BPO) surgery to describe established procedures such as transurethral resection of the prostate (TURP) and, more recently, holmium laser enucleation of the prostate (HoLEP). This article argues that the term no longer reflects contemporary practice, where treatment should be individualised according to patient characteristics, priorities, and surgical expertise. Describing a single procedure as the gold standard risks oversimplifying decision-making and overlooking the growing range of effective evidence-based options. More precise terms, such as “preferred treatment” or “reference standard” in a defined clinical context, better reflect modern guideline-based care and support shared decision-making.

In surgical practice, especially in treating benign prostatic obstruction (BPO), the phrase “gold standard” is used very often. It commonly appears in introductions or even article titles, either to promote a new treatment as a future gold standard or to describe transurethral resection of the prostate (TURP) as the long-standing one.

From the perspective of the European Association of Urology (EAU) Endourology Research Group, we feel this term is no longer fully appropriate, particularly in benign prostate surgery. This is not about challenging tradition for its own sake, but about updating our thinking. Consistent and precise terminology adds value in medicine, and benign prostatic hyperplasia (BPH) guidelines over time have already moved toward more careful, contextual language rather than absolute claims. ¹

The term “gold standard” originally comes from economics, where money was once linked to gold to ensure stability and certainty. However, this system was abandoned because it was too rigid for changing economies. Medicine, in contrast, has continued using the term without always questioning whether it still fits modern practice.

Calling a procedure like holmium laser enucleation of the prostate (HoLEP) a gold standard suggests it is the best choice for every patient and situation. Today, this is hard to justify. Patients differ widely in age, health conditions, anticoagulation use, prostate size, and personal priorities. No single treatment is ideal for everyone.

The term also assumes that “success” means the same thing for all patients. In reality, patients value different outcomes. Some prioritize preserving sexual or ejaculatory function, while others focus on becoming catheter-free or reducing surgical risk. ² Labeling one procedure as the gold standard can hide these trade-offs and oversimplify shared decision-making.

The growing number of surgical options for BPO also shows that there is no single perfect solution. This variety does not reflect confusion, but rather the need to tailor treatment to each individual.

Although “gold standard” is a powerful and concise phrase, more careful wording may better reflect modern practice. Referring to a treatment as a preferred option for a certain group of patients or a reference standard in a specific context is more transparent, supports patient-centered care, and avoids implying that one option is always superior.