A 68-year-old man from Delhi presents with progressive lower urinary tract symptoms for 8 months. He reports nocturia 4–5 times per night, weak urinary stream, hesitancy, and incomplete emptying. Digital rectal examination reveals a smooth, firm, symmetrically enlarged prostate without nodules. Post-void residual (PVR) is 120 mL. International Prostate Symptom Score (IPSS) is 22. Serum PSA is 2.8 ng/mL. Uroflowmetry shows peak flow rate of 8 mL/s. He declines medical therapy initially and asks about surgical options. Which procedure is most appropriate for this patient?

Explanation

## Clinical Assessment **Key Point:** This patient has moderate-to-severe symptomatic BPH with objective evidence of obstruction (peak flow 8 mL/s, PVR 120 mL, IPSS 22) and a prostate gland of moderate size (smooth, symmetric enlargement on DRE). ## Surgical Decision-Making Algorithm ```mermaid flowchart TD A[Symptomatic BPH, failed medical therapy]:::outcome --> B{Prostate size?}:::decision B -->|< 30 g| C{Peak flow & PVR?}:::decision B -->|30–45 g| D[TURP or Laser]:::action B -->|> 45 g| E[Open prostatectomy]:::action C -->|Moderate obstruction| F[TURP preferred]:::action C -->|Mild obstruction| G[TUIP or watchful waiting]:::action F --> H[Gold standard for 30–45 g]:::outcome ``` ## Why TURP is Optimal Here | Feature | Finding | Implication | |---------|---------|-------------| | **Prostate size** | Moderate (symmetric DRE) | Estimated 30–45 g | | **Peak flow** | 8 mL/s | Significant obstruction | | **PVR** | 120 mL | Significant retention | | **IPSS** | 22 (moderate-severe) | Symptomatic obstruction | | **PSA** | 2.8 ng/mL | No malignancy concern | **High-Yield:** TURP is the gold standard for prostate glands 30–45 g with moderate-to-severe LUTS and objective obstruction. It offers excellent long-term symptom relief and durable outcomes [cite:Wein et al. Campbell-Walsh Urology 12e Ch 107]. ## Why Other Options Are Suboptimal **Open suprapubic prostatectomy:** Reserved for glands >45 g or when TURP is contraindicated (e.g., severe cardiopulmonary disease, inability to tolerate spinal anesthesia). This patient's prostate is not that large. **Laser vaporization:** Effective alternative to TURP, particularly in high-risk patients (anticoagulation, severe comorbidity) or very large glands. Not first-line for this moderate-sized gland in an otherwise fit patient. **TUIP:** Indicated only for small glands (<30 g) with mild-to-moderate obstruction. This patient's peak flow (8 mL/s) and PVR (120 mL) indicate more significant obstruction requiring TURP. ## Clinical Pearl **Key Point:** The combination of moderate prostate enlargement, peak flow <10 mL/s, and PVR >100 mL mandates TURP rather than TUIP. TUIP is suitable only for minimal obstruction in small glands.