Surgery for BPH remains an interesting subject in urology, not just because of the new treatment methods that often appear on the horizon, but also because the whole issue of managing a benign condition depends upon the cultural and economic environment in which the discussion takes place.
In countries where access to health care is difficult, a large number of patients with BPH enter the emergency room because of urinary tract retention and receive ether immediate or delayed surgery. These patients may well represent the majority of patients with BPH receiving surgery. In western Europe, urinary tract retention is a more rare event as the development of national health services has made access to health care easier. In the last two decades, the availability of α-blockers, 5-α-reductase inhibitors (5ARIs) and antimuscarinics has helped in the successful management of LUTS resulting from BPH. Among the various drug treatments, only 5ARIs are able to modify the natural history of the disease, lowering the risk of symptom deterioration, AUR and surgery [1,2]. We may discuss whether pharmacological treatment of BPH delays or reduces the need for surgery in the long term, but it has certainly helped in reducing the number of surgical procedures performed in most western countries . Evaluation of modern BPH series suggests a delay in surgical treatment with larger prostate volumes at the time of surgery .
The present paper raises an important issue: surgery of patients with an indwelling catheter is associated with a larger number of complications, a longer hospital stay and higher costs. Although the issue has already been raised in the peer-reviewed literature, the current series is large enough to confirm previously reported data and to extend its validity in an Asian population. We certainly need to inform patients undergoing surgery with an indwelling catheter about the higher risk of complications, but we also need to explore possible prognostic parameters that may help to identify patients at risk of AUR so that surgery is planned before an indwelling catheter is needed. The growing request for cancer treatment has put surgery for benign conditions at risk and waiting lists may easily exceed a year.
This is no longer a problem of good clinical practice but it is also a health and economic issue that should be considered, discussed and managed in the appropriate settings.