The European Association of Urology (EAU) recently updated its guideline on the management of lower urinary tract symptoms (LUTS) in men aged 40 years and older with non-neurogenic LUTS, including benign prostatic obstruction (BPO), detrusor overactivity/overactive bladder (OAB), and nocturnal polyuria. The surgery section was the main focus of this update.

“Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy,” Vasileios I. Sakalis, MD, of Hippokrateion General Hospital in Thessaloniki, Greece, and colleagues from the guideline panel stated in a European Urology summary. “The choice of surgical technique depends on the patient’s prostate size, comorbidities, ability to have anaesthesia, patient preference, and willingness to accept surgery-associated specific side effects; availability of the surgical armamentarium; and experience of the surgeon with these surgical techniques.”

The guideline panel discussed and weighed the surgical options based on data accrued thus far, including resection, enucleation, vaporization, and alternative ablative and nonablative techniques. Here is a compendium of their strong recommendations to treat moderate-to-severe male LUTS:

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  • For resection, offer bipolar or monopolar transurethral resection of the prostate (TURP) to treat men with prostate size of 30-80 mL and transurethral incision of the prostate (TUIP) to treat men with a prostate size less than 30 mL, without a middle lobe.
  • Offer open prostatectomy in the absence of bipolar transurethral enucleation of the prostate and holmium laser enucleation of the prostate in men with a prostate size greater than 80 mL.
  • Offer laser enucleation of the prostate using Ho:YAG laser (HoLEP) as an alternative to TURP or open prostatectomy.
  • Offer 80-W 532-nm potassium titanyl phosphate laser vaporization or 120-W or 180 W 532-nm lithium borate (LBO) laser vaporization to men with a prostate volume of 30-80 mL as an alternative to TURP.
  • For ablative techniques, inform patients of the risk for bleeding and the lack of data on long-term outcomes.
  • Perform prostatic artery embolization (PAE) only in units where the work-up and follow-up are performed by urologists working collaboratively with trained interventional radiologists for the identification of PAE-suitable patients.
  • For nonablative techniques, offer prostatic urethral lift (PUL) to men with LUTS interested in preserving ejaculatory function, with prostate volume less than 70 mL and no middle lobe.
  • Do not offer intraprostatic botulinum toxin-A injection.

The 2024 guideline update will include a literature review. In the meantime, Jean-Nicolas Cornu, MD, PhD, of Charles Nicolle University Hospital in Rouen Cedex, France, who is a guideline panel member, and colleagues recently conducted a systematic review and meta-analysis of 63 clinical trials on minimally invasive surgical therapies, including water vapor thermal therapy (WVTT), PUL, PAE, temporary implantable nitinol device, and transurethral microwave thermotherapy. As expected, TURP increased urine flow the most, but short-term symptom improvement was comparable among surgical therapies. Sexual function was better after WVTT or PUL.


Gravas S, Gacci M, Gratzke C, et al. Summary paper on the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms. Eur Urol. doi:10.1016/j.eururo.2023.04.008

Cornu JN, Zantek P, Burtt G, et al. Minimally invasive treatments for benign prostatic obstruction: a systematic review and network meta-analysis. Eur Urol. 83(6): 534-547. doi:10.1016/j.eururo.2023.02.028