10-Year Data: Delayed BPH Surgery Linked to Increased Risk of Treatment Failure

Pharmacologic therapy is currently the initial management for benign prostatic hyperplasia (BPH). The overall number of BPH-related surgeries has decreased, but the response to medical management varies. Many patients prescribed pharmacologic therapy simply progress to surgery at an older age, and acute urinary retention is becoming a more common surgical indication.

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Researchers at Massachusetts General Hospital conducted the first long-term, population-based study in the current era that examined the association between treatment outcomes and the timing of surgery in men with BPH or lower urinary tract symptoms.

Michelle M. Kim, MD, PhD, director of the Prostate Health Program in the Department of Urology at Mass General, Daniel M. Frendl, MD, PhD, formerly a resident in the Department and now at the Mayo Clinic, and colleagues report in The Journal of Urology that delay in time to surgery following an episode of urinary retention was a predictor of treatment failure. Patients who waited more than 12 months fared the worst.

Methods

Using the New York Statewide Planning and Research Cooperative System, an all-payer claims database, the team identified 17,474 men who underwent outpatient photovaporization or transurethral resection of the prostate between January 1, 2002, and December 31, 2016, and had no prostate cancer diagnosis during that period.

Competing-risks models were used to determine whether the number of preoperative catheterizations (PCs) and time from the first PC to BPH surgery predicted treatment failure, with death as the competing risk. PC was used as a proxy for severe BPH.

The models were adjusted for demographics, preoperative urinary tract infections, Charlson Comorbidity Index, surgical modality, and surgeon volume.

Principal Analyses

The primary endpoint was treatment failure, defined as the composite of any BPH-related reoperation or postoperative catheterization for acute urinary retention at least one month after the index procedure.

At 10 years, the adjusted competing risks analysis revealed a significantly increased risk of treatment failure with an increasing number of PCs and a longer time to surgery.

Number of PCs

• 0 PC—Reference
• 1 PC—Subdistribution hazard ratio (SHR), 1.53 (P<0.001)
• ≥2 PC—SHR, 2.20 (P<0.001)

Time to surgery

• 0 PC—Reference
• <6 months from initial PC to index BPH surgery—SPH, 1.49 (P<0.001)
• ≥6 months—SHR, 2.11 (P<0.001)

The estimated cumulative 10-year rate of treatment failure was:

• 17% for patients without PC vs. 34% for those with ≥2 PC
• 33% for patients with ≥6-month delay from initial PC to index BPH surgery

Sensitivity Analyses

In the subgroup of 1,772 patients who had ≥1 PC:

• There was a near "dose-dependent" increased risk of treatment failure as the number of PC increased
• Patients who experienced ≥12 months delay to surgery had a significantly higher risk of treatment failure (SHR, 1.57; P=0.001) than those who underwent surgery within three months of initial PC
• There was no significant difference in treatment failure between patients who had surgery within 12 months and those who underwent surgery within three months

Recommendations for Primary Care Clinicians and Urologists

Patients who experience an episode of acute retention should be considered for prompt referral to a urologist so they can be closely evaluated for bladder outlet obstruction and the potential need for surgery.

Urologists should weigh whether a patient with BPH and no other underlying pathology contributing to bladder dysfunction may benefit from surgery before it progresses to retention requiring a catheter.

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Learn about the Prostate Health Program at Mass General

Refer a patient to the Department of Urology