Surgical intervention for Bladder Outflow Obstruction (BOO)

24 January 2024 | No further review planned

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The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Bladder outflow obstructive surgery is a therapeutic procedure to treat men with symptomatic lower urinary tract symptoms (LUTS) due to bladder outflow obstruction (BOO). The most common cause for BOO is benign prostatic obstruction (BPO), rarer causes include bladder neck stenosis.

Surgical procedures primarily involve a transurethral endoscopic approach in which prostate tissue is either removed or vapourised to relieve the obstruction. Current recognised approved procedures include:

• Transurethral resection of prostate (TURP).
• Transurethral incision of the prostate (TUIP) or Bladder Neck Incision (BNI).
• Holmium LASER enucleation of the prostate.
• 532 nm laser vaporisation of the prostate (e.g. ‘GreenLight’).
• UroLift.
• Transurethral vaporisation of the prostate (TUVP).
• Transurethral water vapour therapy (Rezum).
• Aquablation.
• Simple robotic prostatectomy.

Non-surgical procedures include interventional radiology techniques such as prostate artery embolization.

The most established procedure for the management of bladder outflow obstruction is Transurethral resection of prostate (TURP), a therapeutic procedure involving removal of tissue from the inner aspect of the prostate using diathermy, via an endoscopic approach.

TURP remains a reliable option and is the mainstay of treatment for many patients. It is usually undertaken on an in-patient basis, with a catheter left in-situ for 24-48 hours post-operatively for the purpose of irrigation. TURP may be undertaken under either general or spinal anaesthesia. TURP causes temporary discomfort, occasionally pain, haematuria and is associated with small risks of infection and acute urinary retention after removal of the catheter. There is also a risk of sexual dysfunction following TURP. There are small but important risks of significant harm, including severe fluid and electrolyte imbalances associated with absorption of large volumes of irrigating fluid (TUR syndrome). TUR syndrome can be avoided by using bipolar diathermy, a variant of the standard technology.

There is an emerging suite of minimally invasive surgical treatments (MISTs) which are replacing TURP as the mainstay of treatment. The increased range of treatments has meant that there is now a requirement for specialist assessment to include more complex discussions with patients about their options. A decision aid to support patients through the selection of individualised treatment options is recommended.

Open simple/benign prostatectomy is very rare and is only undertaken in men with very large prostates and problematic symptoms.

This guidance applies to male adults aged 19 years and over.

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This guidance relates to those who have a prostate, this includes:

• Cismen (men who identify as male and were assigned male at birth).
• Trans women (women who identify as female and were assigned male at birth).
• Non-binary people who were assigned male at birth.
• Some intersex people.

The information has been developed based on guidance and evidence in men. If you are a trans woman, male-assigned non-binary or intersex, some of this information is still relevant to you — but your experience may be slightly different.

Please note for the purposes of this recommendation and to align with the evidence when we use ‘men’ it refers to all those with a prostate.

Only men with severe voiding symptoms and in which a diagnosis of bladder outlet obstruction (BOO) has been made should be offered surgical intervention.

Assessment of BOO should include both a free flow rate and post void residual in men between the ages of 50 and 80.

BOO is defined according to the European Association of Urology where the patient cannot void >150mls, the maximum flow is <10mls/s or with a post void residual >300mls.

Assessment of men with lower urinary tract symptoms should be done in a specialist centre and current best practice is that this should be done in a one stop clinic.

A staged approach to managing BOO in men is recommended:

1. Conservative, or lifestyle interventions should be discussed such a bladder training, hydration management and pelvic floor exercises.
2. Drug therapy should be considered, in the context of more persistent LUTS, or LUTS not responding to simple lifestyle interventions.
3. Where LUTS persist, or if medical management is not tolerated, intervention should be considered using a shared decision-making approach.

Initial management of patients should be done in primary care and is covered by NICE guidance CG97. There is evidence of the long-term side effects of medical management, therefore early referral and assessment for appropriate intervention could be considered for some patients.

Part of the consultation process for patients undergoing BOO surgical or non-surgical intervention should include a validated decision aid tool to ensure that the patients’ desired outcomes have been considered. This allows for an informed consent process which balances outcomes, potential side effects and the patients’ quality of life. The patients preferred treatment option will need to be considered alongside other factors such as their general health. Practical concerns, including the distance required to travel, are important and should also be considered. Appropriate support should be provided to make shared decisions pertinent to physical, emotional, psychological and sexual health. If appropriate, partners and/or carers should be informed and involved. An example of decision aid tool can be found on the NHS website.

This guidance is reflective of current known and approved interventions however in the future, new minimal invasive surgical techniques (MISTs) may be developed. Once the potential new techniques are shown to be safe and effective by NICE, they should be included in the consenting process.

Providers should collaborate to ensure all recognised interventions are available to their populations within a reasonable geographical area. Urological area networks recognised by GIRFT provides a practical solution.

NICE guidance provides clear evidence, in clinical and cost-effectiveness terms, that patients voiding LUTS presumed secondary to BPO, should be offered surgical intervention as part of a stepped approach to management.

TURP has long been the mainstay of surgical treatment for voiding LUTS presumed secondary to prostatic enlargement. The newer surgical modalities outlined above have therefore been evaluated in comparison with TURP, as well as conservative management. NICE CG97 accordingly incorporated a comprehensive matrix of comparative studies between treatment modalities in its evidence review. This reflects increasing complexity in decision making around intervention, increasingly involving ‘which’, as well as ‘when’ or ‘whether’ surgery should be offered.

The recommendation proposed here reflects the full breadth of comparative studies between surgical and non-surgical intervention and conservative management, as well as between different surgical interventions forming the basis of NICE CG97.

Benign prostatic obstruction (BPO) is when the prostate gland becomes larger with age. It can cause urinary symptoms that affect your flow of urine. Making lifestyle changes may help relieve the symptoms. For example, avoiding caffeine and drinking lots of fluids before bedtime. Some medicines may also be helpful. If these are not effective, surgery – an operation – may be appropriate for a small number of people. Several surgical treatment options are available. There are advantages and disadvantages to all treatments.

About the condition

BPO is a common condition, particularly in older men and people assigned male at birth. It is not a form of cancer. The larger the prostate gland gets, the harder it can be for you to pass urine out from the bladder. Symptoms can include, urgently needing to urinate, difficulty in starting the flow of urine, increased frequency in urination, slow flow, and not completely emptying the bladder. In rare cases, the bladder can become distended (stretched). This can cause damage to your kidneys.

What are the BENEFITS of the surgery?

If lifestyle changes and medicines have not worked for you, an operation on the prostate gland may help to improve symptoms. If your kidneys are not working well because of BPO an operation may be helpful.

What are the RISKS?

All surgeries and procedures to improve symptoms carry a risk. These may include bleeding, infection, pain, and how an anaesthetic may affect you. There may also be a risk of developing sexual problems such as erectile dysfunction.

What are the ALTERNATIVES?

Lifestyle changes can help. For example, avoiding caffeine and drinking lots of fluids before bedtime. Doing pelvic floor and bladder training exercises may also be beneficial. There are also medicines you can take to relax and shrink the prostate gland.

Before considering an operation, you should try these changes and medicines. You can speak to a doctor or other clinician to help you decide what will work best for you.

What if you do NOTHING?

Without any lifestyle changes or treatments, symptoms of BPO may worsen over time.

1. NICE clinical guideline (2010) Lower urinary tract symptoms in men: management. [CG97].
2. NICE Medical technologies guidance (2015) UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia [MTG 26].
3. European Association of Urology guideline on the management of non-neurogenic male LUTS.
4. Harrison S (2018) Urology, GIRFT Programme National Specialty Report. GIRFT
5. GIRFT (2022) Urology: towards better care for patients with bladder outlet obstruction
6. Uroweb – European Association of Urology. (n.d.). EAU Guidelines on the Management of Non-neurogenic Male LUTS – DIAGNOSTIC EVALUATION – Uroweb.