BPH care moving beyond watchful waiting, lifelong pills and invasive surgery

For decades, benign prostatic hyperplasia (BPH) has often been managed along a familiar pathway: watchful waiting for mild symptoms, medication for more bothersome lower urinary tract symptoms, and surgery when symptoms progress or complications emerge.But that pathway is becoming less linear. As newer, minimally invasive therapies gain ground, BPH care is shifting toward a more personalized model—one that weighs not only symptom relief, but recovery time, durability, sexual function and patient preference.The shift is reflected in recent work by urologist Dr. Dean Elterman, associate professor, department of surgery at the University of Toronto and the Lang Family Chair in Urologic Innovation, whose research focuses on minimally invasive and patient-centred treatments for BPH. “The biggest shift is that we've moved away from thinking about BPH as a simple plumbing problem—enlarged prostate, blocked urine, fix the blockage—and toward recognizing that lower urinary tract symptoms are multifactorial,” said Dr. Elterman in an email interview with the Medical Post. “The bladder itself, metabolic health, sleep disorders and systemic conditions all contribute.”At the same time, the treatment menu has exploded, said Dr. Elterman, also a urologic surgeon in the division of urology at Toronto’s University Health Network. “Five years ago, a patient who didn't want to take pills had essentially one option: surgery. Today we have a range of minimally invasive procedures that can be done in an office or day-surgery setting, with minimal anesthesia, minimal recovery and critically, minimal impact on sexual function. That has fundamentally changed the conversation we have with patients.”The old “stepwise” model—watch, then medicate, then operate—made sense when the only surgical option was a transurethral resection of the prostate (TURP) under general anesthesia with a hospital stay and real risks of ejaculatory dysfunction, he says.But that has now changed with the availability of procedures like UroLift, Rezúm, Aquablation and the Optilume balloon that can be offered much earlier in the disease course: “Sometimes even before or instead of long-term medication—because their side-effect profiles are dramatically better.”Dr. Elterman says the 2026 American Urological Association (AUA) guidelines and the 2026 European Association of Urology (EAU) guidelines both reinforce that treatment should be driven by patient goals, anatomy and bother, not by an arbitrary step ladder.“If a 55-year-old man is bothered by his symptoms, sexually active and doesn't want to take a pill every day for the rest of his life, it is now entirely reasonable to offer him a minimally invasive procedure upfront. We call these first-line interventional therapies, and they represent one of the most important conceptual updates in the new guidelines.”In a paper published in European Urology Focus in 2025, Dr. Elterman and Dr. Steve Kaplan, professor of urology and director of the Men’s Wellness Program at Mount Sinai, New York, introduced a new way of categorizing BPH treatments, coining the term “first-line interventional therapy,” or FIT. It’s deliberately distinct from MIST, or minimally invasive surgical therapy, which has become a catch-all term that has become too broad to be clinically meaningful, says Dr. Elterman.A true FIT has to meet a specific set of criteria: It needs to be outpatient, deliverable in a clinic or office setting—ideally with a flexible scope under local anesthesia—with rapid recovery, minimal side-effects, no catheter or a very short catheterization period, and critically, it has to preserve the patient's future treatment options.“A FIT should not burn bridges. If a patient tries it and it doesn't work, or if disease progresses, they should still be candidates for any other therapy down the road. That's the 'preserved treatment adaptability' piece.”The procedures that best meet FIT criteria today are the newer generation of prostatic urethral devices—nitinol-based stents and implants that mechanically open the urethra without ablating or destroying tissue.The Zenflow Spring, which recently received U.S. FDA approval (but not yet Health Canada), is a good example.“It's delivered via a flexible scope in the office, preserves sexual function, and is fully reversible—you can remove it entirely if needed. The ProVee System, also recently FDA-approved, operates on a similar philosophy,” said Dr. Elterman. “These are very different from Rezúm or UroLift, which I would put in a different tier—still minimally invasive and excellent procedures, but they typically require some degree of sedation or general anesthesia, a recovery period, and they alter the tissue in ways that are not fully reversible.”Early interventionThe patients who are ideally suited to FIT are men who are bothered by their symptoms, who either don't want to take medication long-term or haven't responded adequately to it, but who are also not ready for—or not interested in—a more definitive surgical procedure. They want something easy, something quick, and something that doesn't close any doors.“The broader point is that we should be offering these options earlier in the disease course, not as a last resort after years of failed medication. If we intervene earlier with a well-tolerated FIT, we may actually protect long-term bladder function—which is the outcome that matters most and the one our traditional step-ladder approach has consistently under-treated.”Family physicians are often the first person a patient talks to about these symptoms, and they play a crucial role in setting expectations, noted Dr. Elterman. “The key message I'd want GPs to convey is that no single treatment is best for every man—there are genuine tradeoffs, and the right choice depends on what the patient values most. TURP and laser enucleation procedures like HoLEP give the most durable, long-lasting symptom relief, but they carry a significant risk of retrograde ejaculation—upwards of 50% to 80%, which matters greatly to sexually active men. The newer minimally invasive procedures preserve ejaculatory function much better, but re-treatment rates over five to 10 years are higher.”For medications, alpha-blockers work quickly but don't change the underlying disease, he says, and 5-alpha-reductase inhibitors take months to work and carry their own sexual side-effects, including reduced libido and erectile dysfunction.“When a patient raises urinary symptoms, ask specifically about bother, ask about sexual function, and refer early rather than cycling through medications for years if the patient is a candidate for intervention.”Two other things he says that he’d want primary healthcare providers to take away:Nocturia is probably the symptom that bothers patients most, and it's historically been under-treated because it was assumed to be all about the prostate. But it often isn't. “It can be driven by nocturnal polyuria, sleep disorders, heart failure or simply aging kidneys. The new EAU guidelines have a sophisticated pathway for nocturia management that includes low-dose desmopressin and sleep medicine referral pathways.” The under-active bladder is an under-recognized condition where the bladder muscle itself is weak, not just obstructed. These patients can look identical to a classic BPH patient on the surface. “But if you aggressively open their outlet without recognizing the underlying bladder dysfunction, you can make them worse. This is an area of active research and a place where we need better non-invasive diagnostic tools.”Gaps in careDespite the range of treatments, there are serious equity issues in Canada, and access to these technologies is highly uneven. Dr. Elterman says that Canada has several gaps in care that don't get discussed enough. Timely access to urologists is a challenge with only 600 urologists in the country (300 in Ontario), or one urologist to every 62,000 Canadians.“A patient in downtown Toronto or Montreal may have access to novel minimally invasive therapies, sometimes covered, sometimes not. A patient in rural New Brunswick or northern Ontario may have access to none of them, and may be waiting months even for a basic TURP. And even when provincial public health insurance plans cover a technology, there may not be funding at the hospital level to even offer it. The new AUA guideline makes ambitious recommendations, but guidelines written for American practice don't automatically translate to the Canadian access and reimbursement reality.”

BPH care moving beyond watchful waiting, lifelong pills and invasive surgery

Register for free access or login.

Related Topics