Learning123 and folks,

BPH is complicated and nuanced as to which procedure is best. There are many BPH choices these days and there will continue to be more and more as the BPH market has essentially an unlimited market. In general, 60% of 60 year olds, 70% of 70 years olds and so on have BPH of which half have symptoms that bother them. There are countless "game changer devices" collecting dust in Urologist's storage closets these days as initial hype of the novel technology was overwhelmed with suboptimal outcomes data and the next greatest thing.

For Learning 123 the first priority is the recurrent infections which could be from the kidney stone as a source or the fact that there is an indwelling catheter - this or self-catheterization undoubtedly leads to infections but at the same time protects the bladder from having to squeeze against resistance (from enlarged prostate). Years of the bladder working against the prostatic resistance leads some men (but not all) to complete bladder weakness and the need for catheterization. If we had a crystal ball we'd operate on those men whose bladder is going to shut down and leave everyone else alone whose bladder will never weaken too much or may die of other causes prior to the prostate causing shenanigans.

For clarity I will attempt to rank order surgical characteristics of different BPH surgeries by characteristic, this is my opinion based on my interpretation of all of the data and my clinical experience (As I helped write the BPH practice guidelines for 6 years I have reviewed a lot of the data) - which of these characteristics is most important to you will augment which bph surgery is best for you.

Success & Durability: Enucleation of any kind (holep, simple (no prostate cancer leave some prostate behind) or radical prostatectomy (+ prostate cancer leave nothing behind which has as a result more negative side effects) >>> aquablation for large glands (> 100 grams), for less the 100 gram prostate = PVP (greenlight) > Rezum > Urolift > Optilume

Sexual Side Effects (mainly from conductive heat applied to prostate, closer to sphincter/check valve = more ejaculatory dysfunction) - Optilume = Urolift (0-1% chance of either), > Rezum (0% ED, 5% EJD), > aquablation (5-10% ED, 10-15% EJD), PVP (10% ED, 50% EJD), Enucleation (10% ED, 100% EJD)

Thus, the better the channel is opened form a surgery, the higher the chance of sexual side effects.

Some men really care about how long the catheter is left behind - its pretty similar for most 3-7 days, urolift and pvp probably win here though with one day typically. Rezum is probably worst here as its effect on the tissue is delayed.

Learning 123, sounds like you need a perc for the stone. After that is settled I would consider radical prostatectomy if you are reasonably healthy as you are watching the prostate cancer at this time anyway. Hope this helps.

Best

Tobias Kohler, MD, MPH
Head of Mayo Mens Health, Rochester, MN