The influence of the medical treatment of LUTS on benign prostatic hyperplasia surgery: do we operate too late?

INTRODUCTION: The aim of this article is to systematically collect the available evidence on the influence of lower urinary tract symptoms (LUTS) medical treatment on benign prostatic hyperplasia (BPH) surgery. EVIDENCE ACQUISITION: A systematic literature search January 1990 until June 2016 was performed by combining the following MeSH terms: "lower urinary tract symptoms", "benign prostatic hyperplasia", "male", "medical treatment", "surgical treatment", "deferred/postponed treatment/intervention", "early intervention/treatment". Each article title and abstract was reviewed for relevance and appropriateness with regards to the topic of this review. EVIDENCE SYNTHESIS: The pharmacological treatment of LUTS is undoubtedly a successful story in the field of urology. Over the last two decades, the introduction of novel pharmaceutical agents has dramatically reduced the rate of BPH surgery interventions all over the world. Thus, nowadays, patients who undergo surgery are generally older, with more severe comorbidities and with larger prostates, theoretically requiring more challenging interventions. Nevertheless, the recent advances in surgical techniques and instruments have counterbalanced this unfavorable scenario and, overall, a non-pejorative trend has been observed in peri-/postoperative complications. On the other hand, evidence from the "pre-pharmacological-treatment era" suggested that immediate BPH surgery might be the best option for patients at risk of severe BPH progression. Still, no clear-cut, shared criteria have yet been established to effectively identify these patients. CONCLUSIONS: Several questions remain unanswered regarding the role of medical treatment in BPH, and good-quality studies available on this topic are surprisingly rare. The evidence presented in this review supports the need for prospective comparative studies evaluating long-term LUTS/BPH pharmacological treatment versus an early surgical intervention, particularly using the emerging laser technologies.