Preoperative Workup for BPH Surgery

How to cite: Sheetz TJ. Preoperative workup for BPH surgery. Grand Rounds in Urology. November 2025. Accessed Feb 2026. https://grandroundsinurology.com/preoperative-workup-for-bph-surgery/

Summary

Tyler J. Sheetz, MD, 2023-25 Kaiser Endourology Fellow, University of California, San Diego, San Diego, California, delivers a practical, evidence-based framework for the preoperative evaluation of patients undergoing surgery for benign prostatic hyperplasia (BPH). He reviews the major components of preoperative workup and clarifies which tests are essential, optional, or unnecessary depending on the planned procedure and clinical context.

Dr. Sheetz acknowledges the wide variability in how providers evaluate patients prior to BPH surgery. He outlines the goals of preoperative assessment, including prostate size, anatomic factors affecting procedure choice, assessment of bladder function, and prostate cancer screening.

Preoperative imaging is reviewed. Computed tomography (CT) can be used to estimate prostate size. Magnetic resonance imaging (MRI) is often available from prostate cancer workup and provides detailed anatomic information, including median lobe presence and zonal anatomy. Transrectal ultrasound is discussed as the gold standard in the United States, offering accurate volume assessment but with invasiveness and patient discomfort. Dr. Sheetz highlights transabdominal ultrasound as an emerging, noninvasive alternative. Data comparing transabdominal ultrasound, MRI, and prostatectomy specimens show a strong correlation, with MRI potentially more accurate for prostates larger than 80 grams.

Cystoscopy is presented as optional rather than mandatory. It may be useful for identifying median lobes, strictures, stones, or recurrent obstruction after prior surgery. Measurement of prostatic urethral length is discussed as a prognostic tool and for planning minimally invasive therapies such as Rezūm™ or UroLift™.

The role of urodynamics is addressed. While guidelines suggest considering pressure-flow studies when diagnostic uncertainty exists, Dr. Sheetz shows evidence showing that urodynamics are usually unnecessary prior to procedures that remove a substantial portion of prostate tissue, particularly holmium laser enucleation. Studies demonstrate favorable outcomes, even in patients with detrusor underactivity or an acontractile bladder, when sufficient tissue is removed.

Dr. Sheetz emphasizes adherence to AUA screening guidelines and notes that routine prostate-specific antigen (PSA) testing solely for BPH surgery is not required outside recommended screening age and risk categories.

About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.