The dark side of transurethral access for LUTS/BPH surgery: a narrative review

The transurethral route is the access of choice for benign prostatic hyperplasia (BPH) surgical treatment. Transurethral resection of the prostate (TURP) has been the gold standard in surgical intervention for BPH; however, the advent of novel surgical techniques and the exploration of new energy sources in recent decades have seen this primacy contested. Nevertheless, the transurethral route harbors numerous challenges and pitfalls that can pose significant risks even for the most experienced endoscopic urologists. Complications associated with transurethral access are well documented yet often underestimated by endoscopic surgeons, primarily because the pathological conditions arising from transurethral surgery typically fall within the realm of those specializing in genitourinary reconstructive surgery. This narrative review describes and critically discusses the specific pitfalls associated with transurethral surgery for BPH. Urethral strictures, transient or permanent postoperative incontinence, reintervention, and de novo /persistent lower urinary tract symptoms (LUTS) represent the main complications of transurethral treatments for BPH. These problems still stand as the foremost challenge for all endoscopists despite recent technological advancements. The use of increasingly miniaturized instruments, more mindful energy application, sphincter-sparing enucleation techniques, and the advent of so-called minimally invasive surgical techniques (MISTs) all contribute to a more conscious and anatomically respectful transurethral approach. An endoscopic transvesical suprapubic access may be another alternative strategy to minimize the complications of transurethral route in the future.