A COMPARISON OF TRANSURETHRAL SURGERY WITH WATCHFUL WAITING FOR MODERATE SYMPTOMS OF BENIGN PROSTATIC HYPERPLASIA

Background. Transurethral resection of the prostate is the most common surgical treatment for benign prostatic hyperplasia. We conducted a m ulticenter randomized trial to compare this surgery with watchful wait ing in men with moderate symptoms of benign prostatic hyperplasia. Met hods. Of 800 men over the age of 54 years who were screened between Ju ly 1986 and July 1989, 556 (mean [+/-SD] age, 66+/-5 years) were studi ed (280 in the surgery group and 276 in the watchful-waiting group). P atients' symptoms and the degree to which they were bothered by urinar y difficulties were measured with standardized questionnaires and medi cal evaluations. The primary outcome measure was treatment failure, wh ich was defined as the occurrence of any of the following: death, repe ated or intractable urinary retention, a residual urinary volume over 350 ml, the development of bladder calculus, new and persistent incont inence, a high symptom score, or a doubling of the serum creatinine co ncentration. Patients were followed for three years. Results. Of the m en randomly assigned to the surgery group, 249 underwent surgery withi n two weeks after the assignment. Surgery was not associated with impo tence or urinary incontinence. The average follow-up period was 2.8 ye ars. In an intention-to-treat analysis, there were 23 treatment failur es in the surgery group, as compared with 47 in the watchful-waiting g roup (relative risk, 0.48; 95 percent confidence interval, 0.30 to 0.7 7). Of the men assigned to the watchful-waiting group, 65 (24 percent) underwent surgery within three years after the assignment. Surgery wa s associated with improvement in symptoms and in scores for urinary di fficulties and interference with activities of daily living (P < 0.001 for all comparisons). The outcomes of surgery were best for the men w ho were most bothered by urinary symptoms at base line. Conclusions. F or men with moderate symptoms of benign prostatic hyperplasia, surgery is more effective than watchful waiting in reducing the rate of treat ment failure and improving genitourinary symptoms. Watchful waiting is usually a safe alternative for men who are less bothered by urinary d ifficulty or who wish to delay surgery.