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Watchful waiting or surgery for BPH


Clinical bottom line

Surgery is the treatment of choice for men with moderate symptoms who were bothered by them. For those not so bothered, watchful waiting would seem a better bet.


JH Wasson et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. New England Journal of Medicine 1995 332: 75-79.


A pilot study showed that the greatest uncertainty about choice of treatment for men with BPH was in those with symptom scores of 10-20 (on a scale of 0-27). Men within this range therefore were eligible for the study which randomised them to surgery (transurethral prostatectomy) or watchful waiting.

Men assigned to surgery underwent transurethral prostatectomy within two weeks. All participants were seen in a general medical clinic 6-8 weeks after randomisation and then twice a year for three years. At each visit various measurements were made and quality of life and bothersomeness of symptoms evaluated.

The main outcome was treatment failure, defined as any of:


There were 280 men who underwent initial surgery and 276 who underwent watchful waiting. Groups were the same at baseline for a number of characteristics. The mean age was 66 years, the mean symptom score 15 out of 27 and peak flow rate about 12 mL/second.

Treatment failure occurred in 23/280 men (8.2%) undergoing initial surgery and 47/276 (17%) in the watchful waiting group. The NNT to avoid one treatment failure was 11 (7 to 30). In the watchful waiting group 65 men (24%) underwent surgery, and the rate was twice as high (31%) in men more bothered by their symptoms at baseline than those who were less bothered (16%).

Men in the surgery group had a larger reduction in symptom score (improved by 10 points) than men in the watchful waiting group (improved by 6 points). Peak urinary flow rate improved by 6 mL/second with surgery, but not at all with watchful waiting.

Improvement occurred after surgery depended on the degree of bother at baseline. It was more successful in those who were more bothered. Watchful waiting had lower percentages of improvement (Figure 1).

Figure 1: Improvement after three years with surgery and watchful waiting, in men more or less bothered at baseline.


This is a really useful study. Surgery would seem to be the treatment of choice for men with moderate symptoms who were more bothered by them. For men who were not bothered, watchful waiting would seem to be an acceptable alternative. Only 1 in 4 would need surgery over three years, and about 1 in 3 would see their symptoms improve.