More than three-quarters of men older than 40 yr experience at least one lower urinary tract symptom (LUTS), which can compromise quality of life (QoL), employment, and social activities [1]. Potential mechanisms contributing to LUTS include benign prostate obstruction (BPO), detrusor underactivity, overactive bladder (OAB), chronic pelvic pain, nocturia, and urethral diseases. Guidelines recommend offering surgical treatment if LUTS/BPO cases are severe and unresponsive to behavioural and pharmacological therapies [2]. The decision to perform surgery is a critical step that requires careful consideration of various factors. Determination of when surgery is appropriate involves assessment of the type and severity of symptoms, bother, impact on QoL, the response to conservative therapies, and the presence of complications. The decision should also take into account the global clinical picture, including the patient’s medical history, associated conditions, prostate size and shape, and factors that may lead to complications to properly estimate the risk/benefit balance. Patient preferences and expectations are also essential considerations in the decision-making process: decisions must be shared between patients and health care providers to ensure that any treatment aligns with patient values and preferences [3]. By carefully considering these factors, urologists try to develop individualised treatment plans that optimise patient outcomes and QoL. However, analysis of the USPTREAM trial revealed that approximately 25% of patients reported worsening symptoms in comparison to baseline at their last follow-up visit, raising concerns about the quality of care in this population [4]. This situation is more common than urologists realise and is badly under-reported.

The European Association of Urology (EAU) guidelines on male LUTS is an evidence-based document containing information on the current best evidence and practice for health care providers [2]. Here we describe practical tips for patient selection to achieve optimal surgical outcomes in BPO.