Lessons of the Past: Why Do Minimally Invasive Therapies for Benign Prostatic Hyperplasia Fail?

While minimally invasive surgical therapies have transformed benign prostatic hyperplasia (BPH) care by minimizing recovery time and safeguarding sexual function, post-surgical outcomes are not always guaranteed. In a plenary session at the 2026 Annual Meeting of the American Urological Association (AUA 2026), experts in surgical interventions for BPH discussed strategies for addressing surgical failure and improving outcomes for patients with residual urinary symptoms. 

Successful surgical outcomes rest on two pillars – selecting the right candidate and leveraging the technical advantages of each procedure – according to Claus Roehrborn, MD, Chair of the Department of Urology at UT Southwestern Medical Center in Dallas, Texas. Roehrborn discussed the reasons for the failure of prostatic urethral lift (PUL) treatment in a plenary session at AUA 2026. 

After the initial approval in the United States, PUL was recommended as a treatment option for men with prostate volumes between 30 and 80 cc without an obstructive median lobe who experienced lower urinary tract symptoms (LUTS) secondary to BPH. The system was subsequently cleared for treating obstructive median lobes, as well as larger prostates, up to 100 cc. A systematic review and meta-analysis of 11 studies that included more than 2,000 patients showed that the annual rate of surgical reintervention for PUL was 6% (Miller et al. J Urol 2020; 204:1019-26). 

“Why does PUL fail?” Roehrborn asked. “There are, in my opinion, two causes: a poorly chosen patient or a properly chosen patient and an improper technique.” The correct placement of the device is crucial and positioning should be verified with imaging, such as pelvic X-rays, after the procedure. Placing the clips too close to the bladder can be responsible for residual or new urinary symptoms, the speaker explained. Guidelines for the management of BPH recommend obtaining a post-void residual (PVR) test, as well as preprocedural imaging studies, typically a cystoscopy, to assess the volume and shape of the prostate. Following these steps can ensure that patients are offered adequate interventions that are tailored to their symptoms and anatomy. 

“In my experience, medications are of limited to no use,” Roehrborn remarked. “I realize that a lot of patients go back on medications after PUL for various reasons and I feel that this [approach] fails in most cases. In my hands, repeated minimally invasive surgical therapies are also of limited value.” Ablative surgery may be the best salvage therapy after PUL failure, Roehrborn said, noting that the next line of therapy should be chosen based on the size and shape of the prostate. Options include transurethral resection of the prostate (TURP) for moderate-size prostates (up to 75 g) and Holmium laser enucleation of the prostate (HoLEP) or robot-assisted simple prostatectomy (RASP) for large prostates. 

Water vapor thermal therapy (WVTT or Rezūm) has become a widespread outpatient treatment for BPH. The indications for the procedure have continued to evolve over the past decade, increasing the complexity of the decision process. “Rezūm in 2026 is different from Rezūm in the original pivotal trial and from the original BPH guidelines in 2023,” according to co-panelist Alexander Small, MD, assistant professor of urology at Albert Einstein College of Medicine in New York. “The AUA guideline framework still centers around prostates 30 to 80 cc, but real-world practice has expanded beyond that. Now people are using [this procedure] for larger glands, for median lobes, for catheter-dependent patients and patients with increasingly complex anatomy. As the patient population expands, understanding failure patterns becomes more and more important.” 

Defining failure is the first step toward a solution, Small said, noting that failure can mean different things in the context of therapies for BPH. “People choose Rezūm for multiple reasons, [including] symptom relief, avoiding a larger surgery, avoiding life-long medications, and preserving ejaculatory function,” Small added. “To patients, failure can mean repeat intervention, restarting medications, bothersome sexual side effects, or treating the wrong phenotype altogether. Each definition produces a different failure rate. So, failure is patient-defined, not just surgeon-defined.”

Retreatment rates after WVTT have varied widely in the literature. While in the pivotal trial, which enrolled carefully selected patients, retreatment rates were low (4.4% at 5 years), real-world data from a broader population have reflected higher retreatment rates. “Failures declare themselves early,” Small remarked. “Most retreatments occur within the first year, with a median time of around 11 months. Clinically, this is important because, if a patient is not clearly improving by 3 to 6 months, something is probably wrong. At that point, we should stop reassuring the patient and start investigating.” 

When trying to get to the bottom of the problem, clinicians should consider other, non-anatomical causes of LUTS, such as undiagnosed overactive bladder or detrusor underactivity. Patients’ anatomy should provide clear clues pointing to the underlying causes of treatment failure and guide the next steps. “Salvage therapy is anatomy-driven, patient-driven, and surgeon-dependent,” Small added. “Ultimately, you should treat the anatomy that you find, not the prior procedure.” Salvage therapies include repeat WVTT, TURP, photoselective vaporization of the prostate, HoLEP, and medical therapy for non-obstructive LUTS. 

“When we think about Aquablation failure, it is not a question of the technology failing the patient, it is the surgeon’s failure to understand how the technology works,” said Ravi Munver, MD, professor of urology at the Hackensack University Medical Center, in New Jersey. Munver discussed surgical outcomes of Aquablation, a transurethral heat-free robotic waterjet procedure that has demonstrated durable efficacy in treating BPH, with 3% to 8% retreatment rates reported at 5 years. “Understanding the failure mechanisms and salvage options is clinically important,” the speaker said. “The most common cause of Aquablation failure is failure to treat the anterior intravesical tissue. The technology itself can create treatment angles as great as 225 degrees. Failure to recognize anterior intravesical tissue can result in obstruction and need for additional procedures.” 

Complications such as urethral strictures or bladder neck issues may require additional interventions and careful counseling of patients. Tissue regrowth is also a consideration when any BPH therapy fails, especially in the context of Aquablation, which inherently removes less tissue compared with enucleation procedures. A lack of understanding of the technology and improper ablation planning may lead to undertreatment, Munver noted. 

TURP is the most common salvage therapy that can target residual tissue due to undertreatment. HoLEP is also feasible and safe, while simple prostatectomy may be performed for very large glands. Repeat Aquablation is a possibility, but Medicare coverage is limited to one procedure. However, clinicians must consider that any of the salvage procedures aside from Aquablation can result in ejaculatory dysfunction. 

“When we define failure, we have to use a broader definition,” said Nicole Miller, MD, professor of urology at Vanderbilt University Medical Center in Nashville, who discussed surgical outcomes of HoLEP and its role as a salvage therapy. “Failure can mean need for surgical retreatment, inadequate symptom relief, continuation of medical therapy, or persistent LUTS. HoLEP is a highly successful procedure. It never fails to relieve bladder outlet obstruction when performed properly. In fact, it can be used as a salvage treatment after every single therapy that we are [discussing].” 

Reasons for HoLEP failure may include inadequate resection, a steep learning curve, technical equipment failure, and poor patient selection (eg, patients with small prostates and urinary retention or mixed LUTS). When patients require retreatment, HoLEP is performed in 50% of the cases. TURP and simple prostatectomy are alternative salvage options. 
“Surgical success can still be a treatment failure if it does not improve the patients’ quality of life,” Miller added. “Do not forget behavioral modifications, medication side effects, and preexisting medical conditions that could be influencing their symptoms. Treating male lower urinary tract symptoms is definitely more than relieving outlet obstruction.”