To identify and evaluate the clinical and demographic determinants of benign prostatic hyperplasia (BPH) surgical care access and selection.

The American Urological Association Quality registry was utilized to evaluate all patients with a BPH diagnosis. This cohort was then queried for patient clinical and demographic factors and physician and practice parameters. The primary outcome was undergoing BPH surgical intervention with further classification by procedural type. Descriptive statistics, as well as univariate and multivariate regression were performed to identify predictors of surgical intervention.

Between 2014 and 2023, 2,197,045 patients with a BPH diagnosis were included, and 159,073 (7.2%) underwent surgery. Resective/ablative procedures were most common (62,173; 39%), followed by minimally invasive surgical techniques (MIST) (51,038; 32%) and enucleation (3350; 2%). On multivariate regression, more severe clinical presentation (older age, longer time from diagnosis, symptoms and sequelae of BPH) were associated with a higher likelihood of surgical intervention (p<0.001). Demographically, higher income patients and non-metropolitan, smaller practices were associated with surgical intervention (p<0.001). When evaluating specific surgical type, factors associated with MIST on multivariate regression included less severe clinical presentation and a nonacademic urology practice.

BPH surgical selection is complex and multifactorial. Patient clinical factors, demographic factors, and provider characteristics all play a role in determining when and what surgery is performed. By identifying these factors, we can begin to assess barriers to care, resource utilization, and decision making.