Personalizing BPH Management: Bladder Stone Removal Alone vs. With Concomitant Laser Enucleation—A Multicenter Perspective With Patient Reported Outcomes and Decisional Regret Analysis

Introduction: The necessity of routinely combining bladder stone removal with surgical treatment for BPH remains debated. We compared the efficacy and safety of bladder stone removal with and without concomitant outlet surgery in patients with BPH. Methods: We conducted a multicenter ambispective cohort study comparing bladder stone removal alone vs. removal with concomitant holmium laser enucleation of the prostate (HoLEP). BPH patients with bladder stones > 1 cm were included. Exclusion criteria ruled out alternative causes of bladder stones. The “stone removal-only” group (n = 63) underwent endoscopic removal at Mount Sinai, while the “HoLEP” group (n = 42) underwent a combined procedure at Sourasky Medical Center. Outcomes included 90-day complications, stone recurrence, IPSS scores, and decisional regret. Results: At baseline, HoLEP patients had higher PVR, greater use of 5-ARI, and more frequent preoperative catheterization, while the stone removal-only group had greater stone burden. Compared to HoLEP, stone removal alone was associated with higher bladder stone recurrence (14% vs. 0%) and a slightly higher symptom burden (median IPSS: 8 vs. 4), but lower overall (13% vs. 31%) and major complication rates (0% vs. 5%). Despite these differences, 77% of patients managed by stone removal alone remained free of BPH surgery at 3 years and reported higher long-term satisfaction. Based on the results, we developed a shared decision-making tool and user-friendly app for clinical use (PreOp Decision). Conclusion: Bladder stone removal alone is a viable option for selected patients, and BPH surgery should be guided by obstruction severity, not stone presence. Shared decision-making is essential, and our proposed questionnaire may help guide treatment selection pending future validation.