Benign but burdensome: Complications and management of benign prostatic hyperplasia during active surveillance of prostate cancer in a large cohort.

OBJECTIVE: To evaluate the prevalence of benign prostatic hyperplasia (BPH) interventions, incidence of BPH-related complications, and subsequent management among men on active surveillance (AS) for prostate cancer (CaP). METHODS: We retrospectively analyzed a prospectively maintained AS database from a single tertiary cancer center. After informed consent, men with clinically localized CaP who initiated AS between 2006 and 2016 were enrolled and followed longitudinally through 2025.Men with <6 months of follow-up or missing key data were excluded. Baseline demographics, lower urinary tract symptoms (LUTS) medication use, and prior BPH surgical history were collected. Outcomes included LUTS interventions during AS (initiation of pharmacologic therapy or surgery) and BPH-related complications. Multivariable logistic regression was used to identify factors associated with complications. RESULTS: A total of 744 men (median age 64 years) with a median follow-up of 108 months were included. Prior to AS, 24% had received LUTS-directed treatment. During AS, 278 men (38%) underwent LUTS intervention with medications or surgery. Ninety-nine men (13%) experienced a BPH-related complication. Larger prostate volume was independently associated with increased odds of complications (OR 1.03 per cc, 95% CI 1.02-1.04, P < 0.001). Among men with complications, 17 (17.7%) underwent BPH surgery. Four men discontinued AS and pursued radical prostatectomy primarily due to uncontrolled LUTS. CONCLUSIONS: BPH-related complications are common among men on AS, yet definitive surgical management is infrequently pursued even after complications. Larger prostate volume identifies patients at increased risk. These findings highlight the need for systematic assessment and evidence-based management of LUTS/BPH in the AS population.