---
title: Age is not the first thing to check before prostate surgery
publication: Medical Insights Korea
section: columns
category: Prostate
canonical_url: https://medicalinsightskorea.com/columns/urology/age-is-not-the-first-thing-to-check-before-prostate-surgery
author: Jeman Ryu, Specialist in Urology
author_type: contributing clinician, not editorial staff
author_practice: Goldman Urology Clinic, Seoul Station
author_credential_issued_by: Ministry of Health and Welfare, Republic of Korea
author_profile: https://medicalinsightskorea.com/authors/jeman-ryu
editorial_note: Signed opinion by the named clinician. Written by them, edited and translated by Medical Insights Korea. Not a reported article, and not a clinical review of this publication's reporting.
published: 2026-09-11T08:00:00+09:00
modified: 2026-09-11T08:00:00+09:00
content_type: opinion
license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL.
---

# Age is not the first thing to check before prostate surgery

A urologist on the questions that actually decide whether an older man can have his prostate operated on — the drugs, the size of the gland, what a previous operation left behind, and the bladder nobody examined.

## Answer

Age on its own does not decide whether a man with benign prostatic enlargement can have surgery: in a national database of 1,798 men in their eighties who had prostate surgery, the independent predictors of complications were ASA class, dependent functional status, operative time and having an open rather than an endoscopic operation — the number of years was not among them — and the questions that do decide are which anticoagulant or antiplatelet drugs the patient takes and whether they can safely be stopped, how large the gland is, what a previous operation or implant left behind when symptoms return, and whether the bladder muscle still contracts, because a bladder worn down by years of pushing against an obstruction may not recover its strength even after the obstruction is removed.

## Key takeaways

- Age is not an independent predictor of complications after prostate surgery. In 1,798 octogenarians in a US national surgical database, the predictors were ASA class, dependent functional status, operative time and open rather than endoscopic surgery.
- In the same series, laser enucleation took a median 94 minutes against 153 for open simple prostatectomy, and needed transfusion in 3.2 percent of patients against 27.5 percent.
- Anticoagulant and antiplatelet drugs are a reason to plan the operation differently, not to cancel it. Stopping them on the patient's own initiative can raise the risk of a clot or a cardiovascular event.
- A very large prostate once meant an open operation. Endoscopic enucleation now removes large glands through the urethra, but a larger gland still means more tissue, more bleeding to control and a longer recovery.
- Symptoms returning after a previous prostate operation do not necessarily mean the prostate has regrown. Scarring can narrow the bladder outlet or urethra, and a previously placed implant has to be accounted for.
- In 59 men having laser enucleation after a previous prostatic urethral lift, baseline incontinence symptoms were significantly more severe than in matched men having their first prostate operation — but the outcomes after surgery were no different.
- Long-standing obstruction damages the bladder muscle. In men with measured detrusor underactivity, contractility did not improve a year after prostate surgery even though symptoms, flow rate and residual volume did.
- Postponing treatment purely because of age is not automatically the safe choice: untreated obstruction can lead to repeated retention, urinary infection and effects on the upper urinary tract and kidney function.

## Full article

“He is quite old — is it still all right for him to have prostate surgery?” It is a question I am asked constantly by elderly patients with benign prostatic enlargement and by the families who come with them. The stream has weakened and the nights are broken by repeated trips to the bathroom, but the moment an operation is mentioned, worry comes first. If there is hypertension or diabetes, and heart medication on top, more so. Sometimes the conclusion has already been reached before the consultation starts: uncomfortable as it is, at his age it is probably better to put up with it.

Deciding on surgery for benign prostatic enlargement is not a matter of sorting patients into possible and impossible by age. Among men in their eighties there are patients who are active and whose cardiopulmonary function is stable, and there are younger patients whose general condition is poor from several coexisting illnesses. What actually has to be examined is not the age on the identity card but the present state of the body, the coexisting conditions, the drugs being taken, the size and shape of the prostate, and how the bladder is working.

> **What the largest series in this age group actually found**  
> Of 136,991 men who had surgery for benign prostatic obstruction in the American College of Surgeons National Surgical Quality Improvement Program between 2010 and 2023, 1,798 were octogenarians. The independent predictors of thirty-day complications were higher ASA class, dependent functional status, longer operative time, and having an open simple prostatectomy rather than a laser enucleation. Age itself was not one of them — every man in that comparison was already over eighty, and what separated them was condition and operation. The same series is the argument for the endoscopic route in this group: laser enucleation took a median 94 minutes against 153 for open surgery, required transfusion in 3.2 percent against 27.5 percent, and sent more patients home rather than on to another facility.

### The drugs come first

In older patients there are many variables to confirm before an operation. Beyond hypertension and diabetes, cardiac and cerebrovascular disease is common, and with it drugs that suppress clotting — antiplatelet agents and anticoagulants. These are related to bleeding during surgery, and yet they cannot simply be stopped at will. In some patients, stopping the drug raises the risk of a clot or a cardiovascular or cerebrovascular event instead.

So what has to be established in advance is which drug is being taken, whether it can be interrupted, and how much of a burden the patient can bear from the operation and the anaesthetic. That is a question for the cardiology team as much as for the urologist, and it is settled before a date is set rather than on the morning of the operation.

### The size of the gland changes the operation

The state of the prostate itself governs the difficulty. If it has grown very large, the volume of tissue that must be removed to secure the urinary passage is correspondingly greater. In the past a prostate that was too big required an operation opening the abdomen to remove the enlarged tissue. Now holmium laser enucleation of the prostate and similar techniques allow large volumes of prostate tissue to be removed with an endoscope passed through the urethra.

That does not make every operation equally straightforward simply because nothing is cut open. The larger the prostate, the more tissue there is to remove, and the more there is to consider in controlling bleeding and in recovery afterwards.

### When it is not the first operation

For a patient who has already had prostate surgery or a procedure, the situation is different again. Urinary difficulty returning after treatment does not necessarily mean the prostate has grown back. Remaining tissue may have enlarged, but scarring at the operated site may equally have narrowed the bladder outlet or the urethra. If a procedure such as a prostatic urethral lift was performed, the implants still in place and the state of the surrounding tissue also have to be assessed.

Treating a different cause the same way is unlikely to produce the result the patient wants, so the more this is a repeat operation, the more the process of establishing the present state accurately matters.

> **What a previous implant does and does not change**  
> A single-institution registry compared 59 men having holmium laser enucleation after a previous prostatic urethral lift with 118 matched men having enucleation as their first prostate operation. The men who had had the implant arrived with significantly more severe incontinence symptoms at baseline, and their tissue was slower to morcellate. What did not differ was the outcome: after surgery the two groups were comparable. Prior treatment is a reason to look carefully before operating, not a reason to expect a worse result.

### The organ nobody asks about

There is one more thing to examine here, and it is the bladder. Benign prostatic enlargement does not end as a problem of the prostate alone. Pushing urine out through a narrowed passage, with effort, over a long period, accumulates a burden on the bladder muscle. When its contractile strength falls away with time, voiding function may not recover as much as expected even after enough prostate tissue is removed to widen the passage. In severe cases repeated retention and urinary infection follow, and the upper urinary tract and kidney function can be affected.

That is why continuing to postpone treatment purely because of age is not necessarily the safe choice.

> **Precisely what does and does not recover**  
> A small study measured this directly. Twenty-four men having prostate surgery were divided by pre-operative pressure-flow studies into those with detrusor underactivity and those without. A year after surgery the underactive group had significantly improved symptom scores, quality of life, peak flow and residual volume — but their measured bladder contractility index had not risen. The muscle did not get stronger; the men got better. It is an exploratory study of two dozen patients and should be read as such, but it makes the distinction worth holding onto: a weakened bladder is a reason to set expectations carefully and to measure before operating, not a reason to conclude that surgery will achieve nothing.

### What the question should be

In treating an elderly patient, or one with existing illness, what matters is not only whether an operation can be done. If surgery is needed, what is required is to find first what risk factors this particular patient carries, and then to plan how those risks will be reduced. The same method cannot be applied to a patient whose bleeding risk has to be accounted for, a patient with a very large prostate, and a patient whose symptoms have returned after previous surgery. The operation, the anaesthetic and the management before and after all have to change with the patient's condition.

There is no single operation for benign prostatic enlargement that is best for every patient. What matters is finding, among several treatments, the one suited to the state of this prostate and this man's general health. Rather than abandoning treatment on the grounds of age or existing illness alone, it is worth assessing the present voiding state, bladder function and general condition accurately, and weighing the benefit that treatment can bring against its risk. The first thing to establish before prostate surgery in an older patient is not his age. It is how the treatment he needs can be given while reducing what it costs him.

**The same operation, approached from the bleeding risk**

- [He cannot stop his blood thinners. That is not a reason to rule out prostate surgery](https://medicalinsightskorea.com/columns/urology/bph-surgery-when-the-blood-thinners-cannot-be-stopped) — A urologist on what the guidelines name for patients on antithrombotic therapy.

## Sources

- Abdelaziz A, Williams A, Bakbak H, Meyreles M, Porto JG, Kendrekar P, Waldo Garcia A, Katz JE, et al. Comparing outcomes of laser enucleation of prostate with robotic and open simple prostatectomy in octogenarians: insights from NSQIP. Journal of Endourology 2026;40(5):579-586. doi:10.1177/08927790261416035. PMID:42015523. https://doi.org/10.1177/08927790261416035
- Vale L, Charrua A, Martins-Silva C, Albino-Teixeira A, Cruz F, Antunes-Lopes T. Selected patients with benign prostatic enlargement and detrusor underactivity may benefit from prostate surgery: an exploratory study. Urology Research & Practice 2026;52:1-5. doi:10.5152/tud.2026.26005. PMID:42381342. https://doi.org/10.5152/tud.2026.26005
- Patel A, Guo JN, Xu P, McDonald A, Fadl-Alla A, Krambeck A. Holmium laser enucleation of the prostate after prostatic urethral lift: the state of bother. International Urology and Nephrology 2026; online ahead of print. doi:10.1007/s11255-026-05150-z. PMID:42082863. https://doi.org/10.1007/s11255-026-05150-z
- Goueli R, Badlani GH, Welliver C, Anderson PD, Bauer SR, Dana T, Donalisio da Silva R, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline (2026) Part III: Procedural/Surgical Management. The Journal of Urology 2026;216(2):161-170. doi:10.1097/JU.0000000000005099. PMID:42095468. https://doi.org/10.1097/JU.0000000000005099
- Romero-Otero J, García-Gómez B, García-González L, García-Rojo E, Abad-López P, Justo-Quintas J, et al. Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice. BJU International 2020;126(1):177-182. doi:10.1111/bju.15028. PMID:32020749. https://doi.org/10.1111/bju.15028

## Citation

Jeman Ryu (2026). "Age is not the first thing to check before prostate surgery". Medical Insights Korea. https://medicalinsightskorea.com/columns/urology/age-is-not-the-first-thing-to-check-before-prostate-surgery

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