## 4 Discussion  
The increase in average life expectancy results in a greater occurrence of functional disorders in aging male patients, with BPH representing one of the most-common and bothersome diseases of aging males, creating an adverse effect on patients' quality of life. Moreover, lower urinary tract symptoms are strongly associated with aging. This was clearly demonstrated in different series and countries, including the Florey Adelaide Male Ageing Study from Australia, where there was a marked effect of age, with 31.5% of men aged 70-80 years reported some degree of bothersome LUTS, compared to 13.4% of the youngest-aged men in the cohort [15]. While some functional decline of the lower urinary tract undoubtedly occurs, with aging being an independent predictor, some other risk factors indirectly correlated with aging processes, such as abdominal fat mass, plasma glucose, obstructive sleep apnea, HDL cholesterol, and energy intake may produce an incremental effect on the intensity of the symptoms, thus potentially shortening the time to the need for surgical management [16]. Additionally, [PERSON] et al. investigated the adverse events related to BPH in the U.S. from 1998 to 2008 and reported significant sequelae, including acute renal failure, bladder stones, and urinary retention [17]. For BPH treatment, there are several options--medical, surgical, and procedural management [18; 19]. In general, surgical treatment is utilized in medically refractory BPH and TURP and has been the traditional gold standard of surgical treatment [20; 21]. However, newer procedures have recently come to the forefront, with some suggesting that HoLEP is potentially a new gold standard of BPH surgery, as it can also treat obstruction caused by high-intensity focused ultrasound (HIFU) treatment for prostate cancer [22; 23]. Recently, UroLift was introduced as a minimally invasive, office-based treatment for BPH, which has shown favorable surgical outcomes [24; 25]. Although we demonstrate that TURP is still the most-common surgery to treat BPH in the U.S. (Figure 2), the number of UroLift procedures has increased remarkably in recent years. The total medical costs related to BPH surgery demonstrate an annual increase, likely from increasing costs of non-TURP options, and it remains to be seen if this trend continues, as other alternative procedures continue with more widespread adoption. There are some interesting trends worth mentioning during the study period. With regards to age, the mean age of those who underwent BPH surgery demonstrated a gradual increase from 67.4 years old in 2004 to 73.4 years old in 2017 (Table 1). In terms of racial differences, we find no disparity among races, which supports the results from a previous study [26]. The increasing age of patients undergoing procedural intervention may reflect increasing safety in BPH treatments and greater efficacy of medical treatments,  
Figure 3: Graph of annual medical costs related to surgery. with the decision of clinicians to delay the need for surgical intervention until later in the disease course. The diagnostic workup prior to BPH procedural management and the studies used are not standardized, so controversy exists regarding what is necessary. These studies include post-void residual measurement, urodynamics, cystourethroscopy, and transrectal ultrasound [27]. We find that cystourethroscopy is the most-common diagnostic tool prior to surgery. The second-most-common diagnostic tool is a PVR, and two-thirds of patients in our study underwent both cystourethroscopy and a PVR. These studies showed consistency throughout the study period and as such, costs of this workup remained low and stable. Our study also demonstrates a steady decrease in the detection of incidental prostate cancer. Several studies have also reported a decrease in incidentally detected prostate cancer due to earlier PSA screening [18; 28]. In terms of incidentally detected prostate cancer during BPH surgery, the detection rate reported by a selection of studies ranges from 21% to 4.8% [18].