Dr. Na Jun-chae, Goldman Urology Clinic Jamsil Branch
Benign prostatic hyperplasia (BPH) is a condition in which the prostate becomes enlarged and compresses the urethra, leading to various urinary difficulties as urine flow becomes obstructed. In most cases, watchful waiting or medication is attempted first, but when symptoms do not improve, surgical treatment may be considered. There are several surgical options for BPH, and the most appropriate method depends on the patient’s condition and individual needs. Therefore, a precise diagnosis is essential to determine whether surgery is truly necessary and which procedure is most suitable.
There are several surgical approaches for treating BPH. One of the most widely used methods is holmium laser enucleation of the prostate (HoLEP), which removes enlarged prostate tissue using a holmium laser. In this procedure, the tissue is separated along the natural plane between the prostate capsule and the enlarged prostate and then removed from the body. Another option is the prostatic urethral lift (UroLift), a relatively simple procedure that uses an endoscope to place implants that hold the prostate tissue apart, thereby widening the urethra and improving urine flow.
Aquablation, also known as robotic waterjet surgery, removes enlarged prostate tissue using high-pressure water without generating thermal energy. The Rezum system, on the other hand, treats BPH by injecting steam into the prostate through a small needle, causing targeted tissue necrosis. For elderly patients or those who wish to preserve ejaculation function, the iTIND procedure may also be considered. iTIND involves inserting a temporary nitinol stent into the prostate for about one week to widen the urethra. Each of these methods has its own advantages and limitations, and the most appropriate choice varies depending on the patient’s condition and clinical needs.
When the prostate size reaches approximately 70–80 grams or more, it is generally considered a large prostate. In such cases, HoLEP surgery is commonly recommended because it can effectively remove a large amount of prostate tissue. HoLEP can also be highly effective when there is a prominent median lobe, bladder neck obstruction, or when the prostate protrudes into the urethra or bladder.
For elderly patients or those with underlying medical conditions—particularly patients who must continue taking medications such as aspirin after a stroke—less invasive treatment methods are often preferred. Procedures such as robotic waterjet surgery, UroLift, and Rezum may be recommended because they carry a lower risk of bleeding and can generally be performed in a less invasive manner.
Some patients are also concerned about wearing a urinary catheter for a long period after surgery. For patients who are particularly uncomfortable with this possibility, minimally invasive procedures such as UroLift may be recommended, as patients can often be discharged without a catheter. In addition, HoLEP and Aquablation typically do not require prolonged catheter use.
Patients who are concerned about recurrence may be advised to consider HoLEP or Aquablation. These procedures remove prostate tissue more completely and therefore tend to have lower recurrence rates. By contrast, UroLift simply retracts the prostate tissue without removing it, which can result in a relatively higher chance of recurrence. For younger patients, preservation of ejaculation function may be an important consideration. Because HoLEP may lead to retrograde ejaculation, alternatives such as UroLift, Rezum, Aquablation, or iTIND may be recommended.
Financial considerations can also influence the choice of surgery. HoLEP is covered by national health insurance in Korea, making it relatively more affordable. Other procedures may not be covered by insurance, which can increase the cost burden for patients.
Ultimately, selecting the most appropriate surgical method for BPH requires careful evaluation of each patient’s condition and individual needs. Choosing a medical institution capable of performing the full range of BPH procedures is important for truly personalized treatment. Patients considering surgery for BPH are advised to have thorough consultations with their physician to determine the treatment approach best suited to their situation.