A man in his early 70s visited the clinic with worsening urinary symptoms despite having undergone transurethral resection of the prostate (TURP) four years earlier at another hospital. He reported that his urine stream had become weaker and more uncomfortable over time.
Uroflowmetry testing revealed a maximum urinary flow rate of 8.9 mL/s. Considering that a normal maximum flow rate is typically above 15 mL/s, this indicated significant urinary obstruction. The uroflow curve was also abnormal, showing a low peak flow and prolonged voiding time rather than the typical smooth bell-shaped pattern.
A prostate ultrasound was performed next. Although the total prostate volume was measured at 12.4 cc—within the normal range—there was noticeable enlargement of the central portion of the prostate. To further evaluate the condition, cystoscopy was performed. The results confirmed that the median lobe of the prostate had significantly enlarged and was obstructing the urinary passage.
When comparing images from before and after the TURP procedure performed four years earlier, it was clear that the original surgery had been successful at the time. However, over time, regrowth of the median lobe had occurred, leading to recurrent obstruction.
This case illustrates that even when the overall prostate size appears normal, localized enlargement—such as in the lateral lobes or median lobe—can still block the prostatic urethra and cause significant urinary symptoms. In such cases, surgical treatment is often more effective than medication. Because the patient’s symptoms were severe, revision surgery using holmium laser enucleation of the prostate (HoLEP) was performed. The enlarged tissue was removed using a holmium laser, and the patient’s urinary flow improved significantly after surgery.
This example highlights an important clinical consideration: some surgical treatments for benign prostatic hyperplasia may carry a risk of recurrence over time due to continued prostate growth. However, many patients are not fully aware of these differences before undergoing treatment. Understanding the characteristics, advantages, and limitations of each surgical option is essential when selecting the most appropriate approach.
Transurethral resection of the prostate (TURP) has long been considered the standard surgical treatment for BPH. This procedure uses an electrical loop to shave away enlarged prostate tissue through an endoscope inserted via the urethra. TURP has been widely performed for more than 30 years and is still commonly used today. However, it carries a risk of bleeding, and residual prostate tissue may remain after the procedure, which can lead to recurrence over time. As a result, newer techniques such as HoLEP, UroLift, and Aquablation have gradually gained popularity.
The prostate urethral lift procedure (UroLift) is a minimally invasive technique in which small implants are placed to hold the enlarged prostate lobes apart, thereby opening the urethra. It can often be performed under local anesthesia and has advantages such as minimal bleeding and a low risk of retrograde ejaculation. However, it has limitations. It may not be suitable for patients with large prostate volumes or significant median lobe enlargement. In addition, as the prostate continues to grow with age, retreatment may be required.
Holmium laser enucleation of the prostate (HoLEP) is a surgical technique that removes the enlarged prostate tissue completely using a holmium laser. It is often compared to removing the inner portion of an orange while leaving the outer peel intact. Because the obstructive tissue is fully removed, HoLEP has one of the lowest recurrence rates among surgical treatments for BPH. The laser also allows for simultaneous cutting and coagulation, which reduces bleeding and promotes faster recovery. However, one potential side effect is retrograde ejaculation, where semen flows backward into the bladder during ejaculation.
When comparing recurrence rates, studies have reported that TURP has a five-year retreatment rate of approximately 6.1%, UroLift around 13.6%, and HoLEP about 3%. These findings suggest that HoLEP offers the lowest likelihood of recurrence among these commonly used procedures.
In clinical practice, treatment decisions are individualized. For younger patients who are particularly concerned about preserving ejaculation, UroLift may be considered if they meet the appropriate criteria. In most other cases, HoLEP is often recommended due to its durability and strong clinical outcomes.
As men age, urologic conditions such as benign prostatic hyperplasia can significantly impact quality of life. Providing clear and practical information about available treatments can help patients make informed decisions and maintain a healthier, more comfortable life.