Benign prostatic hyperplasia (BPH) is a condition in which the prostate enlarges and compresses the urethra, leading to various urinary symptoms such as weak stream, incomplete emptying, and increased frequency. Initial management typically involves watchful waiting or medication. However, when symptoms persist or worsen, surgical treatment may be considered. The choice of surgical approach should be individualized based on the patient’s health status, prostate size and anatomy, symptom severity, and treatment goals.
There are several surgical options available for BPH. Holmium laser enucleation of the prostate (HoLEP) removes enlarged prostate tissue using a holmium laser, separating it from the prostatic capsule and extracting it completely. Prostatic urethral lift (UroLift) is a minimally invasive procedure that uses implants to retract prostate tissue and widen the urethra. Aquablation therapy is a robot-assisted, waterjet-based technique that removes prostate tissue using high-pressure saline without thermal damage. The Rezūm system delivers steam into the prostate to ablate excess tissue. Each method has its own advantages and limitations, and the optimal choice depends on individual patient needs.
For patients with a large prostate, typically greater than 70–80 grams, HoLEP is often recommended. It is highly effective even in significantly enlarged prostates and can also address complex anatomy, such as a prominent median lobe, bladder neck obstruction, or intravesical protrusion of the prostate.
For older patients or those with underlying medical conditions, especially those who must continue antiplatelet therapy such as aspirin due to stroke risk, minimally invasive options are preferred. Procedures like Aquablation, UroLift, and Rezūm are associated with lower bleeding risk and can often be performed more safely in these populations.
For patients who wish to avoid prolonged catheterization, minimally invasive procedures such as UroLift are often preferred. These approaches may allow catheter-free discharge or significantly shorter catheter duration. HoLEP and Aquablation also typically require only short-term catheter use compared to more invasive procedures.
For patients concerned about recurrence, HoLEP and Aquablation are strong options. Both techniques remove a substantial amount of prostate tissue, resulting in durable outcomes and lower retreatment rates. In contrast, UroLift repositions rather than removes tissue, which may lead to a relatively higher likelihood of recurrence over time.
For patients who prioritize preservation of ejaculation, this factor should be carefully considered when selecting a procedure. HoLEP carries a higher risk of retrograde ejaculation, whereas UroLift, Rezūm, and Aquablation are generally associated with better preservation of ejaculatory function, making them more suitable for younger or sexually active patients.
Cost is another important consideration. HoLEP is typically covered by national health insurance in many healthcare systems, making it a more cost-effective option. In contrast, procedures such as UroLift, Rezūm, and Aquablation may not be fully covered and can result in higher out-of-pocket expenses.
In summary, BPH surgery is not a one-size-fits-all solution. The best approach depends on aligning the treatment method with the patient’s specific condition, preferences, and priorities. With access to a full range of surgical options, truly personalized treatment is achievable. Patients considering BPH surgery are encouraged to have a detailed consultation with their urologist to determine the most appropriate and effective treatment plan.