Benign prostatic hyperplasia (BPH) is a condition in which the prostate gradually enlarges and compresses the urethra, interfering with normal urine flow. Common lower urinary tract symptoms include a weak urinary stream, intermittent flow, a sensation of incomplete emptying, and frequent nighttime urination (nocturia).
Treatment for BPH is broadly divided into medical therapy and surgical intervention. Medical treatment includes several types of medications. Alpha-blockers help relax the urethra and improve urine flow. 5-alpha reductase inhibitors reduce prostate size over time. Additional medications may be used to control bladder overactivity or reduce nocturnal symptoms. However, medication alone often does not provide a definitive solution, and many patients eventually require surgical treatment.
Several surgical options are available for BPH, each with distinct advantages and limitations.
Holmium laser enucleation of the prostate (HoLEP) uses a holmium laser to precisely separate and remove enlarged prostate tissue from the prostatic capsule. This technique allows for complete removal of the obstructing tissue, resulting in a very low recurrence rate. It also enables tissue analysis, which can aid in diagnosing prostate cancer if suspected. HoLEP is effective even in cases with a large prostate, prominent median lobe enlargement, or bladder neck obstruction. Additionally, bladder stones can be treated simultaneously. Because it is often covered by national health insurance, it tends to be more cost-effective. However, temporary catheterization is usually required after surgery, and side effects such as retrograde ejaculation may occur.
Prostatic urethral lift (UroLift) is a minimally invasive procedure performed using cystoscopy. It involves placing implants to retract and hold the enlarged prostate tissue away from the urethra, thereby improving urine flow. The procedure is quick, typically taking 5 to 10 minutes, and has a low risk of bleeding. It can be performed under local anesthesia and often does not require catheterization. Preservation of ejaculatory function is a major advantage. However, because the tissue is not removed, it may not provide a long-term solution, and recurrence rates are relatively higher. It is also not always covered by insurance, and costs may increase depending on the number of implants used. Furthermore, it may not be suitable for very large prostates or cases with significant median lobe enlargement.
Aquablation therapy is a robot-assisted surgical technique that uses high-pressure water jets to remove prostate tissue. It is minimally invasive and typically completed within about 15 minutes. Because it does not use thermal energy, the risk of damage to surrounding tissues is reduced, and complications such as urethral stricture are less common. The use of real-time imaging allows surgeons to preserve structures important for ejaculation, resulting in a lower incidence of retrograde ejaculation. However, this procedure is generally not covered by insurance and may involve higher costs.
The Rezūm system is another minimally invasive option that uses steam injections delivered through a small needle into the prostate tissue. The steam causes targeted tissue necrosis, leading to gradual shrinkage of the enlarged prostate. The procedure typically takes 10 to 15 minutes and can be performed under local anesthesia, making it suitable for older patients or those with underlying medical conditions. It has a low risk of bleeding and a relatively low incidence of sexual side effects. However, symptom improvement may take several weeks to months, as the tissue gradually shrinks. Catheterization may be required for a longer period compared to other procedures, and it is not always covered by insurance, resulting in higher out-of-pocket costs.
Each of these surgical options has unique characteristics, and the optimal choice depends on the patient’s condition, priorities, and treatment goals. Timely and appropriate treatment is essential in managing BPH effectively. Patients experiencing bothersome urinary symptoms are encouraged to consult a urology specialist to determine the most suitable, personalized treatment approach.