Benign prostatic hyperplasia (BPH) is a condition that occurs only in men, in which the prostate enlarges and compresses the urethra, leading to various urinary symptoms. Common symptoms include a weak urinary stream, intermittent flow, a sensation of incomplete emptying after urination, and increased urinary frequency.
To diagnose BPH, several evaluations are performed to assess urinary function and prostate size. Uroflowmetry and post-void residual urine tests help determine the patient’s voiding pattern and whether urine is being adequately emptied from the bladder. Transrectal ultrasound is used to measure prostate volume, while cystoscopy allows direct visualization of the urethra, prostate, and bladder. In Korea, BPH is generally suspected when prostate volume exceeds 30 cc, and a prostate larger than 80 cc is considered significantly enlarged.
Treatment decisions are guided by symptom severity, often assessed using the International Prostate Symptom Score (IPSS). In patients with mild symptoms or relatively small prostate size, medical therapy is usually effective. Common medications include alpha-blockers, which relax the urethra to improve urine flow, and 5-alpha reductase inhibitors, which reduce prostate size. Additional medications targeting bladder function may also be used to alleviate symptoms such as frequency and nocturia.
When symptoms do not improve with medication or when side effects limit treatment, surgical options are considered. A range of procedures is available. Holmium laser enucleation of the prostate (HoLEP) removes enlarged prostate tissue completely using a laser. UroLift mechanically retracts prostate tissue to widen the urethra without removing tissue. Aquablation, a waterjet-based robotic procedure, allows precise removal of prostate tissue, while Rezūm therapy uses steam to ablate excess tissue.
Among these options, HoLEP is considered one of the most effective methods for removing prostate tissue and is often recommended because it is covered by national health insurance in many settings. However, HoLEP has a significant learning curve and requires a high level of surgical expertise. In addition, the cost of equipment can be substantial, which may limit its availability in some clinics. As a result, some centers may prefer simpler but less effective procedures. Despite this, when performed by experienced surgeons in well-equipped institutions, HoLEP can provide excellent outcomes. For example, a 68-year-old patient who presented with complete urinary retention and required catheterization achieved a peak urinary flow rate of 23.7 mL/sec after undergoing HoLEP, which is considered within the normal range for comfortable urination.
It is important to note that no surgical treatment is entirely without limitations. In the case of HoLEP, retrograde ejaculation—where semen flows backward into the bladder—occurs relatively frequently. Therefore, no single procedure can be considered perfect for all patients. Choosing the most appropriate treatment requires careful evaluation of individual symptoms, prostate characteristics, and patient preferences.
BPH management should be tailored to each patient. Consulting with an experienced urology specialist and selecting a treatment option based on a comprehensive understanding of available procedures can significantly improve treatment satisfaction and outcomes.