This page goes over the most commonly performed, as well as latest, surgical options for BPH. The opinions expressed are my own, however I did try to keep it as evidence based as possible.
HoLEP
See my other page for a detailed explanation of the procedure. Here is a video of an actual procedure.
TURP
TURP, or transurethral resection of the prostate, has long been considered the “gold standard” for BPH surgery. This is because it has a long standing track record of good performance. It is effective because it opens up the prostate channel by cutting away the obstructing tissue. Although there are a host of alternative options for BPH, TURP still remains the most commonly performed surgery because of its efficacy and familiarity among urologists.
In terms of disadvantages when compared to HoLEP, there are several.
The main disadvantage is that there is a size limitation for which TURP is effective. When the prostate size starts to get larger than 80 to 100 cc, there is simply too much tissue to resect for TURP to be effective. Often times, with large prostates, if the urologist cannot do a HoLEP, he will recommend that the patient have a Simple Prostatectomy (a surgery with an incision/incisions on the abdomen) or staged TURP (meaning it is done in two separate surgeries).
Another disadvantage is a higher re-treatment rate compared to HoLEP. When the obstructing prostate tissue is resected, as opposed to enucleated, it is harder to reliably remove all of the tissue. The tissue plane between the outer capsule and the inner tissue can be hard to identify with resection (as opposed to enucleation). This leads to a higher chance that another procedure will be required in the future due to regrowth.
Finally, TURP has a higher rate of delayed bleeding after surgery. During the healing process (usually seen after a few weeks), the remaining prostate tissue starts to slough off, and at that time, bleeding can occur. There is generally more sloughing that occurs with TURP (compared to HoLEP), and thus the risk for heavy delayed bleeding requiring intervention (catheterization, surgical procedure to remove the blood clots) is higher for TURP compared to HoLEP. In fact, the AUA (American Urology Association) guidelines recommend HoLEP over TURP for men on blood thinners (plavix, warfarin, xarelto, eliquis) for this very reason.
Regardless, TURP is an effective procedure for men with BPH and the majority of men who undergo this procedure will be satisfied with their outcome.
TUIP
TUIP, or transurethral incision of the prostate, is another surgical option for BPH. TUIP can be performed with a variety of energy devices, including a cautery device and laser. TUIP involves incising the prostate in several locations to open up the prostatic channel. It is an effective option for men with small prostates. In particular, some men are born with prostate anatomy that is prohibitive to urine exiting the bladder (the medical term is known as a high median bar). TUIP offers treatment for these men with less disruption of the normal prostate anatomy. It often preserves a mans ability to ejaculate normally. Retrograde ejaculation (or ejaculation that goes back into the bladder and is later urinated out) is a common side effect of prostate medications (tamsulosin) and prostate procedures (TURP, HoLEP, Laser Ablation, Simple Prostatectomy). For some men, avoiding this side effect is important. Especially those who are younger and interested in fathering children.
Photovaporization of the Prostate / Laser Ablation
Laser Ablation procedures are alternative options for the management of BPH. The most commonly performed among them is the photovaporization of the prostate (PVP). These procedures use a laser to ablate the obstructing prostate tissue and thus create a wider prostate channel.
There are a couple advantages of laser ablation over TURP.
The main one is that there is a lower bleeding rate during the procedure. I do not typically finding bleeding during prostate procedures to be a major concern however. Rarely is it necessary to need a blood transfusion during the surgery.
Another advantage is a low depth of energy penetration from the laser. This translates to a lower risk of injury to surrounding tissue, including the nerves that go to the penis to assist with erections. I find that this is more of a theoretical concern than a realistic one however, as men have rarely been shown to have side effects that could be attributed to energy penetration beyond the prostate. In fact, these days TURP is done using a bipolar instrument, where the energy stays very close to the area of resection.
The final advantage (which I think is the biggest one) pertains to the PVP specifically. These days, the laser is very powerful and urologists who perform this procedure commonly have had good success treating fairly large prostates (>100 grams). These are prostates that a TURP cannot effectively treat.
Laser ablation has some disadvantages however.
The main one is that no tissue is removed from the prostate that can be sent to analyze for cancer. 10% of the time, a man is found to have prostate cancer after TURP, HoLEP, or Simple Prostatectomy. Although often this cancer is low grade and insignificant, it can sometimes be more aggressive and thus would be important to know if it was found.
In my opinion, another disadvantage is that ablation procedures have more irritative voiding symptoms during the recovery period. As this tissue resorbs or sloughs off, men often experience increased urinary urgency, frequency, nighttime voiding, and burning with urination. It can be quite bothersome. I find this to be more common after laser ablation than TURP or HoLEP. A laser ablation surgeon may disagree.
Another disadvantage is a higher rate of delayed bleeding compared to HoLEP. Although the AUA guidelines recommend Laser Ablation (along with HoLEP) over TURP for men on blood thinners due to its ability to control bleeding during the surgery, it has a higher rate of delayed bleeding compared to HoLEP. This has to do with the fact that this ablated tissue often sloughs off after a few weeks and blood vessels underneath have the potential bleed.
The final criticism of laser ablation has been a historically higher re-treatment rate compared to TURP. Certainly it is higher than HoLEP. For PVP however, this concern has lessened as the laser has become more powerful.
In summary, many urologists perform laser ablation, and it is an effective option for BPH. If this type of procedure is your urologist’s preferred method of treating BPH, and he/she performs it commonly, then you will likely have a good outcome and be satisfied with your result.
Urolift
Urolift is a nice, minimally invasive, option for men with BPH. It uses tacking suture to hold the prostate channel open.
It has the advantage, compared to other surgeries, of minimal disruption to the native prostate tissue. In my opinion, this can be a good option for men with smaller prostates as well as men who have improvement with prostate medications but cannot tolerate them due to side effects. Also, it does not result in retrograde ejaculation, so it can be a good option for men in whom this is a major concern. There is little down time from the procedure with quick return to normal activity (no lifting restrictions post operatively, for example).
It results in an improvement in urinary symptoms over medications, however not quite to the extent that a procedure that removes prostate tissue (TURP, HoLEP, ablation) can do. It also has a higher retreatment rate compared to TURP, HoLEP, and laser ablation.
Overall, men who are appropriately selected for this procedure notice a lasting, and significant, improvement in their urinary symptoms.
Rezum
Rezum is another nice, minimally invasive option, for men with BPH. Rezum uses water vapor to disperse energy in a fix area around a needle inserted into the prostate. The water vapor cannot penetrate the capsule between the outer and inner parts of the prostate, so the energy stays confined to the obstructing prostate tissue. This translates to a lower risk of injury to surrounding tissue, including the nerves that go to the penis to assist with erections. I find that this is more of a theoretical concern than a realistic one however, as men have rarely been shown to have side effects that could be attributed to energy penetration beyond the prostate.
There is little down time from the procedure with quick return to normal activity (no lifting restrictions postoperatively, for example). Most urologists leave a foley catheter in for a few days after the procedure, however some do not. There is a delay to noticing improvement in urination due to the requirement of the tissue needing to be reabsorbed into the body after it has been treated.
Since I do not have experience in performing this procedure, I cannot speak accurately in regards to the symptoms and recovery afterwards. Historically speaking, procedures similar to this (transurethral microwave therapy, for example) have been fraught with a lot of irritative voiding symptoms (urgency, frequency, nighttime voiding, burning with urination) postoperatively. The reason that most urologists leave a catheter in afterwards for a few days is because of this very reason. It can also be difficult to urinate right away due to swelling.
Overall, this is a novel procedure that is a major improvement in minimally invasive ablation therapy. Not all mens’ prostates are shaped the same way, and thus the ability to direct the treatment into the area desired (due to use of the needle) is the key to this therapy.
Aquablation
Aquablation uses a guidance system to direct an autonomous, robotically controlled, instrument that ablates the prostate tissue in a systematic manner using a high frequency pulsed water jet. By marking out the intended area of treatment, there is excellent control in determining which parts of the prostate are ablated. It has been shown to be effective in larger size prostates. So this could could become a good option for patients with enlarged prostates who do not live in parts of the country where HoLEP is offered.
The procedure does have post treatment bleeding issues (since the water is not hemostatic) that is managed with cauterization of the bladder neck at the end of the case.
The procedure spares some tissue at the prostatic apex, thus preserving antegrade ejaculation in 90% of men.
Long term efficacy should be good due to its ability to reliably ablate a large volume of tissue. I do think the retreatment rate will prove to be slightly higher than HoLEP due to its inability to ablate anterior tissue. Apical tissue may grow over time as well. Finally, some men with poor detrusor (bladder) contractility (functional ability to squeeze) may not get adequate symptom improvement due to preservation of apical prostate tissue. Long term follow up is necessary for this new technology to make the above determinations.
https://youtu.be/D-VNCa760qo
Simple Prostatectomy
Simple prostatectomy is the oldest, and most definitive option, for BPH. A simple prostatectomy removes the obstructing prostate tissue through an incision, or incisions, on the abdomen. In terms of what it is accomplishing, it does the same thing that a HoLEP does. It enucleates, or completely removes, the obstructing tissue in the middle of the prostate. Unlike the HoLEP however, it is a more invasive procedure. These days, it is often done laparoscopically (small incisions across the abdomen) with the assistance of the Da Vinci Surgical Robot. Historically, it has been done as an “open” procedure through a single, larger, incision on the lower abdomen. Some urologists still perform it this way. Either way, it is a very effective option for men with large prostates (in whom TURP would be ineffective). It has a very low re-treatment rate (< 2%, same as the HoLEP). The downside is that it is a more invasive procedure with a longer recovery time, longer catheterization time, and a higher bleeding risk when compared to HoLEP.
Prostate Artery Embolization
Prostate Artery Embolization (PAE) is another minimally invasive option for BPH. It is accomplished through a small stab incision in the groin area. A catheter is then placed in the leg artery and directed up into the pelvis towards the arteries that supply blood to the prostate. Material is then injected into the prostate arteries, effectively cutting off its blood supply. It can stop severe bleeding from the prostate. It will also result in shrinkage of the prostate over time as the body resorbs the dying tissue, and subsequent improvement in urinary symptoms. It can be a challenging procedure to perform for an interventional radiologist, although it is something they generally are fairly comfortable with and experienced in.