Benign prostatic hyperplasia (BPH) is a common condition affecting millions of men, where the prostate gland enlarges and compresses the urethra, leading to bothersome urinary symptoms like frequency, urgency, and a weak stream. For many years, the surgical answer to BPH was the Transurethral Resection of the Prostate (TURP), which became the standard procedure for removing obstructive tissue. As technology and surgical techniques have evolved, less invasive alternatives have emerged, offering effective relief with fewer side effects or a faster recovery. These options, ranging from advanced laser surgeries to minimally invasive office treatments, provide different balances of durability, risk, and recovery time.
Medication and the Traditional Surgical Standard
The first line of defense against BPH symptoms is typically medication. Alpha-blockers, such as tamsulosin or alfuzosin, relax the smooth muscles in the prostate and bladder neck, improving urine flow. For men with a significantly enlarged prostate, 5-alpha reductase inhibitors like finasteride or dutasteride may be added. These work over several months to shrink the gland by blocking testosterone conversion.
When medication fails, or if complications such as recurrent urinary tract infections or kidney issues arise, surgery is necessary. The traditional surgical standard, TURP, involves inserting an instrument through the urethra to cut away excess prostate tissue using an electrified wire loop. This procedure creates a wider channel for urine flow.
While TURP offers excellent, long-lasting symptom relief, it requires a hospital stay of one to two days and carries risks. A common side effect is retrograde ejaculation, where semen flows backward into the bladder during orgasm, occurring in a majority of patients. The invasive nature of TURP drives the search for less disruptive options.
Advanced Laser Procedures
Advanced laser procedures offer efficacy comparable to TURP but with reduced bleeding and shorter recovery times. Holmium Laser Enucleation of the Prostate (HoLEP) is a durable option that cores out the entire obstructive inner portion of the prostate gland. This enucleation process is performed through the urethra, allowing HoLEP to treat even very large prostates that standard TURP might struggle with.
HoLEP is highly effective, demonstrating durability comparable to TURP with very low long-term re-treatment rates. Patients experience shorter catheterization times and a reduced risk of bleeding, making it suitable for men on blood thinners.
Another laser technique is Photoselective Vaporization of the Prostate (PVP), often known as GreenLight, which uses a high-power laser to vaporize the obstructive tissue. PVP controls bleeding effectively and often allows for faster hospital discharge. This vaporization method is generally better suited for men with small to medium-sized prostates. Both HoLEP and PVP achieve excellent results, but like TURP, they carry a high risk of causing retrograde ejaculation due to tissue removal near the bladder neck.
Minimally Invasive Office Treatments
Minimally Invasive Surgical Treatments (MISTs) focus on rapid recovery and preserving sexual function. Prostatic Urethral Lift (PUL), or UroLift, is a non-ablative procedure using small, permanent implants to pull the enlarged prostate lobes apart. These implants hold the compressed urethra open, relieving obstruction without cutting or removing tissue.
Since UroLift avoids tissue removal, it has a low risk of causing sexual side effects, including retrograde ejaculation. It is typically performed as an outpatient procedure under local anesthesia, allowing a swift return to normal activities. UroLift is an attractive option for men with smaller to moderate-sized prostates due to immediate relief and sexual function preservation.
Another MIST is water vapor thermal therapy, Rezūm, which uses steam energy to ablate obstructive prostate tissue. Sterile water vapor is injected directly into the prostate, destroying problematic cells. The body absorbs the treated tissue over several weeks, gradually reducing prostate volume and improving symptoms. Rezūm is also an outpatient procedure that preserves sexual function and can treat slightly larger prostates than UroLift.
Comparing Durability and Key Side Effects
Comparing procedures involves a trade-off between long-term durability, preservation of sexual function, and recovery time. TURP and HoLEP offer the highest long-term durability, with re-treatment rates under 10% after 10 years, providing maximum lasting relief. However, they are associated with the highest risk of retrograde ejaculation, occurring in 45% or more of patients.
MISTs prioritize rapid recovery and minimal impact on sexual health. Procedures like UroLift and Rezūm have significantly lower rates of retrograde ejaculation, typically under 5% for Rezūm and near zero for UroLift. This benefit trades off with long-term durability, as re-treatment rates for MISTs are higher, sometimes reaching 5-10% after five years.
Recovery time is shortest for MISTs, which are often performed in an office setting with a return to normal activity in days. TURP and HoLEP require a hospital stay and a longer recovery period, though HoLEP generally shortens catheterization time compared to TURP. The optimal choice is highly individualized, depending on the patient’s prostate size, symptom severity, and personal priorities regarding sexual function and durability.