Benign prostate enlargement (BPE), is a common condition affecting many men as they age. It involves overgrowth of the central areas of the prostate gland which causes obstruction to the urine flow. It can lead to troublesome urinary symptoms, including difficulty starting urination, frequent urination, weak flow and urinary retention. Fortunately, several surgical options are available to address these issues, providing relief and improving quality of life.

Procedures available for benign prostate enlargement and urinary retention

What are the main surgical treatments for BPE and urinary retention?

Surgical interventions for BPE are chosen based on the severity of symptoms, the size of the prostate (volume in cc), the patient's overall health and preferences. The main options include:

1. Aquablation

This relatively new technique involves removal of BPH tissue using a high-powered jet of water (saline) from a urethrally inserted device directed in a programmed way assisted by real-time ultrasound imaging of the prostate. Additional cauterisation is then required to stop bleeding.

Benefits: Results have been reported superior to TURP for moderate sized prostates (<80 cc) over 5 years and also effective for large (50-150cc) prostates in short term studies. Very low rates of retrograde ejaculation, as specific tissue is left, no effect on erections and very low incontinence rates, can be day-case.

Downsides: Doesn’t remove as much prostate and improvement in urine flow not as good as HoLEP in large prostates which may regrow and bleed. Limited, and no long term, data for very large prostates, high re-treatment rates for large prostates, risk of blood loss, no tissue available for histological analysis so an incidental cancer may be undiagnosed.

2. Holmium laser enucleation of the prostate (HoLEP)

A very established procedure (since 1980s) where all the obstructing prostate tissue is enucleated using a urethrally inserted laser in the tissue plane between the central and peripheral prostate zones. The bloc of central tissue is then removed by morcellation in the bladder.

Benefits: A truly size-independent technique (30-300+ cc) and according to 2024 European and UK National guidelines the recommended procedure for large (>80cc) and very large (>150cc) prostates as much less blood loss and shorter recovery time than TURP, and durable results, no effect on erections, suitable for patients on blood thinning drugs, good tissue for analysis, can be day-case.

Drawbacks: Requires specialised expertise, risk of temporary urine leakage with very large prostates, retrograde ejaculation common but can be reduced if specific tissue is left, however this increases need for re-treatment.

3. Transurethral resection of the prostate (TURP)

Once considered the gold standard for BPE surgery, TURP involves removing obstructing prostate tissue by repeated resection of prostate ‘chips’ by a urethrally inserted resectoscope using an electrical cautery loop.

Benefits: Rapid symptom relief, improved urinary flow, and effective treatment for small and moderate sized prostates. Standard urological procedure that every urologist learns.

Drawbacks: Not recommended for large prostates, not all the BPH tissue is removed so risks re-growth, recurrence of symptoms and bleeding. Greater risk of bleeding, infection, sepsis, than Aquablation and HoLEP increasing with prostate size, usually causes retrograde ejaculation, erection problems can occur as heat used, low risk of incontinence.

4. Open prostatectomy

A traditional surgical approach reserved for very large prostates, now largely replaced by HoLEP. It involves making an abdominal incision to remove the enlarged prostate tissue.

Benefits: Effective for the removal of very large prostates in severe cases of BPE when HoLEP not available.

Drawbacks: Longer recovery time, higher risk of complications, longer hospital stay and more invasive than all other techniques.

4. Transurethral resection of the prostate (TURP)

Once considered the gold standard for BPE surgery, TURP involves removing obstructing prostate tissue by repeated resection of prostate ‘chips’ by a urethrally inserted resectoscope using an electrical cautery loop.

Benefits: Rapid symptom relief, improved urinary flow, and effective treatment for small and moderate sized prostates. Standard urological procedure that every urologist learns.

Drawbacks: Not recommended for large prostates, not all the BPH tissue is removed so risks re-growth, recurrence of symptoms and bleeding. Greater risk of bleeding, infection, sepsis, than Aquablation and HoLEP increasing with prostate size, usually causes retrograde ejaculation, erection problems can occur as heat used, low risk of incontinence.

5. Prostate artery embolisation (PAE)

A non-surgical procedure involving cutting off the blood supply to the prostate by placing metallic coils in the lumen of the prostate arteries, causing it to die and shrink. Used in large and very large prostates.

Benefits: Minimally invasive, minimal risk of sexual dysfunction.

Drawbacks: May not be as effective as surgical options for severe symptoms, can result in problems from the dead prostate tissue, effects take longer to become apparent, higher rates of post-operative urinary retention, risk of radiation exposure from the extensive X-ray imaging required, technically difficult.

6. Urolift System

A minimally invasive technique where small implants pin-back the prostate tissue away from the urethra to improve urine flow.

Benefits: No cutting or tissue removal, quick recovery, and preservation of sexual function, may be good option in some high risk patients.

Drawbacks: May not be suitable for very large prostates or severe symptoms, not as effective or long lasting as tissue removing techniques, the history of permanent urological implants is poor and long term results are not known.

7. Green light laser ablation

Uses laser energy with specific affinity for blood constituents to vaporise obstructing prostate tissue using a urethral placed probe.

Benefits: Good for patients on blood thinners, equivalent to TURP in removing tissue with much less blood loss, shorter post-operative stay, low rates of erectile dysfunction and incontinence, can be day-case.

Drawbacks: Post-operative discomfort, doesn’t remove as much tissue as TURP, not suitable for very large prostates or large prostates with retention, higher recurrence and re-do rates than some other treatments, no tissue for histological analysis.

8. Rezum

This minimally invasive technique involves injecting steam into the obstructing prostate tissue using a urethrally inserted device. The heat causes a portion of the prostate tissue to die and shrink back thereby reducing obstruction to the urine flow.

Benefits: Quick and easy to do and learn, very low rates of retrograde ejaculation, incontinence and erection problems, produces improved urine flow in correctly selected patients, day-case, low-cost.

Downsides: No tissue removed so limited relief of obstruction and risk of regrowth, no tissue for analysis, requires a post-operative catheter for several days and sometimes longer, higher risk of post operative urinary retention, not recommended for large prostates, some patients have post-operative pain.

What are the key things to consider when choosing the right procedure for BPE?

The outcomes and side effects are dependent on how much of the obstructing prostate tissue is removed.

The choice of treatment depends on several factors:

Prostate size: Larger prostates should be treated by HoLEP or Aquablation with very large prostates most suitably treated by HoLEP, while smaller or moderate enlargements might respond well to TURP or the minimally invasive treatments Urolift and Rezum if symptoms are not severe.

Patient health: Patients with bleeding disorders or other medical conditions may prefer minimally invasive options like PAE, Rezum or the laser procedures.

Symptom severity: Severe urinary retention with large prostates is arguably best treated by HoLEP as this removes the most tissue. Patients with bladder stones are also best treated by HoLEP as the Holmium laser can be used to remove the stone at the same time.

Previous prostate surgery: Patients with recurrent symptoms due to incomplete removal or regrowth of prostate tissue after previous surgery are best treated with HoLEP or possibly Aquablation. HoLEP is arguably best for re-do surgery after Urolift as can deal with the clips.

Lifestyle preferences: Patients prioritising preservation of ejaculation function may opt for Rezum, Urolift or Aquablation.

What’s involved in recovery and follow-up for BPE surgery?

Recovery times vary depending on the procedure. Endoscopic techniques such as HoLEP and Aquablation often allow patients to return to normal activities within days. More invasive surgeries like open prostatectomy may require weeks of recovery.

Regular follow-ups are essential to monitor progress, address any complications, and ensure lasting symptom relief. Patients experiencing ongoing urinary retention or incomplete symptom resolution should consult their urologist to explore additional treatment options.

Choosing the right procedure is a collaborative decision between the patient and their healthcare provider, ensuring the best possible outcome tailored to individual needs.