Tag Archive for: prostate enlargement

Prostate Artery Embolisation: Who May Benefit, Important Caveats, and Can It Be Done After Radiotherapy?

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Lower urinary tract symptoms: poor flow, hesitancy, incomplete emptying, frequency, urgency and nocturia, are common as men age. When benign enlargement of the prostate (BPH) is genuinely responsible, treatment may include lifestyle measures, medication, minimally invasive procedures or surgery. Prostate artery embolisation (PAE) is one option that may be considered for appropriately assessed patients.

PAE is not simply a “smaller TURP”. It works differently, is performed by an experienced interventional radiologist, and has a different balance of benefits, limitations and risks. The most important question is not whether the prostate looks large, but whether prostatic obstruction is actually causing the patient’s symptoms.

What is prostate artery embolisation?

PAE is a minimally invasive, image-guided procedure. A small catheter is introduced through an artery, usually at the wrist or groin, and guided into the arteries supplying the prostate. Tiny permanent particles or, in selected expert practice, a liquid embolic agent are delivered to reduce blood flow to the hyperplastic prostate tissue. This causes controlled ischaemia, gradual shrinkage of the transition zone and reduced compression of the urethra.

The procedure can often be performed without a general anaesthetic and does not require instruments to pass through the urethra. Improvement, when it occurs, is usually progressive rather than immediate and may take several weeks or months. Results vary, and some men obtain little benefit or require another treatment.

Regulatory note for Australian readers: The TGA regulates therapeutic goods, including medicines and medical devices; it does not “approve” or endorse a medical procedure or an individual health service. References to PAE in this article should not be interpreted as TGA endorsement. Any embolic agent, catheter or other medical device used must be lawfully supplied in Australia and used in accordance with its applicable regulatory status, intended purpose and clinical governance requirements.

Important Wesley Hospital research

Associate Professor Nicholas Brown, an interventional radiologist affiliated with The University of Queensland and I-MED Radiology at The Wesley Hospital, led the following Australian studies of PAE.

The P-EASY ADVANCE randomised controlled trial, published in BJU International in 2024, compared PAE with combined tamsulosin and dutasteride therapy in 39 treatment-naïve men with enlarged prostates, moderate-to-severe symptoms and obstructed or equivocal urodynamic studies. At follow-up, 63% of men treated with PAE were urodynamically unobstructed, compared with 28% receiving medication. Within this study population and follow-up period, the PAE group had greater improvements in prostate volume, urinary flow, incomplete emptying, overall symptom score and quality of life. The trial was small, the estimates should not be generalised to every patient, and larger comparative trials with longer follow-up are required.

The follow-up P-EASY PLUS study, published in BJU International in 2025, assessed 105 men at a mean of 18 months. Mean prostate volume fell by 30.6%, total symptom scores improved by 55%, quality-of-life scores improved by 65.9%, and maximum urinary flow increased by 5 mL/second. Among the 57 men who completed paired urodynamic testing, the proportion classified as obstructed fell from 66.7% to 29.8%. No major procedural complication or new urinary incontinence was reported in this cohort; new retrograde ejaculation occurred in 2%. These are group-level study outcomes and do not guarantee an individual result. The authors noted that longer-term comparative research is required.

The P-EASY ADVANCE publication received the BJUI Global Prize for 2026. This statement describes the publication award only; it is not a patient-outcome claim, regulatory endorsement or guarantee of treatment effectiveness.

Author disclosure: I, Dr Joseph Schoeman, was a co-author of both Wesley Hospital studies. I performed some of the urodynamic studies for this article. Readers should take this relationship into account when considering the discussion. The results are reported with their limitations and placed alongside independent guidelines, randomised trials and systematic reviews. No patient testimonial or individual outcome has been used in this article.

Who may be a good candidate?

PAE may be considered when a man has:

  • bothersome moderate-to-severe urinary symptoms attributable to benign prostatic obstruction;
  • an enlarged prostate, particularly a moderately large or very large gland;
  • inadequate relief, unacceptable adverse effects or a preference not to take long-term medication;
  • a wish to avoid transurethral or more invasive surgery;
  • increased anaesthetic or surgical risk;
  • a preference for an option with lower reported rates of ejaculatory dysfunction or urinary incontinence in some studies, while recognising that these complications can still occur;
  • catheter-dependent urinary retention where obstruction from BPH is considered reversible and bladder contractility is adequate; or
  • recurrent or refractory bleeding shown to arise from the prostate in selected circumstances.

Current European Association of Urology guidance recommends offering PAE to men with moderate-to-severe LUTS due to benign prostatic obstruction who want a minimally invasive option and accept that outcomes may be less optimal than TURP. The American Urological Association also permits PAE as a treatment option when performed by appropriately trained clinicians, but grades the evidence as conditional.

What assessment is needed before PAE?

A large prostate does not prove obstruction, and urinary symptoms are not always caused by the prostate. Appropriate assessment may include:

  • symptom and quality-of-life scoring;
  • urinalysis and urine culture when indicated;
  • PSA assessment and prostate-cancer evaluation appropriate to age and risk;
  • digital rectal examination;
  • urinary flow rate and post-void residual measurement;
  • ultrasound or MRI assessment of prostate size and anatomy;
  • cystoscopy where haematuria, urethral stricture, bladder-neck pathology, stones or bladder disease is suspected;
  • urodynamic studies when the diagnosis is uncertain, symptoms are mixed, bladder contractility may be poor, or prior pelvic treatment has complicated the picture; and
  • CT or MR angiographic assessment of pelvic arterial anatomy, renal function and contrast risk when requested by the interventional radiologist.

The best decisions are generally made jointly by a urologist and an experienced PAE interventional radiologist.

Potential advantages of PAE

Potential advantages include:

  • no prostate tissue resection and usually no general anaesthetic;
  • day-stay or short hospital admission in many patients;
  • lower reported rates of major bleeding and transfusion than some operative procedures in comparative studies;
  • low reported, but not zero, rates of urinary incontinence;
  • a lower reported likelihood of retrograde ejaculation than with TURP or enucleation procedures in available studies;
  • usefulness in some very large prostates and medically complex patients; and
  • preservation of later surgical options if symptoms persist or recur.

Caveats: what PAE may not do as well

Compared with TURP or endoscopic enucleation, PAE generally produces a less immediate and less pronounced improvement in urinary flow and objective relief of obstruction. A Cochrane review found that short-term symptom improvement may be similar to TURP, but the certainty of evidence was low and retreatment may be more likely after PAE. Meta-analyses and longer-term randomised data generally show stronger objective improvement after TURP. Comparisons across studies must be interpreted cautiously because patient selection, technique, follow-up and outcome definitions differ.

PAE also does not provide prostate tissue for histology. Prostate cancer must therefore be considered and investigated before treatment rather than assumed to be excluded by a fall in prostate size or PSA afterward.

Technical success depends heavily on operator experience. Prostatic arteries are tiny, variable and sometimes severely atherosclerotic. Embolic material can rarely reach non-target vessels supplying the bladder, rectum or penis. Pre-procedure vascular imaging and cone-beam CT can reduce this risk but add iodinated contrast exposure and ionising radiation.

Side effects and complications

Common short-term effects form part of a post-embolisation syndrome and may include pelvic or perineal discomfort, urinary frequency and urgency, dysuria, fatigue, nausea, low-grade fever or a small amount of blood in the urine or semen. Temporary difficulty passing urine and the need for a catheter can occur.

Less common complications include urinary infection, access-site bruising or haematoma, contrast reaction, kidney injury, arterial injury, prostate infection or abscess, and passage of necrotic prostate tissue. Rare but important complications of non-target embolisation include ischaemic injury to the bladder, rectum or penis. Severe skin injury from fluoroscopic radiation is also rare but is a recognised procedural concern, particularly during prolonged or technically difficult cases.

Contraindications and reasons to pause

PAE is generally unsuitable, or requires correction and specialist review first, when there is:

  • an active urinary tract or systemic infection;
  • suspected or untreated prostate or bladder cancer requiring diagnostic clarification;
  • symptoms predominantly caused by urethral stricture, bladder-neck contracture, bladder stone, neurogenic dysfunction, overactive bladder or another non-BPH condition;
  • a poorly contractile or decompensated bladder unlikely to empty even if outlet resistance is reduced;
  • severe pelvic arterial atherosclerosis, occlusion, tortuosity or anatomy that prevents safe selective catheterisation;
  • an uncorrectable bleeding disorder;
  • a severe iodinated-contrast allergy that cannot be safely managed;
  • significant renal impairment where contrast risk is unacceptable; or
  • inability to tolerate arterial access, fluoroscopy or the required aftercare.

Small prostate size is not an absolute prohibition, but it makes careful confirmation of the cause of obstruction particularly important and may reduce the likelihood of benefit. A prominent obstructing median lobe is not automatically a contraindication in experienced hands, although prostate anatomy should be considered alongside all alternative treatments.

Can PAE be performed after prostate radiotherapy?

Potentially yes, but prior pelvic or prostate radiotherapy is not a routine indication, and the decision must be individualised. It is neither sensible to call radiotherapy an automatic absolute contraindication nor appropriate to assume that PAE will relieve every post-radiation urinary symptom.

After radiotherapy, poor flow, urgency, frequency, pain, retention or bleeding may result from:

  • persistent benign prostatic obstruction;
  • radiation cystitis and reduced bladder capacity;
  • detrusor overactivity or poor bladder contractility;
  • urethral stricture or bladder-neck stenosis;
  • prostate-cancer recurrence or progression;
  • infection, stones or clot retention; or
  • a combination of these problems.

PAE is most likely to help only when a meaningful component of the problem is supplied by vascular, enlarged prostate tissue or confirmed prostatic obstruction. It will not correct a urethral stricture, a scarred bladder neck, radiation cystitis, a small fibrotic low-capacity bladder or detrusor failure.

Evidence specifically studying PAE for BPH-type obstruction after completed radiotherapy is sparse. Most major BPH trials did not establish a dedicated post-radiotherapy evidence base. Radiotherapy can also alter pelvic tissues and small blood vessels, making angiographic anatomy and tissue response less predictable. For that reason, these patients should be assessed in a multidisciplinary setting and often benefit from cystoscopy, flow and residual testing, imaging and formal urodynamics before treatment.

PAE has been studied in men with prostate cancer and is being investigated before radiotherapy to reduce gland size and urinary symptoms. Embolisation has also been used for refractory bleeding of prostatic origin, including bleeding associated with malignancy or radiation. However, embolisation for life-threatening radiation-related haematuria may target vesical or other pelvic arteries and is a different clinical problem from PAE for benign outlet obstruction. These two indications should not be confused.

In a post-radiotherapy patient, PAE may therefore be reasonable when:

  1. recurrent cancer, infection and urethral or bladder-neck stenosis have been excluded or appropriately managed;
  2. investigations demonstrate an enlarged, vascular prostate with genuine outlet obstruction;
  3. bladder function is adequate enough to benefit from reducing resistance;
  4. pelvic arterial anatomy permits safe selective embolisation; and
  5. the patient understands that outcome data are limited and that further treatment may still be required.

How does PAE compare with surgery?

There is no universally “best” procedure. TURP, GreenLight laser, HoLEP or other enucleation procedures usually provide faster and more complete mechanical relief of obstruction. PAE is less invasive and some comparative studies report fewer ejaculatory or perioperative adverse effects; however, symptom relief can be slower, objective improvement may be smaller and retreatment may be more likely.

The right option depends on prostate size and configuration, the severity and cause of symptoms, bladder function, cancer risk, medical fitness, sexual priorities, arterial anatomy, previous pelvic treatment and the patient’s tolerance for the possibility of later retreatment.

The take-home message

PAE is an available treatment option for selected men with symptomatic benign prostatic obstruction. The Wesley Hospital P-EASY studies contribute Australian randomised and urodynamic data on symptoms, quality of life and obstruction, but their findings should be considered with the study designs, sample sizes, follow-up and declared author relationships.

It remains essential to diagnose the cause of symptoms before treating the scan. PAE is not a cure for every urinary problem and does not replace cancer assessment, cystoscopy or urodynamics when these are clinically indicated. After radiotherapy, PAE may be technically and clinically possible, but the evidence is limited and patient selection must be particularly rigorous.

References and further reading

  1. Brown N, et al. P-EASY ADVANCE: a randomised controlled trial of prostate embolisation versus medication for BPH. BJU International. 2024. doi: 10.1111/bju.16479.
  2. Brown N, et al. P-EASY PLUS: preliminary and follow-up urodynamic studies. BJU International. 2025. doi: 10.1111/bju.16808.
  3. Mark P, Brown NI, Ormiston WEL. Current considerations in prostate artery embolisation. CVIR Endovascular. 2026;9:45. doi: 10.1186/s42155-026-00689-5.
  4. European Association of Urology. Guidelines on the Management of Non-neurogenic Male LUTS: Disease Management. Current online edition accessed September 2026.
  5. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to BPH: AUA Guideline Amendment 2023. Journal of Urology. 2024;211:11–19. doi: 10.1097/JU.0000000000003698.
  6. Jung JH, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms in men with BPH. Cochrane Database of Systematic Reviews. 2022. Cochrane evidence summary.
  7. Müllhaupt G, et al. Prostatic artery embolisation versus TURP for benign prostatic obstruction: long-term outcomes of a randomised trial. European Urology. 2024. PubMed record.
  8. Zumstein V, et al. Prostatic artery embolization versus standard surgical treatment for LUTS secondary to BPH: systematic review and meta-analysis. European Urology Focus. 2019;5:1091–1100. doi: 10.1016/j.euf.2018.09.005.
  9. Parikh N, et al. Prostate artery embolization in the setting of prostate cancer. Seminars in Interventional Radiology. 2025. Full text.
  10. Kably I, et al. Prostatic artery embolization in refractory haematuria of prostatic origin. Techniques in Vascular and Interventional Radiology. 2020. PubMed record.
  11. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods. Updated 18 June 2026.
  12. Therapeutic Goods Administration. General requirements for advertising therapeutic goods to the public. Updated 11 March 2025.
  13. Australian Health Practitioner Regulation Agency. Advertising guidelines and other guidance. Accessed 22 September 2026.

Australian publication and advertising statement

This article is intended as balanced disease and treatment education. It does not advertise a named embolic product, catheter, medicine or device; offer an inducement; use testimonials; promise a cure; or claim that PAE is safe, risk-free, superior or effective in every case. Mention of the TGA, Ahpra, professional guidelines, a hospital, a journal or an award does not imply endorsement of this article, the author or the treatment.

Clinical claims are linked to identified publications and should be reviewed when the article is updated. Any future addition of brand names, booking prompts, prices, before-and-after images, patient stories, sponsored links or manufacturer-supplied material may change the regulatory character of the page and should undergo a fresh compliance review.

This article provides general information current at the stated review date and is not personal medical advice. It does not establish a doctor–patient relationship. Benefits and risks differ between individuals. Suitability for PAE should be decided after assessment by appropriately qualified clinicians, commonly including a urologist and an interventional radiologist. Patients should seek urgent medical care for inability to pass urine, fever or sepsis symptoms, severe pain, heavy bleeding or clot retention.

PAE BJU article

Enlarged Prostate (BPH): Understanding Prescription Combination Therapy

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Benign prostatic hyperplasia (BPH), also called benign prostate enlargement, becomes more common as men get older. An enlarged prostate may narrow the urethra or affect the way the bladder works.

Possible symptoms include:

  • a slow or intermittent urinary stream
  • difficulty starting urination
  • straining to urinate
  • a feeling that the bladder has not emptied fully
  • urinary frequency or urgency
  • waking at night to urinate
  • dribbling after urination
  • urinary retention

These symptoms are not always caused by an enlarged prostate. Infection, overactive bladder, urethral narrowing, bladder stones, neurological conditions and prostate or bladder cancer can sometimes produce similar symptoms. An appropriate clinical assessment is therefore important before treatment is selected.

What treatments are available?

Management depends on symptom severity, prostate size, bladder emptying, general health and personal preferences. Options may include:

  • monitoring and lifestyle measures
  • prescription medicines
  • minimally invasive procedures
  • prostate surgery

No single option is best for every patient. A treatment that improves symptoms in one man may be unsuitable for another.

How prescription combination therapy works

For selected men, a doctor may prescribe two types of medicine together:

  1. An alpha blocker, such as tamsulosin, relaxes smooth muscle in the prostate and bladder neck. This may improve urine flow and symptoms relatively quickly, although response varies.
  2. A 5-alpha-reductase inhibitor, such as dutasteride or finasteride, alters the hormonal pathway involved in prostate growth. Over time, it may reduce prostate volume and lower the risk of urinary retention or BPH-related surgery in appropriately selected men.

These medicines are available only on prescription. They may be prescribed separately or, in some circumstances, in a fixed-dose combination. This article does not recommend a particular medicine or brand.

The prostate-reducing component acts gradually. Any benefit is generally assessed over months rather than days. Combination therapy is commonly considered as a longer-term treatment, but regular review remains important.

Who might be considered for combination therapy?

A doctor may consider combination treatment for a man who has moderate-to-severe urinary symptoms associated with a demonstrably enlarged prostate and an increased risk of BPH progression.

The decision may take account of:

  • how troublesome the symptoms are
  • prostate size and shape
  • PSA results, interpreted in clinical context
  • urinary flow rate
  • the amount of urine left in the bladder after voiding
  • previous urinary retention
  • the expected benefits, limitations and adverse effects of treatment
  • other illnesses and medicines
  • the patient’s preferences, including the importance of preserving sexual and ejaculatory function

Prostate size alone should not determine treatment. Some men with large prostates have few symptoms, while a smaller prostate can still cause obstruction because of its shape, a tight bladder neck or another condition.

Assessment before treatment

Depending on the individual, assessment may include:

  • a urinary, medical and medication history
  • a validated symptom questionnaire
  • physical examination, which may include a digital rectal examination
  • urine testing
  • PSA testing after discussion of its benefits and limitations
  • kidney-function blood tests
  • urinary flow measurement
  • ultrasound assessment of prostate size and post-void residual urine
  • a bladder diary
  • cystoscopy or urodynamic testing in selected cases

The purpose is to confirm the likely cause of the symptoms and identify complications or conditions that require a different approach.

Possible benefits and limitations

An alpha blocker may improve urine flow and some symptoms within days or weeks. It does not substantially shrink the prostate.

A 5-alpha-reductase inhibitor works more slowly. In men with prostate enlargement, it may reduce prostate volume and lower the long-term risk of acute urinary retention or BPH-related surgery. Not every patient will experience a worthwhile improvement.

Combination treatment may improve symptoms more than either medicine alone in appropriately selected patients, but it also exposes the patient to the adverse effects of both medicine classes. It controls BPH rather than permanently curing it. Symptoms may recur or progress, and a procedure may still be required.

Clinical-trial averages cannot predict an individual patient’s result. Benefits and harms should be reviewed with the prescribing doctor.

Possible adverse effects

Adverse effects differ between people. The Consumer Medicine Information supplied with the prescribed medicine should be read, and new or troublesome symptoms should be discussed with the prescriber or pharmacist.

Sexual and ejaculatory effects

Possible effects include:

  • reduced semen volume or absent ejaculation
  • semen passing backwards into the bladder
  • reduced sexual desire
  • difficulty achieving or maintaining an erection
  • changes in fertility or semen characteristics

Some sexual adverse effects have been reported to persist after a 5-alpha-reductase inhibitor is stopped, although their frequency, cause and predictors remain uncertain. Persistent symptoms deserve appropriate assessment.

Dizziness and low blood pressure

Alpha blockers may cause dizziness, light-headedness, weakness or, less commonly, fainting—particularly when standing up. The risk may be greater when treatment begins or when combined with other medicines that lower blood pressure. Patients who become dizzy should take care to avoid falls and seek medical advice.

Breast and other changes

5-alpha-reductase inhibitors may cause breast tenderness or enlargement. A breast lump, nipple discharge or persistent one-sided change requires medical assessment rather than being assumed to be a medicine effect.

Other reported adverse effects can include headache, tiredness, palpitations, nasal congestion, gastrointestinal discomfort, skin reactions, testicular symptoms and mood changes. The exact safety information depends on the medicine prescribed.

Seek urgent help

Urgent medical attention is appropriate for symptoms such as:

  • swelling of the face, tongue or throat, or difficulty breathing
  • collapse or fainting
  • a painful, prolonged erection
  • a severe blistering or peeling skin reaction
  • suicidal thoughts or severe psychological distress
  • inability to pass urine, especially with increasing lower abdominal pain

In Australia, call Triple Zero (000) in an emergency. Lifeline is available on 13 11 14 for crisis support. These services do not replace assessment by the treating clinician.

PSA monitoring

5-alpha-reductase inhibitors commonly lower PSA. This does not eliminate the possibility of prostate cancer.

A new PSA baseline may need to be established after treatment begins. Later results must be interpreted with knowledge that the patient is taking this type of medicine. A confirmed increase from the lowest PSA reached may require further assessment, even if the result falls within a laboratory’s usual reference range.

Patients should tell any clinician ordering or interpreting a PSA test about all current and recent prostate medicines.

Cataract or glaucoma surgery

Tamsulosin and some other alpha blockers are associated with intraoperative floppy iris syndrome, which may complicate cataract or glaucoma surgery.

Patients should tell their ophthalmologist about current or previous alpha-blocker use. They should not stop a prescribed medicine solely for an eye operation unless advised by the relevant treating clinicians, because stopping it may not remove the surgical risk.

Mood and persistent symptoms

Sexual, cognitive and mood symptoms have been reported during or after treatment with 5-alpha-reductase inhibitors. The evidence about persistent syndromes, their frequency and causation continues to evolve.

This uncertainty should be discussed without either assuming that persistent symptoms will occur or dismissing symptoms that a patient experiences. New depression, marked anxiety or sexual dysfunction should be reviewed. Suicidal thoughts require urgent assistance.

Monitoring treatment

Follow-up may include review of:

  • symptom response and quality of life
  • dizziness and postural blood pressure
  • sexual and ejaculatory function
  • mood changes
  • urinary flow and post-void residual urine
  • PSA results
  • kidney function when clinically indicated

Lack of early improvement does not necessarily mean the slower-acting component has failed. However, severe or worsening symptoms should not be managed by continuing medicine indefinitely without reassessment.

When might a procedure or surgery be considered?

A procedure may be discussed when there is:

  • recurrent or persistent urinary retention
  • catheter dependence
  • recurrent infection associated with poor bladder emptying
  • bladder stones
  • recurrent visible bleeding attributed to BPH
  • kidney or upper urinary tract effects from obstruction
  • a high or increasing post-void residual volume
  • persistent troublesome symptoms despite appropriate conservative treatment
  • unacceptable medicine adverse effects
  • a preference for a procedural option after informed discussion

Procedural choices include established operations and selected minimally invasive treatments. Suitability depends on prostate anatomy, bladder function, general health, bleeding risk, expected durability and the importance of preserving ejaculation. Each option has potential benefits, limitations and complications.

Questions to discuss with your doctor

  • What is the most likely cause of my urinary symptoms?
  • Is my prostate enlarged, and am I at risk of progression?
  • What are the reasonable alternatives, including observation, medicines and procedures?
  • How likely is each option to help in my circumstances?
  • What sexual, ejaculatory, blood-pressure and mood effects should I consider?
  • How will treatment affect the interpretation of my PSA?
  • When should treatment be reviewed or changed?
  • Which symptoms require urgent assessment?

The bottom line

Prescription combination therapy can be one option for selected men with bothersome urinary symptoms, prostate enlargement and a risk of BPH progression. It is not suitable for every urinary problem and does not guarantee that surgery will be avoided.

The choice should follow an individual assessment and a balanced discussion of expected benefit, possible harm, alternatives and the option of no immediate treatment. Do not start, stop or change a prescription medicine without advice from the prescribing clinician.

This article provides general educational information. It is not medical advice and does not promote or recommend a particular prescription medicine or brand. Treatment decisions should be made with an appropriately qualified health professional after individual assessment.

References and further reading

 

Benign Prostate Enlargement and Water-Vapour Therapy: A Patient Guide

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Benign prostate enlargement, also called benign prostatic hyperplasia or BPH becomes more common as men age. Enlargement may narrow the urethra, increase resistance to urinary flow and affect the way the bladder stores or empties urine.

Not every enlarged prostate causes symptoms, and not every urinary symptom is caused by the prostate. Treatment should therefore begin with an assessment of the likely cause, the effect on quality of life and whether complications are present.

This article explains BPH and the role of transurethral water-vapour therapy as one of several possible treatments. It does not recommend a particular product, device, clinician or health service.

What symptoms can BPH cause?

Lower urinary tract symptoms may include:

  • a slow or weak urinary stream
  • difficulty starting urination
  • stop–start flow
  • straining to urinate
  • a feeling that the bladder has not emptied
  • passing urine frequently
  • urgency
  • waking at night to urinate
  • dribbling after urination
  • urinary retention

The size of the prostate does not always match symptom severity. A large prostate may cause few problems, while a smaller prostate can obstruct flow because of its shape, a tight bladder neck or a prominent median lobe.

What else can cause urinary symptoms?

Similar symptoms may arise from:

  • urinary tract infection
  • overactive bladder
  • urethral stricture
  • bladder stones
  • impaired bladder-muscle contraction
  • neurological disease
  • prostate or bladder cancer
  • medicines that affect bladder function
  • excessive fluid, caffeine or alcohol intake
  • constipation or sleep disorders

Visible blood in the urine, recurrent infection, kidney impairment, bladder stones, persistent retention or rapidly worsening symptoms require appropriate investigation.

How is BPH assessed?

Assessment may include:

  • a urinary, medical and medication history
  • a validated symptom questionnaire
  • physical examination
  • digital rectal examination
  • urine testing
  • PSA testing after discussion of its benefits and limitations
  • kidney-function testing when indicated
  • urinary flow measurement
  • ultrasound assessment of prostate size and post-void residual urine
  • a bladder diary
  • cystoscopy or urodynamic testing in selected cases

It is particularly important to distinguish bladder-outlet obstruction from weak bladder contraction. Opening the prostate outlet may not restore normal emptying if the bladder muscle is unable to contract adequately.

Does every man with BPH need treatment?

No. Men with mild, non-bothersome symptoms and no complications may choose observation with periodic review.

Conservative measures may include:

  • moderating excessive evening fluid intake
  • reducing caffeine or alcohol when these worsen symptoms
  • treating constipation
  • reviewing relevant medicines
  • avoiding habitual “just in case” voiding where appropriate
  • managing diabetes, sleep apnoea or leg swelling when they contribute to nocturia

Fluid should not be restricted excessively, particularly in hot weather or when dehydration is a risk.

What treatment options are available?

Depending on symptoms, anatomy and risk, options may include:

  • monitoring and lifestyle measures
  • prescription medicines
  • minimally invasive surgical therapies
  • transurethral resection or vaporisation
  • laser enucleation
  • other endoscopic enucleation techniques
  • simple prostatectomy for selected very large glands

Each option differs in speed of improvement, durability, anaesthetic requirements, catheter time, bleeding risk, sexual effects and likelihood of retreatment.

What is transurethral water-vapour therapy?

Water-vapour therapy is a minimally invasive treatment intended to reduce selected areas of benign prostate tissue that are contributing to obstruction.

A specialised instrument is passed through the urethra. A needle delivers controlled water vapour into planned areas of prostate tissue. As the vapour condenses, thermal energy disrupts the targeted cells. The body then gradually reabsorbs treated tissue over the following weeks and months.

Unlike resection or enucleation, obstructing tissue is not physically removed during the procedure. Improvement is therefore delayed while inflammation settles and treated tissue reduces.

The exact device, intended purpose, contraindications and instructions for use should be confirmed from the current Australian Register of Therapeutic Goods entry and manufacturer-approved documentation.

Who might be considered?

Water-vapour therapy may be discussed with selected men whose bothersome symptoms are likely to arise from benign prostate obstruction and who understand the alternatives and likelihood of retreatment.

Assessment may consider:

  • symptom severity and quality-of-life impact
  • prostate volume and shape
  • lateral-lobe or median-lobe obstruction
  • urinary flow and residual urine
  • bladder contractility
  • previous urinary retention
  • coexisting bladder or urethral disease
  • anaesthetic and bleeding risk
  • the importance of preserving ejaculation
  • the patient’s preference regarding recovery, durability and retreatment

The pivotal randomised study enrolled a defined group of men, including prostate volumes between 30 and 80 mL. Evidence outside the studied population is less mature and may rely on observational data.

Larger prostates, catheter-dependent retention or previous prostate procedures do not automatically determine suitability, but the expected results and evidence may differ. A tissue-removing operation may provide more predictable or faster relief in some patients.

When may it be unsuitable?

Reasons to avoid or reconsider water-vapour therapy may include:

  • active urinary infection
  • suspected prostate or bladder cancer requiring investigation
  • urethral stricture preventing safe access
  • poor bladder contractility
  • symptoms caused mainly by overactive bladder rather than obstruction
  • bladder stones or another condition better treated during a different operation
  • anatomy unlikely to be treated adequately
  • severe obstruction or complications requiring rapid, predictable decompression
  • a contraindication in the approved instructions for the proposed device

Suitability must be decided individually. A median lobe is not necessarily an exclusion, but its anatomy and treatment plan require careful assessment.

How is the procedure performed?

The procedure is performed through the urethra, without an external incision. The device is positioned within the prostatic urethra, and treatment is delivered to selected areas according to prostate length, volume and shape.

Anaesthesia and perioperative care vary by patient and facility. The procedure is often performed as day surgery, but same-day discharge is not guaranteed.

Patients should receive individual instructions about:

  • fasting and anaesthesia
  • urine testing
  • antibiotics where clinically indicated
  • anticoagulant and antiplatelet medicines
  • transport and activity after the procedure
  • catheter care
  • symptoms requiring urgent review

Anticoagulant or antiplatelet medicines must not be stopped without advice from the clinician who manages them.

Will a catheter be needed?

Many patients need a temporary urinary catheter because treatment initially causes swelling. Catheter duration varies with prostate anatomy, baseline bladder emptying, pre-existing retention and the clinical course.

Some patients cannot pass urine after the catheter is removed and require reinsertion or intermittent catheterisation. Urgent review is needed if a patient cannot urinate and develops increasing lower-abdominal pain.

When might symptoms improve?

Water-vapour therapy does not usually provide immediate improvement. Urgency, frequency, discomfort or flow may temporarily worsen because of inflammation and swelling.

Improvement may begin over several weeks and continue for several months. The timing and degree of benefit vary, and some patients obtain inadequate relief.

Possible short-term effects

Common or expected effects can include:

  • burning or discomfort when urinating
  • blood in the urine
  • blood or discolouration in the semen
  • urinary frequency or urgency
  • a temporarily weaker stream
  • pelvic or perineal discomfort
  • catheter-related discomfort
  • temporary urinary retention

Patients should follow the written aftercare advice from their treating team.

Other risks and complications

Possible complications include:

  • urinary tract infection
  • prostatitis or systemic infection
  • bleeding
  • persistent urinary retention
  • worsening urgency or incontinence
  • urethral stricture or bladder-neck narrowing
  • ejaculatory change
  • erectile or sexual symptoms
  • chronic pelvic or urinary discomfort
  • failure to improve symptoms
  • need for repeat treatment or another prostate operation

Serious complications are uncommon but possible. Fever, chills, inability to urinate, heavy bleeding, severe pain or feeling systemically unwell require prompt assessment.

What about ejaculation and erections?

Preserving sexual and ejaculatory function is an important goal for many patients considering minimally invasive treatment. Clinical studies have reported relatively low rates of new sexual dysfunction after water-vapour therapy in selected populations.

However:

  • preservation cannot be guaranteed
  • changes in ejaculation can occur
  • erectile function may change for reasons unrelated to the procedure
  • trial definitions and selected participants may not reflect every patient
  • comparison with other procedures depends on technique, anatomy and baseline function

Sexual priorities should be discussed before treatment, along with the more established risk of ejaculatory change after tissue-removing operations.

What did the pivotal five-year study find?

Five-year follow-up from a sham-controlled randomised study reported sustained average improvement in symptoms and urinary flow among study participants who received water-vapour therapy. Reported outcomes included an approximate 48% improvement in symptom score and a 4.4% surgical retreatment rate over five years.

These figures require context:

  • they are group averages, not a prediction for an individual
  • the trial used defined eligibility criteria
  • follow-up does not show what happens over a lifetime
  • some participants did not obtain adequate relief
  • “surgical retreatment” does not capture every medication restart, investigation or non-surgical intervention
  • results may differ with larger prostates, retention, previous surgery or different anatomy

The evidence supports water-vapour therapy as a possible option for selected men; it does not establish it as the best treatment for all men with BPH.

Can the prostate continue to grow?

Yes. The procedure treats selected obstructing tissue present at the time. It does not stop the biological process of benign prostate growth.

Symptoms may remain controlled, recur because of further growth, or persist for another reason such as bladder dysfunction. Younger patients should consider the possibility of needing additional treatment during their lifetime.

How does it compare with tissue-removing surgery?

Water-vapour therapy generally involves less immediate tissue removal and slower improvement than transurethral resection or enucleation.

Potential reasons a patient might consider it include a preference for a less invasive approach and a desire to reduce the chance of ejaculatory change. Potential disadvantages include delayed benefit, postoperative irritation, catheterisation, uncertainty in less-studied anatomies and the possibility of retreatment.

Tissue-removing surgery may be more suitable when there is:

  • severe or recurrent urinary retention
  • very large or complex obstructing anatomy
  • bladder stones
  • recurrent infection caused by poor emptying
  • kidney or upper-tract effects from obstruction
  • substantial bleeding attributable to BPH
  • a need for faster or more predictable relief

No procedure is best for every patient.

Follow-up

Review may assess:

  • urinary symptoms and quality of life
  • urinary flow
  • post-void residual urine
  • infection or retention
  • catheter-related problems
  • sexual or ejaculatory effects
  • need for continuing BPH medicine
  • whether another diagnosis or treatment should be considered

Persistent or worsening symptoms should prompt reassessment rather than repeated reassurance that improvement will eventually occur.

Questions to discuss with a urologist

  • Are my symptoms caused by prostate obstruction?
  • Is my bladder contracting adequately?
  • What is my prostate size and anatomy?
  • Do I have complications that favour a more definitive operation?
  • What are the alternatives, including observation and medicines?
  • How quickly is each option likely to help?
  • What are the risks to ejaculation, erections and continence?
  • How long might I need a catheter?
  • What is the likelihood of needing another procedure?
  • Is the exact proposed device included in the ARTG for this use?
  • What out-of-pocket costs may apply?

Australian regulatory considerations

The Australian Register of Therapeutic Goods (ARTG) records therapeutic goods that may be legally supplied in Australia, unless an exemption or authorised access pathway applies. Inclusion is specific to the sponsor, device and intended purpose; it is not a recommendation that the device is suitable or superior for an individual patient.

Device status, instructions for use, contraindications, reimbursement and availability can change. These should be checked at the time treatment is considered.

The bottom line

BPH is common, but urinary symptoms require assessment because prostate obstruction is only one possible cause.

Transurethral water-vapour therapy is one minimally invasive option for selected men. It may improve urinary symptoms while offering a different balance of recovery, sexual effects and retreatment risk from tissue-removing surgery. Improvement is gradual, catheterisation is common, benefit is not guaranteed and further treatment may be needed.

The choice should follow an informed discussion of observation, medicines, minimally invasive treatments and established surgical options, taking account of prostate anatomy, bladder function, complications and personal priorities.

This article provides general disease education and does not replace individual medical advice. It does not promote or recommend a particular therapeutic device, brand, clinician or health service.

References and further reading

 

Robotic-Assisted Enucleation of the Large Benign Prostate / Robotic-Assisted Simple Prostatectomy RASP

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A modern surgical option for very large benign prostate enlargement

Benign prostatic hyperplasia (BPH), or benign prostate enlargement, becomes increasingly common as men age. For many men, symptoms can initially be controlled with medication or minimally invasive treatments. However, when the prostate becomes very large, simply creating a small channel through the prostate may not provide the durable result required.

Robotic-assisted simple prostatectomy (RASP), sometimes described as robotic-assisted adenoma enucleation, is designed to remove the bulk of the obstructing benign prostate tissue while leaving the outer prostate capsule behind.

Importantly, this is not the same operation as a robotic radical prostatectomy for prostate cancer. In a radical prostatectomy, the entire prostate and seminal vesicles are removed. In robotic simple prostatectomy, only the enlarged central adenoma responsible for urinary obstruction is removed.

Current guidelines recognise robotic-assisted simple prostatectomy as an established surgical option for men with large to very large prostates.

Why does a large prostate cause problems?

The prostate surrounds the urethra immediately below the bladder.

As benign prostate tissue enlarges, it can compress and distort the urethra. The bladder then has to work increasingly hard to push urine through this narrowed channel.

Symptoms may include:

  • Weak urinary stream
  • Hesitancy or difficulty starting urination
  • Straining
  • Intermittent urinary flow
  • A feeling that the bladder has not emptied properly
  • Frequent urination
  • Urgency
  • Getting up repeatedly at night to urinate
  • Acute or chronic urinary retention
  • Recurrent urinary infections
  • Bladder stones
  • Blood in the urine
  • Progressive deterioration of bladder function
  • In severe cases, obstruction affecting the kidneys

Surgery is particularly appropriate when significant symptoms persist despite conservative or medical therapy, or when BPH produces complications such as recurrent urinary retention, infection, bladder stones, recurrent bleeding or renal impairment.

When is robotic prostate enucleation considered?

Robotic-assisted enucleation is particularly attractive when the prostate is large or very large.

There is no magical prostate volume at which the robot suddenly becomes necessary. Treatment needs to be individualised according to prostate anatomy, symptoms, bladder function, other medical conditions and the surgeon’s expertise.

In practice, robotic simple prostatectomy is most commonly considered for prostates approximately 80–100 mL or larger, and can be particularly useful for extremely large glands well beyond 150–200 mL.

The EAU describes simple prostatectomy as a treatment primarily for substantially enlarged prostates, traditionally above approximately 80–100 mL.

Typical indications include:

  • Severe lower urinary tract symptoms caused by a very large prostate
  • Recurrent urinary retention
  • Dependence on an indwelling or intermittent urinary catheter
  • Failure or intolerance of BPH medications
  • Recurrent bladder infections associated with obstruction
  • Recurrent bleeding from a large vascular prostate
  • Bladder stones associated with prostate obstruction
  • Very high residual urine volumes
  • Progressive bladder dysfunction caused by obstruction
  • Upper urinary tract or renal consequences from longstanding obstruction
  • A very large median lobe protruding into the bladder
  • A very large prostate where conventional TURP would be impractical or require extensive resection

Robotic surgery can also be useful when another bladder procedure, such as removal of large bladder stones or repair of a bladder diverticulum, needs to be performed at the same operation.

How is the operation performed?

The procedure is usually performed under a general anaesthetic using a robotic surgical platform.

Several small incisions are made in the abdomen. Robotic instruments and a high-definition three-dimensional camera are introduced through these ports.

The surgeon remains completely in control of the operation. The robot does not perform the surgery independently. Rather, it translates the surgeon’s hand movements into extremely precise movements of miniature instruments inside the body.

There are several variations of robotic simple prostatectomy, including transvesical, transcapsular, extraperitoneal and newer single-port approaches.

Finding the natural plane

The principle of the operation is beautifully simple.

The enlarged prostate consists of an inner adenoma surrounded by the compressed outer prostate or surgical capsule.

The surgeon identifies the natural anatomical plane between these layers and carefully separates the adenoma from the capsule.

Think of removing the flesh of an orange while deliberately leaving the peel behind. 🍊

The obstructing prostate adenoma is progressively freed from its surrounding capsule and removed.

Bleeding points can be precisely controlled using robotic suturing and cautery. The remaining prostate cavity and bladder are then reconstructed according to the surgical technique being used.

The removed prostate tissue is sent to pathology for examination.

What happens to the prostate afterwards?

The prostate is not completely removed.

The peripheral prostate and capsule remain in the body.

This is important because:

  1. PSA does not normally fall to zero after the operation.
  2. The remaining prostate tissue can still develop prostate cancer in the future.
  3. Appropriate PSA surveillance and prostate cancer screening should therefore continue.

Occasionally, previously unsuspected prostate cancer may also be identified when the removed adenoma is examined by the pathologist.

What happens to urinary flow?

Removing the obstructing adenoma creates a very large channel between the bladder and the remaining prostatic urethra.

Most appropriately selected patients experience substantial improvements in:

  • Urinary flow
  • Bladder emptying
  • Residual urine
  • Urinary symptoms
  • Quality of life

Studies of laparoscopic and robotic simple prostatectomy demonstrate substantial improvements in urinary symptom scores and maximum urinary flow rates.

For a man who has spent years waiting for his bladder to negotiate with a very large prostate, the improvement in flow can be rather dramatic.

The urinary catheter

A urinary catheter is placed during the operation.

This allows urine to drain freely while the bladder and prostate cavity heal. Depending upon the operation and surgeon’s technique, continuous bladder irrigation may initially be used to prevent blood clots accumulating within the bladder.

How long does the catheter stay in?

Catheter duration varies considerably between surgical techniques and centres.

Following conventional robotic simple prostatectomy, a catheter commonly remains for approximately 5–10 days, although some contemporary techniques permit earlier removal.

Recent comparative studies report catheter durations around 5–11 days following RASP, although protocols vary substantially between surgeons and institutions.

Laser enucleation procedures such as HoLEP generally permit earlier catheter removal. A 2026 meta-analysis comparing robotic simple prostatectomy with laser enucleation found that catheterisation was approximately 3.5 days shorter after laser enucleation.

In some patients a cystogram may be performed before catheter removal, particularly when extensive bladder reconstruction has been performed.

What can I expect after catheter removal?

The first few days can be a little lively.

Patients may experience:

  • Urinary frequency
  • Urgency
  • Mild burning
  • Blood in the urine
  • Passing occasional small clots
  • Temporary leakage
  • A sudden improvement in urinary flow

Urinary frequency and urgency can take longer to settle if the bladder has been struggling against obstruction for many years.

Removing the obstruction fixes the prostate problem, but an ageing or overactive bladder does not necessarily receive the memo immediately.

Advantages of robotic-assisted enucleation

For appropriately selected men with very large prostates, potential advantages include:

Removal of a very large amount of obstructing tissue

Rather than simply widening the channel, the procedure anatomically removes most of the transition-zone adenoma.

Suitable for extremely large prostates

The technique is relatively independent of prostate size and can be particularly useful when the prostate is enormous.

Excellent visualisation

The robotic system provides magnified three-dimensional vision and excellent access to the bladder and prostate.

Precise control of bleeding

Robotic suturing allows individual bleeding vessels to be identified and controlled.

Lower morbidity than traditional open simple prostatectomy

Compared with open surgery, robotic simple prostatectomy generally produces less blood loss, lower transfusion rates and shorter hospitalisation, although robotic operations can take longer.

Simultaneous bladder surgery

Large bladder stones, selected bladder diverticula and other pathology can potentially be managed during the same operation.

Durable removal of obstruction

Because most of the obstructing adenoma is removed, substantial recurrent obstruction from regrowth is uncommon.

Possible complications

As with any major surgical procedure, complications can occur.

Bleeding

Some bleeding is expected because the prostate has a rich blood supply.

Blood transfusion is uncommon with modern robotic techniques but remains possible, particularly with exceptionally large glands, anticoagulant therapy or significant postoperative bleeding.

Rarely, significant bleeding may require return to theatre.

Urinary infection

A urinary infection can occur following surgery or while the catheter is present.

Symptoms can include fever, burning, cloudy urine or feeling systemically unwell.

Blood clots and catheter blockage

Bleeding can produce clots within the bladder.

Continuous bladder irrigation may therefore be used during the early postoperative period. Occasionally a catheter may require irrigation or replacement, and rarely clot evacuation under anaesthesia is necessary.

Temporary urinary incontinence

Some men experience temporary urinary leakage following catheter removal.

This generally improves as the external urinary sphincter adapts to the newly unobstructed urinary channel.

Pelvic floor exercises may assist recovery.

Persistent severe stress urinary incontinence is uncommon but remains a recognised complication.

Urinary urgency

Urgency, frequency and urge incontinence may temporarily become more noticeable after surgery.

Men who had longstanding bladder obstruction may have developed detrusor overactivity or impaired bladder function. Consequently, bladder symptoms may take weeks or months to settle and occasionally require additional treatment.

Bladder neck contracture

Scar tissue can occasionally develop around the bladder outlet.

If significant, this may require an endoscopic procedure to reopen the channel.

Urethral stricture

Scar tissue can develop within the urethra following instrumentation or catheterisation.

This is uncommon but may require dilatation, urethrotomy or, rarely, reconstructive surgery.

Injury to surrounding structures

Rare complications include injury to the:

  • Bladder
  • Ureteric openings
  • Ureter
  • Rectum
  • Bowel
  • Blood vessels

Major complications requiring additional surgery are uncommon but possible.

General surgical complications

These include:

  • Deep vein thrombosis
  • Pulmonary embolism
  • Chest infection
  • Cardiovascular complications
  • Anaesthetic complications
  • Port-site hernia
  • Wound infection

Appropriate preventative measures are used according to individual patient risk.

What happens to ejaculation?

This deserves particular emphasis.

Retrograde or absent ejaculation is very common.

During normal ejaculation, the bladder neck closes and semen travels forward through the urethra.

After removal of a large prostate adenoma, this mechanism is altered. Semen may pass backwards into the bladder or there may be very little visible ejaculate.

The sensation of orgasm usually remains, but ejaculation is frequently dry or markedly reduced.

This can significantly affect fertility and should be discussed before surgery in men who may wish to father children.

What about erections?

Robotic simple prostatectomy is different from radical prostatectomy for prostate cancer.

The prostate capsule and surrounding neurovascular structures are generally preserved.

Consequently, erectile dysfunction is not an inevitable consequence of robotic simple prostatectomy.

Temporary deterioration can occur following any major pelvic operation, particularly in older men with pre-existing vascular or erectile problems, but many men maintain their preoperative erectile function.

Will the prostate grow back?

One of the major advantages of anatomical enucleation is its durability.

The majority of the obstructing adenoma is physically removed rather than simply compressed or partially vaporised.

Some benign prostate tissue remains and can slowly enlarge over many years, so recurrent obstruction is possible, but clinically significant regrowth requiring repeat surgery appears uncommon.

Long-term RASP-specific retreatment data are less mature than data for older procedures because robotic simple prostatectomy is a newer technique. Studies nevertheless show durable functional improvement, and contemporary comparisons demonstrate similar symptom and flow improvements between RASP and anatomical endoscopic enucleation.

For perspective, long-term data for traditional open simple prostatectomy, which uses the same fundamental principle of adenoma enucleation, show endourological reintervention rates of approximately 3% at one year, 6% at five years and 8.8% at eight years. These figures should not be presented as RASP-specific recurrence rates, but they demonstrate the durability of complete adenoma enucleation.

Robotic enucleation versus HoLEP

Both procedures are excellent options for large prostates.

HoLEP removes the adenoma through the urethra using a holmium laser and subsequently morcellates the tissue within the bladder.

Robotic simple prostatectomy approaches the prostate through the abdomen and bladder or prostate capsule.

Recent evidence suggests that both produce substantial and broadly comparable improvements in urinary symptoms, urinary flow and bladder emptying.

HoLEP generally has the advantages of:

  • No abdominal incisions
  • Shorter catheterisation
  • Shorter hospitalisation in many series
  • Very low blood loss
  • Excellent durability

Robotic surgery may be particularly attractive when:

  • The prostate is exceptionally large
  • There are very large bladder stones
  • Concomitant bladder reconstruction is required
  • Prostate anatomy makes a robotic approach advantageous
  • The surgeon has extensive robotic experience
  • Endoscopic enucleation expertise is not available

The best procedure is therefore not determined by prostate volume alone.

Robotic enucleation versus TURP

TURP remains an excellent operation for appropriately sized prostates, but attempting to resect an enormous prostate piece by piece can become a lengthy undertaking.

Robotic enucleation removes the adenoma anatomically and is therefore particularly suited to large-volume disease.

For very large prostates, current guidelines support simple prostatectomy and anatomical endoscopic enucleation rather than assuming conventional TURP is the optimal treatment.

Recovery after robotic prostate enucleation

Hospital stay varies according to the technique, prostate size and individual recovery.

After discharge, patients are generally encouraged to walk regularly but avoid strenuous exercise and heavy lifting during the early healing period.

Blood in the urine may come and go for several weeks, particularly after physical activity.

Patients should seek medical attention for:

  • Inability to pass urine
  • A catheter that stops draining
  • Heavy persistent bleeding
  • Large blood clots
  • Fever or chills
  • Increasing abdominal pain
  • Chest pain or shortness of breath
  • Significant calf swelling or pain

Is robotic-assisted enucleation right for every large prostate?

No.

The decision should take into consideration:

  • Prostate volume and anatomy
  • Severity of urinary symptoms
  • Urinary flow and residual urine
  • Bladder function
  • Previous urinary retention
  • Presence of bladder stones or diverticula
  • PSA and prostate cancer risk
  • Previous prostate surgery
  • Anticoagulant or antiplatelet medication
  • General health
  • Anaesthetic risk
  • Patient priorities regarding ejaculation and sexual function
  • Availability and experience of the treating surgeon

Alternatives may include HoLEP, other forms of endoscopic enucleation, bipolar TURP, GreenLight laser surgery, Aquablation, prostate artery embolisation, medical therapy or continued observation, depending upon prostate size, anatomy and the individual patient’s circumstances.

The bottom line

For men with a very large benign prostate causing significant urinary obstruction, robotic-assisted prostate enucleation offers a powerful and durable surgical solution.

Rather than trimming away small amounts of tissue, the surgeon follows the natural anatomical plane around the prostate adenoma and removes the obstructing tissue almost in its entirety.

The trade-off is that this remains a significant operation, usually requiring several days of catheterisation and a period of recovery. Retrograde or absent ejaculation should be expected, and complications including bleeding, infection, temporary incontinence, bladder neck contracture and urethral stricture can occur.

For the appropriately selected patient, however, the combination of substantial adenoma removal, excellent urinary flow improvement, low retreatment requirements and the precision of robotic surgery makes robotic-assisted simple prostatectomy an important contemporary option for the very large benign prostate.

This information is intended for general patient education and does not replace individual assessment and advice from a urologist.

TURP for Benign Prostatic Hyperplasia (BPH)

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The Traditional Benchmark for Prostate Surgery

For decades, Transurethral Resection of the Prostate (TURP) has been one of the most established surgical treatments for urinary obstruction caused by benign prostatic hyperplasia (BPH).

Although newer technologies such as GreenLight laser vaporisation, HoLEP, Aquablation, Rezūm and robotic-assisted simple prostatectomy/enucleation have expanded the treatment menu, TURP remains an important benchmark against which many newer procedures are compared.

The basic principle is refreshingly straightforward: remove the obstructing prostate tissue from the inside and create a wider channel for urine to pass through.

What is BPH?

Benign prostatic hyperplasia is the non-cancerous enlargement of the prostate that commonly occurs as men age.

As the prostate enlarges around the urethra, it may progressively restrict urinary flow. Symptoms can include:

  • A weak urinary stream
  • Difficulty starting urination
  • Straining to urinate
  • Intermittent or stop-start flow
  • Feeling that the bladder has not emptied completely
  • Urinary frequency
  • Urgency
  • Getting up several times at night to urinate
  • Acute or chronic urinary retention

Importantly, prostate size and symptoms do not always travel together. A relatively modest prostate can produce significant obstruction, while some very large prostates cause surprisingly little trouble.

What is a TURP?

TURP stands for Transurethral Resection of the Prostate.

There is no external incision.

A specialised telescope called a resectoscope is passed through the urethra and into the prostate. A small electrical loop is then used to progressively remove pieces of obstructing prostate tissue.

Think less “removing the prostate” and more opening up the tunnel through it.

The outer portion of the prostate remains behind. TURP is therefore very different from a radical prostatectomy, where the entire prostate is removed to treat prostate cancer.

The removed prostate tissue is usually sent to pathology for examination.

Monopolar versus Bipolar TURP

There are two principal forms of TURP.

Monopolar TURP

Traditional monopolar TURP uses electrical current passing between the resection loop and a grounding pad on the patient.

It requires non-conductive irrigation fluid during surgery.

One uncommon but potentially serious complication is TUR syndrome, where excessive absorption of irrigation fluid can cause dilution of the blood sodium concentration.

Bipolar TURP

Modern bipolar TURP allows the electrical circuit to remain localised around the resection electrode and permits the use of normal saline irrigation.

This substantially reduces the risk of TUR syndrome and has made TURP safer, particularly when longer operating times are required.

For this reason, bipolar TURP has become widely used in contemporary practice.

Who Should Consider TURP?

TURP is generally considered when urinary symptoms from benign prostate enlargement are sufficiently troublesome or when BPH begins causing complications.

Common indications include:

Moderate to severe lower urinary tract symptoms

Men whose symptoms remain troublesome despite medication, or who prefer definitive surgical treatment, may benefit from TURP.

Recurrent urinary retention

Repeated episodes requiring catheterisation suggest significant bladder outlet obstruction.

Catheter-dependent urinary retention

Some men become unable to urinate without a catheter. TURP may restore spontaneous voiding, although success also depends on how well the bladder muscle continues to function.

Recurrent urinary tract infections

Incomplete bladder emptying can contribute to recurrent infections.

Bladder stones

Persistent obstruction and residual urine may encourage bladder stone formation.

Recurrent bleeding from an enlarged prostate

Significant or recurrent haematuria attributable to BPH can occasionally be an indication for surgery.

Progressive bladder dysfunction

Longstanding obstruction may cause bladder wall thickening, diverticula, increasing residual urine and eventually impaired bladder contractility.

Kidney impairment or hydronephrosis due to bladder outlet obstruction

This represents an important indication for relieving the obstruction.

What Size Prostate is Suitable for TURP?

TURP has traditionally been particularly suitable for prostates in approximately the 30–80 mL range.

The 2026 European Association of Urology guideline continues to regard TURP as a standard surgical treatment for appropriately selected men with moderate-to-severe lower urinary tract symptoms and prostates in this general size range.

Larger prostates can certainly be treated by TURP, particularly in experienced hands, but increasing gland size means:

  • Longer operating time
  • Greater bleeding risk
  • More tissue requiring resection
  • Potentially incomplete adenoma removal
  • Greater likelihood of requiring staged surgery

For substantially larger glands, anatomical enucleation procedures such as HoLEP or, in selected patients, robotic-assisted simple prostatectomy/enucleation may offer advantages because they remove a greater proportion of the obstructing adenoma.

When Might TURP Not Be Appropriate?

There are relatively few absolute contraindications to TURP, but there are circumstances where surgery should be delayed or another approach considered.

Active urinary infection

A symptomatic urinary tract infection should generally be treated before elective surgery because instrumentation can increase the risk of sepsis.

Uncorrected bleeding disorder

Significant coagulopathy requires appropriate assessment and management before surgery.

Anticoagulant and antiplatelet medications require individualised management. They should never simply be stopped without medical advice, as the risk of bleeding must be balanced against the patient’s cardiovascular or thromboembolic risk.

Severe urethral stricture disease

If a resectoscope cannot safely pass through the urethra, the urethral problem may require treatment first or an alternative surgical strategy may be required.

Very large prostate

This is not an absolute contraindication, but procedures such as HoLEP or robotic/open simple prostatectomy may be more appropriate for some very large glands.

Poor bladder contractility

Not every weak stream is caused purely by the prostate.

A bladder that has become significantly underactive may still empty poorly even after an excellent TURP.

This distinction can be particularly important in men with chronic urinary retention, neurological disease, diabetes or very large residual urine volumes. Urodynamic pressure-flow studies can occasionally help determine whether obstruction, impaired bladder contraction, or a mixture of both is responsible.

What Happens During TURP?

TURP is usually performed under either general or spinal anaesthesia.

The resectoscope is passed through the urethra to the prostate.

The surgeon progressively removes obstructing prostate tissue until a wide channel has been created between the bladder and the urethra.

Bleeding points are cauterised during the procedure.

At completion, a urinary catheter is usually inserted. Continuous bladder irrigation may be used initially to prevent blood clots accumulating inside the bladder.

Most patients remain in hospital until the urine has cleared sufficiently and the catheter can safely be removed.

What Should I Expect Afterwards?

It is common to experience:

  • Blood in the urine
  • Burning or stinging during urination
  • Increased urinary frequency
  • Urgency
  • Temporary difficulty controlling urgency
  • Intermittent blood or small clots for several weeks

The urinary stream often improves relatively quickly, while frequency and urgency can take longer to settle.

This is particularly true when the bladder has been fighting obstruction for many years. Removing the obstruction does not necessarily make an irritable bladder forget its old habits overnight.

Risks and Complications of TURP

TURP is well established and generally safe, but it remains an operation and complications can occur.

Bleeding

Some bleeding is expected.

Occasionally bleeding may be sufficient to require:

  • Prolonged bladder irrigation
  • Blood transfusion
  • Return to theatre for evacuation of blood clots and control of bleeding

Significant transfusion is much less common with contemporary techniques than historically.

Infection

Urinary tract infection can occur following TURP.

Patients with long-term catheters, recurrent infections or significant residual urine may have a higher risk.

Rarely, infection can progress to urosepsis.

Temporary Urinary Retention

Some patients cannot urinate immediately after catheter removal.

The catheter may need to be reinserted temporarily.

This is more likely when the bladder muscle has become weak following longstanding obstruction.

Retrograde Ejaculation

One of the most important long-term consequences of TURP is retrograde ejaculation.

Normally, the bladder neck closes during ejaculation so semen travels forwards through the penis.

After TURP, the bladder neck may remain open during ejaculation. Semen therefore travels backwards into the bladder and is subsequently passed harmlessly with the urine.

The orgasmic sensation is usually preserved, but little or no semen may emerge from the penis.

Retrograde ejaculation is common after conventional TURP and should be discussed before surgery, particularly in younger men concerned about fertility or preservation of ejaculation.

Erectile Dysfunction

Most men do not develop erectile dysfunction simply because they have undergone TURP.

Some men report changes in erectile function after surgery, while others notice improvement associated with better sleep, fewer urinary symptoms and improved general wellbeing.

Age, cardiovascular disease, diabetes, medications and pre-existing erectile dysfunction frequently have a greater influence on erections than the TURP itself.

Urinary Incontinence

Temporary urgency and urge leakage can occur during recovery.

Persistent significant urinary incontinence following uncomplicated TURP is considerably less common.

A contemporary systematic review and meta-analysis of randomised TURP studies reported an overall incontinence rate of approximately 8%, although this includes differing definitions and follow-up intervals and therefore should not be interpreted as an 8% rate of permanent severe incontinence.

Urethral Stricture After TURP

One of the important delayed complications is a urethral stricture.

A stricture is scar tissue that progressively narrows the urethra.

Symptoms may include:

  • A gradually weakening urinary stream
  • Spraying or splitting of the stream
  • Straining
  • Incomplete bladder emptying
  • Recurrent urinary infections
  • Urinary retention

The reported rate varies considerably between studies.

The EAU urethral stricture guideline reports urethral stricture rates following monopolar or bipolar TURP of approximately 1.7–11.7%, reflecting differences in surgical technique, instrumentation, follow-up and definitions.

A more recent systematic review of randomised TURP studies found an overall urethral stricture rate of approximately 3%.

For patient counselling, therefore, a reasonable practical message is:

Urethral stricture occurs in roughly 2–5% of contemporary TURP patients in many series, although reported rates vary more widely.

Potential contributing factors include the diameter of the resectoscope, duration of surgery, urethral trauma, postoperative catheterisation and other technical factors.

A stricture may be treated with urethral dilatation, endoscopic urethrotomy or, for more complex or recurrent strictures, urethroplasty.

Bladder Neck Contracture

Scar tissue can also develop at the bladder neck following TURP.

This is called bladder neck stenosis or bladder neck contracture.

The EAU guideline reports rates following TURP ranging approximately 2.4–9.7%, although contemporary rates vary considerably according to technique and patient population.

It can produce symptoms very similar to recurrent BPH and may require an endoscopic bladder neck incision or resection.

Can the Prostate Grow Back After TURP?

Yes, but perhaps “grow back” is slightly misleading.

TURP removes the obstructing inner portion of the prostate but does not remove the entire prostate gland.

Remaining benign prostate tissue can therefore enlarge over subsequent years.

Some men eventually develop recurrent obstruction and require another operation.

Importantly, not every patient who develops recurrent urinary symptoms has recurrent BPH. Other causes include:

  • Urethral stricture
  • Bladder neck contracture
  • Overactive bladder
  • Underactive bladder
  • Recurrent adenoma
  • Prostate cancer

Assessment is therefore preferable to simply assuming that “the prostate has grown back.”

What is the Redo Rate After TURP?

TURP provides durable symptom improvement for most men, but reoperation becomes more common with increasing follow-up.

A large systematic review involving 119 studies and more than 130,000 patients estimated TURP reoperation rates of approximately:

Time after TURP Reoperation rate
1 year 4.0%
2 years 5.0%
3 years 6.0%
5 years 7.7%

Longer-term population data also demonstrate the durability of TURP. An Austrian nationwide analysis cited by the EAU found actual repeat TURP rates of approximately 2.4% at one year, 6.1% at five years and 8.3% at eight years. When procedures for urethral stricture and bladder neck stenosis were also included, the overall retreatment rate reached approximately 12.7% at eight years.

These figures highlight an important distinction:

“Redo TURP” and “reoperation after TURP” are not necessarily the same thing.

A subsequent procedure might be required because of recurrent prostate obstruction, but it may instead be required to treat a urethral stricture or bladder neck contracture.

TUR Syndrome

Traditional monopolar TURP carries a small risk of TUR syndrome, caused by absorption of large volumes of non-saline irrigation fluid. This is a serious complication occasionally requiring an ICU admission as it can cause brain swelling.

This can result in:

  • Low blood sodium
  • Nausea and vomiting
  • Confusion
  • Blood pressure changes
  • Neurological disturbances
  • Cardiovascular complications

Modern bipolar TURP using saline irrigation has dramatically reduced this particular complication.

Does TURP Cause Prostate Cancer?

No.

BPH and prostate cancer are different diseases.

However, because TURP only removes part of the prostate, prostate cancer can still develop in the remaining gland.

Appropriate PSA surveillance and prostate assessment may therefore still be required after TURP.

Occasionally, unsuspected prostate cancer is discovered when TURP tissue is examined by the pathologist.

Advantages of TURP

TURP remains popular because it offers several important advantages:

  • Long-established procedure
  • Excellent improvement in urinary flow
  • Significant improvement in urinary symptoms
  • No external incision
  • Widely available
  • Tissue is obtained for pathological examination
  • Durable results
  • Particularly effective for appropriately selected medium-sized prostates
  • Extensive long-term outcome data

Despite the arrival of numerous newer technologies, TURP remains an important reference standard for surgical treatment of BPH. Long-term studies demonstrate sustained improvement in urinary symptoms and flow.

Disadvantages of TURP

Potential disadvantages include:

  • Anaesthetic and surgical risks
  • Bleeding
  • Catheterisation and hospital admission
  • Retrograde ejaculation
  • Temporary urinary urgency
  • Infection
  • Urethral stricture
  • Bladder neck contracture
  • Small risk of persistent incontinence
  • Possibility of future retreatment
  • Less suitable than anatomical enucleation for some very large prostates

TURP versus Modern BPH Surgery

TURP remains highly effective, but it is no longer the only surgical option.

Depending on prostate size, anatomy, medications, general health and the importance of preserving ejaculation, alternatives may include:

  • GreenLight laser vaporisation
  • HoLEP
  • Aquablation
  • Rezūm water-vapour therapy
  • Prostatic urethral lift
  • Other minimally invasive surgical therapies
  • Robotic-assisted simple prostatectomy or adenoma enucleation

Long-term comparisons increasingly suggest that anatomical endoscopic enucleation procedures can achieve lower retreatment rates than TURP in appropriately selected patients, particularly with larger glands.

There is therefore no single “best prostate operation” for every patient.

The aim is to match the procedure to the prostate, bladder and priorities of the man attached to them.

The Bottom Line

TURP remains one of the most proven and effective operations for benign prostate obstruction.

It can provide substantial and durable improvement in urinary flow and lower urinary tract symptoms, particularly in men with appropriately sized prostates and confirmed bladder outlet obstruction.

Patients should nevertheless understand the potential longer-term complications. Urethral stricture is generally reported in the low single-digit percentages in contemporary studies, although published rates range more widely. Repeat intervention becomes progressively more likely with longer follow-up, with pooled data suggesting a reoperation rate of approximately 7–8% by five years.

TURP may be the old workhorse of BPH surgery, but it has not wandered off to the retirement paddock just yet. For the right prostate and the right patient, it remains a highly effective treatment.

Important Information

This information is intended for general patient education and does not replace individual medical advice. The most appropriate treatment for BPH depends on prostate size and anatomy, severity of obstruction, bladder function, medications, general health, sexual priorities and personal preferences. A consultation with a urologist can help determine whether TURP or an alternative treatment is most appropriate.

So, if you are having issues with your flow and you want to find out more about your options, come see your local Brisbane and Caboolture urologist, Uro-Jo for advice.

Laser Vaporisation for Benign Prostate Enlargement

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A Modern, Low-Bleeding Treatment for an Enlarged Prostate

Benign prostate enlargement, also called benign prostatic hyperplasia (BPH), is extremely common as men get older. As the prostate enlarges around the urethra, it can gradually restrict urinary flow, rather like slowly tightening a collar around the urinary pipe.

Symptoms may include:

  • A slow or weak urinary stream
  • Difficulty starting urination
  • Straining to urinate
  • Intermittent or stop-start flow
  • A feeling that the bladder has not emptied properly
  • Urinary frequency and urgency
  • Getting up several times at night to urinate
  • Episodes of urinary retention

Many men can initially be managed with lifestyle modification or medication. When symptoms become troublesome, complications develop, or medication is no longer effective or desirable, surgery may be considered.

One well-established minimally invasive surgical option is GreenLight laser photoselective vaporisation of the prostate (PVP).

What Is GreenLight Laser Prostate Surgery?

GreenLight PVP is an endoscopic procedure performed through the urethra. There are no abdominal incisions.

A telescope is passed through the urethra to the prostate. A specialised laser fibre is then used to progressively vaporise the obstructing prostate tissue and create a wider channel through which urine can flow.

Unlike TURP, where pieces of prostate tissue are physically cut away, GreenLight treatment predominantly converts the obstructing tissue into vapour while simultaneously sealing blood vessels.

The result is a combination of tissue removal and excellent haemostasis.

What Laser Is Used?

The GreenLight system uses a 532-nanometre green laser.

Modern GreenLight systems commonly use a lithium triborate (LBO) crystal to generate the 532 nm wavelength, with the contemporary high-powered platform delivering up to 180 watts.

Earlier systems included:

Generation Laser Maximum power
Early GreenLight KTP 80 W
GreenLight HPS LBO 120 W
GreenLight XPS LBO 180 W

The current European Association of Urology guideline describes the 180 W system as the contemporary standard platform for GreenLight PVP.

Why Is the Laser Green?

The colour is not merely decorative.

The 532 nm wavelength is strongly absorbed by haemoglobin, the pigment contained within red blood cells. It is much less strongly absorbed by water.

This property allows the laser energy to be preferentially absorbed by the vascular prostate tissue.

The laser has a relatively shallow tissue penetration of approximately 0.8 mm, producing rapid vaporisation while creating a limited zone of coagulation underneath the treated surface.

This gives GreenLight its two particularly useful characteristics:

Vaporisation + haemostasis

As prostate tissue is vaporised, small blood vessels are simultaneously coagulated.

This is why the operative field can remain remarkably clear and why GreenLight surgery generally produces less bleeding than traditional TURP.

Who May Benefit from GreenLight Laser Surgery?

GreenLight PVP may be considered for men with moderate to severe urinary symptoms caused by benign prostatic obstruction, particularly when conservative or medical treatment has not provided adequate relief.

Surgery may also be recommended when BPH results in complications such as:

  • Recurrent urinary retention
  • Dependence on a urinary catheter
  • Recurrent urinary tract infections associated with obstruction
  • Bladder stones
  • Recurrent visible haematuria attributable to BPH
  • Progressive bladder dysfunction
  • Significant residual urine
  • Upper urinary tract deterioration or renal impairment secondary to obstruction

Surgery is also reasonable when symptoms remain sufficiently troublesome despite medication, or when a patient does not wish to continue long-term medical therapy.

What Size Prostate Can Be Treated?

GreenLight PVP is particularly well established for prostates approximately 30–80 mL in volume.

The 2026 European Association of Urology guidelines recommend 532 nm GreenLight PVP as an alternative to TURP for men with moderate-to-severe LUTS and benign prostatic obstruction in this prostate-size range.

Larger prostates can certainly be treated by experienced GreenLight surgeons, but the operation becomes progressively more time-consuming as prostate volume increases.

Importantly, evidence supporting PVP in prostates above approximately 100 mL is less robust than the evidence supporting anatomical enucleation procedures such as HoLEP.

The AUA guideline similarly notes that PVP may be less effective in very large prostates and that retreatment becomes an increasingly important consideration.

For a very large prostate, HoLEP or robotic-assisted simple prostatectomy/enucleation may therefore provide more complete adenoma removal.

What Happens During GreenLight PVP?

The operation is usually performed under general or spinal anaesthesia.

A telescope is passed through the penis and urethra until the obstructing prostate is visualised.

The laser fibre is introduced through the telescope.

The surgeon progressively vaporises the obstructing prostate tissue, generally working from the bladder neck towards the apex of the prostate while carefully protecting the urinary sphincter.

The goal is not necessarily to remove the entire prostate.

Instead, the obstructing transition-zone tissue is removed sufficiently to create a wide, low-resistance urinary channel.

A urinary catheter is usually placed at the end of the operation.

Because bleeding is generally limited, catheterisation and hospitalisation can often be shorter than following conventional TURP.

Some appropriately selected patients can undergo the procedure as day surgery.

Advantages of GreenLight Laser Surgery

Less bleeding

This is arguably GreenLight’s greatest strength.

Because the 532 nm wavelength is absorbed by haemoglobin, tissue vaporisation and coagulation occur simultaneously.

Compared with TURP, studies have demonstrated lower transfusion rates and less bleeding.

Particularly useful when bleeding risk matters

GreenLight may be attractive in older patients or men with cardiovascular disease who require antiplatelet or anticoagulant medication.

The EAU guidelines specifically recognise GreenLight PVP as an option in selected patients receiving anticoagulant or antiplatelet therapy, although individual management of these medications still needs to be determined before surgery.

Shorter catheterisation

Many patients can have their catheter removed relatively quickly after surgery.

Shorter hospital stay

GreenLight surgery is frequently suitable for overnight or even day-case treatment in appropriately selected patients.

No external incision

The entire procedure is performed through the urethra.

No TUR syndrome

GreenLight PVP uses saline irrigation and does not carry the classical dilutional hyponatraemia or “TUR syndrome” associated with older monopolar TURP techniques.

Effective symptom improvement

GreenLight PVP can produce substantial improvements in:

  • Urinary flow
  • Bladder emptying
  • IPSS symptom scores
  • Quality of life

Randomised trials of contemporary GreenLight PVP have demonstrated symptom and flow improvements broadly comparable with TURP over short- to medium-term follow-up.

What Are the Side Effects?

Most men experience some temporary urinary irritation during the recovery period.

Burning or stinging when urinating

This is common initially and usually improves as the prostatic urethra heals.

Urinary frequency and urgency

The bladder may remain irritable for several weeks.

It is important to remember that removing the obstruction does not instantly reset a bladder that may have been struggling against that obstruction for many years.

Blood in the urine

Small amounts of bleeding can occur intermittently during healing, despite the excellent haemostatic properties of the laser.

Temporary difficulty urinating

Occasionally swelling after surgery means that the catheter needs to remain in place longer or needs to be reinserted.

Urinary infection

As with any endoscopic urinary procedure, urinary infection can occur.

Retrograde Ejaculation

One of the most important issues to discuss before surgery is ejaculation.

Following conventional GreenLight PVP, semen may travel backwards into the bladder rather than forwards through the penis during orgasm.

This is called retrograde ejaculation.

The orgasm usually remains present, but little or no semen may be produced.

This is particularly important for younger men concerned about fertility or preservation of ejaculation.

GreenLight should therefore not automatically be described as an “ejaculation-preserving” operation.

Does GreenLight Cause Erectile Dysfunction?

For most men, erectile function is preserved.

Current evidence does not demonstrate a major difference in erectile-function outcomes between GreenLight PVP and conventional TURP.

Sexual function, however, is influenced by many factors including age, vascular health, diabetes, medications and pre-existing erectile function.

Less Common Complications

Potential complications include:

  • Significant bleeding
  • Urinary tract infection
  • Temporary urinary retention
  • Urethral stricture
  • Bladder-neck contracture
  • Temporary urinary incontinence
  • Rare persistent urinary incontinence
  • Persistent urgency or overactive bladder symptoms
  • Incomplete removal of obstructing tissue
  • Recurrent prostate enlargement
  • Requirement for further prostate surgery

One Important Limitation: There Is Usually No Tissue for Pathology

This is an important difference between GreenLight PVP and TURP or HoLEP.

With TURP, prostate chips are removed.

With HoLEP, the enucleated adenoma is morcellated and retrieved.

With GreenLight PVP, much of the treated tissue is vaporised.

Consequently, there may be little or no prostate tissue available for histological examination.

For this reason, appropriate assessment for prostate cancer should be undertaken before GreenLight surgery when clinically indicated, using PSA, examination, MRI and/or prostate biopsy where appropriate.

GreenLight vs TURP vs HoLEP vs Robotic-Assisted Simple Prostatectomy

There is no single “best” prostate operation for every man.

The appropriate procedure depends on:

prostate size + prostate anatomy + bleeding risk + bladder function + patient priorities + surgeon expertise.

Feature GreenLight PVP TURP HoLEP Robotic Simple Prostatectomy / Enucleation
Approach Transurethral Transurethral Transurethral Abdominal robotic
Energy 532 nm laser Electrical 2,140 nm holmium laser Robotic dissection ± energy
Tissue treatment Vaporisation Resection Anatomical enucleation Anatomical enucleation
Tissue for pathology Limited/none Yes Yes Yes
Bleeding Very low Low-moderate Very low Low-moderate
Best established size ~30–80 mL ~30–80 mL Virtually size-independent Large/very large prostates
Large prostate >100 mL Possible, but less ideal Less attractive Excellent option Excellent option
Catheter duration Usually short Short Usually short Usually longer
Hospital stay Short Short Short Generally longer
Anticoagulation advantage Good Less favourable Good Less favourable
Learning curve Moderate Familiar technique Significant Significant
Durability in very large glands Less certain Good Excellent Excellent
Incisions None None None Abdominal port incisions

GreenLight vs TURP

TURP has traditionally been regarded as the benchmark operation against which newer BPH procedures are compared.

GreenLight achieves broadly similar improvements in urinary symptoms and flow for appropriately selected prostates.

Its principal advantages over TURP are:

  • Less perioperative bleeding
  • Lower transfusion requirements
  • Shorter catheterisation
  • Shorter hospitalisation
  • Excellent visibility during surgery
  • Potential advantages in patients at increased bleeding risk

Its disadvantages include:

  • Longer operating time in some patients
  • Lack of tissue for histology
  • Potentially higher retreatment rates over longer follow-up
  • Reduced efficiency as prostate size becomes very large

Long-term population data suggest that although reoperations for bleeding are less common after PVP, overall cumulative reoperation may be higher than after TURP.

So GreenLight’s strength is low perioperative morbidity, while TURP retains excellent durability and provides tissue for histology.

GreenLight vs HoLEP

HoLEP is fundamentally different.

GreenLight predominantly vaporises the obstructing prostate.

HoLEP enucleates the adenoma anatomically from the surgical capsule, rather like removing the inside of an orange while leaving the peel behind.

HoLEP uses a pulsed 2,140 nm holmium laser, which is strongly absorbed by water rather than haemoglobin.

The major advantage of HoLEP is that it is essentially prostate-size independent.

A 40 mL prostate can be enucleated.

So can a 100, 150 or even 200+ mL prostate in experienced hands.

The AUA guideline specifically recognises HoLEP as a prostate size-independent surgical option.

HoLEP also removes a larger proportion of the obstructing adenoma and provides tissue for histological examination.

Its principal disadvantages are its technical complexity, significant learning curve and potential for temporary postoperative stress urinary incontinence, particularly following treatment of very large glands.

For very large prostates, HoLEP will generally provide more complete anatomical adenoma removal than conventional GreenLight vaporisation.

GreenLight vs Robotic-Assisted Prostate Enucleation

For very large benign prostates, another option is robot-assisted simple prostatectomy (RASP), sometimes described as robotic prostate adenoma enucleation.

This is very different from a robotic radical prostatectomy performed for prostate cancer.

The entire prostate is not removed.

Instead, the enlarged benign adenoma is dissected away from the remaining prostate capsule.

It essentially achieves the same anatomical objective as HoLEP but approaches the prostate through the abdomen and bladder or prostate capsule rather than through the urethra.

Robotic simple prostatectomy is particularly attractive for very large or anatomically complex prostates, particularly when associated bladder pathology can be addressed simultaneously.

Its disadvantages include:

  • Abdominal surgery
  • Robotic port incisions
  • Longer catheterisation
  • Longer hospital stay
  • Greater surgical invasiveness
  • Higher resource utilisation

Recent comparative evidence suggests that both robotic simple prostatectomy and laser enucleation provide excellent outcomes for prostates ≥80 mL, while endoscopic laser enucleation generally provides faster perioperative recovery.

So Which Operation Is Best?

A useful way of thinking about these procedures is not as competitors, but as different tools for different prostates.

GreenLight PVP

Particularly attractive for:

  • Small-to-moderately enlarged prostates
  • Approximately 30–80 mL glands
  • Patients where minimising bleeding is particularly important
  • Older or medically complex patients
  • Patients requiring rapid recovery and short catheterisation

TURP

Remains an excellent option for:

  • Small-to-moderately enlarged prostates
  • Conventional benign prostatic obstruction
  • Situations where prostate tissue for histology is desirable
  • Centres with extensive TURP experience

HoLEP

Particularly attractive for:

  • Moderate, large and extremely large prostates
  • Men requiring maximal adenoma removal
  • Recurrent BPH after previous surgery
  • Patients where long-term durability is particularly important
  • Patients wishing to avoid abdominal surgery despite a very large prostate

Robotic-Assisted Simple Prostatectomy

Particularly attractive for:

  • Very large prostates
  • Complex prostate anatomy
  • Large intravesical adenomas
  • Patients with associated bladder pathology requiring treatment
  • Situations where endoscopic enucleation expertise is unavailable or a robotic approach offers anatomical advantages

The Bottom Line

GreenLight laser photoselective vaporisation is an effective, minimally invasive surgical treatment for benign prostate enlargement.

Its 532 nm laser is selectively absorbed by haemoglobin, allowing prostate tissue to be vaporised while simultaneously achieving excellent haemostasis.

Its particular strengths are:

less bleeding, short catheterisation, short hospitalisation and rapid recovery.

For appropriately selected men with moderate-sized prostates, symptom improvement is broadly comparable with TURP.

As prostate size increases, however, anatomical enucleation becomes increasingly attractive. HoLEP and robotic-assisted simple prostatectomy remove the adenoma more completely and are particularly effective for very large prostates. HoLEP achieves this endoscopically, whereas robotic surgery achieves it through an abdominal approach.

The choice therefore should not simply be:

“Which operation is newest?”

A better question is:

“Which operation best suits this prostate, this bladder and this patient?”

Prostate size and shape, urinary symptoms, bladder function, bleeding risk, medications, general health, PSA assessment, sexual priorities and the surgeon’s experience should all contribute to the final decision.

This information is intended for general patient education and does not replace individual assessment and discussion with a urologist.