HoLEP vs aquablation vs ? which is best procedure to preserve all func

Good point.

PAE is up and coming however lacks rigorous long term follow up. There is a reason for this - interventional radiologists aren't equipped (flow testing, u/s to check for post void residual) and don't have clinics to monitor long term outcomes (3 month post op checks followed by yearly follow up). The difference in follow up makes it very difficult to know what the true outcomes of the procedures actually are. When we looked at the data about 5 years ago, the AUA recommended PAE to be considered experimental. Since that time, more studies have come out and now PAE is considered to be at the level of MIST treatments (minimally invasive like urolift or rezum which make a trade off of durability for sparing of sexual side effects). Like all BPH treatments it is probably best served in specific clinic circumstances. PAE largely works by shrinking the prostate by choking off the blood supply to the gland - the amount of tissue that goes away is variable, and this really, really varies based on the accuracy and vigilance of getting the key blood vessels going to the prostate - this is not easy by any means. Patients should consider taking dutasteride or finasteride for a year as this mimics the approach without ANY surgical risk (reduces blood supply to prostate and thus shrinks it). In my mind, PAE is promising but not yet proven for the average BPH patient, I have seen several PAE failures for which I had to resect residual tissue. In my mind, the current ideal candidate is someone on blood thinners who cant come off of them with an enormous gland and is pretty sick (risky for anesthesia). We have exceptionally talented IR MDs in Rochester who I have personally seen operate - so if you opt for this approach come to Mayo. Hope this helps.

Dr. Kohler
Professor of Urology
Mayo Clinic Rochester, MN

Learning123 and folks,

BPH is complicated and nuanced as to which procedure is best. There are many BPH choices these days and there will continue to be more and more as the BPH market has essentially an unlimited market. In general, 60% of 60 year olds, 70% of 70 years olds and so on have BPH of which half have symptoms that bother them. There are countless "game changer devices" collecting dust in Urologist's storage closets these days as initial hype of the novel technology was overwhelmed with suboptimal outcomes data and the next greatest thing.

For Learning 123 the first priority is the recurrent infections which could be from the kidney stone as a source or the fact that there is an indwelling catheter - this or self-catheterization undoubtedly leads to infections but at the same time protects the bladder from having to squeeze against resistance (from enlarged prostate). Years of the bladder working against the prostatic resistance leads some men (but not all) to complete bladder weakness and the need for catheterization. If we had a crystal ball we'd operate on those men whose bladder is going to shut down and leave everyone else alone whose bladder will never weaken too much or may die of other causes prior to the prostate causing shenanigans.

For clarity I will attempt to rank order surgical characteristics of different BPH surgeries by characteristic, this is my opinion based on my interpretation of all of the data and my clinical experience (As I helped write the BPH practice guidelines for 6 years I have reviewed a lot of the data) - which of these characteristics is most important to you will augment which bph surgery is best for you.

Success & Durability: Enucleation of any kind (holep, simple (no prostate cancer leave some prostate behind) or radical prostatectomy (+ prostate cancer leave nothing behind which has as a result more negative side effects) >>> aquablation for large glands (> 100 grams), for less the 100 gram prostate = PVP (greenlight) > Rezum > Urolift > Optilume

Sexual Side Effects (mainly from conductive heat applied to prostate, closer to sphincter/check valve = more ejaculatory dysfunction) - Optilume = Urolift (0-1% chance of either), > Rezum (0% ED, 5% EJD), > aquablation (5-10% ED, 10-15% EJD), PVP (10% ED, 50% EJD), Enucleation (10% ED, 100% EJD)

Thus, the better the channel is opened form a surgery, the higher the chance of sexual side effects.

Some men really care about how long the catheter is left behind - its pretty similar for most 3-7 days, urolift and pvp probably win here though with one day typically. Rezum is probably worst here as its effect on the tissue is delayed.

Learning 123, sounds like you need a perc for the stone. After that is settled I would consider radical prostatectomy if you are reasonably healthy as you are watching the prostate cancer at this time anyway. Hope this helps.

Best

Tobias Kohler, MD, MPH
Head of Mayo Mens Health, Rochester, MN

@tkohler I had the Urolift inserted around six years ago. This past October I had an Aquablation performed as the Urolift failed. During the procedure a stone 4CMs was located in the bladder. Upon removal it was noted that the stone surrounded a small piece of metal from the Urolift. I had a renal stone removed today from the right ureter and another 2CM size stone with metal was found in the bladder since October. NOT a fan of the Urolift. Hope this helps.

@jaemiami I wish it had worked for me. No ejaculation 😞. On the bright side, I can pee again!

I had aquablation in September 2024. I was completely asymptomatic until my prostate completely shut me down. I lived on a Foley catheter for 4 months, and had two bacterial infections, while I learned and considered options. I'm in Connecticut and Yale has one of the best Holep surgeons in America. He guaranteed me I'd never need surgery again, and that I'd be shooting backwards. I couldn't get comfortable with the idea of a laser burning out most of my prostate. Connecticut has one surgeon at Middlesex hospital who does aquablation. Make a long story short...I'm still peeing normally and have not lost an sexual function. You will bleed more with aquablation...it's a temporary thing. I was 120 grams...now I'm guessing around 60...still large. I'm 66 and in good shape. I eat lots of broccoli and pumpkin seeds. If I ever run into problems again I wouldn't hesitate to do another aquablation. They keep making the equipment better and the surgeon is now capable of making multiple passes. I hope that helps.

I'm 69. I had HoLEP in April, 2022 after previously having a Urolift procedure and then Greenlight Laser procedure. The Urolift didn't help at all. They said I was emptying more volume but frequencies/urgencies continued to get worse. The Greenlight procedured was great at first. I had the strongest stream since my 20s and U/F decreased for several weeks, in less than 2 months all symptoms returned. They told me I have a very fast growing prostrate. My surgeon referred me to another for a robotic procedure. That surgeon receommended HoLEP and referred me to a qualified surgeon. I stayed overnight in the hospital for observation and to remove catheter, life has been great since. A few weeks of peeing out a few clots. Everything functions great. Sex resumed about a week after the procedure. Good luck!

@icorus1959 I know the doctor you spoke with, Dr. K right? I wound up doing the HoLEP with him last week, I really wrestled with the same thought I'm 68, in excellent shape, athletic etc. The thought of RE really bothers me, but my situation was I had a very large median lobe which was causing the blockage and had really high retention, like 500ml of urine which could really damage my kidneys long term. I'm not sure if I made the right decision or not, my prostate size was 64 grams, so different set of circumstances. In addition, Dr K said my prostate was like an obstacle course so I'm not sure which solution was best for me, I guess I rolled the dice here. Either way I certainly hope the Aqua gives you the long term results you need.

@markbph1 Yup...Kellner. I'm two years out and still peeing normally. No retention. Get up once per night...and no retro. Now if I could only find women I like life would be grand.