Benign prostatic hyperplasia (BPH) Surgery Options

@heath2026 Aside from the poster’s age, might HoLEP be favored over aquablation due to the size of his prostate?

@psblin99 May I ask why you’ve opted for aquablation over HoLEP? My urologist recommended both, but favored HoLEP. FWIW, I’m 74, and my prostate is 124/133 grams.

@amishboy51 To be honest I realize at 73 technology is leaving me behind. The decision was difficult. I guess Aqublation won because a robotic computer does it.

@amishboy51
Thanks for your response.
My prostate is mildly enlarged at 27cc but with 1 cm intravesical extension. Bladder: Mild trabeculation. Results from cystoscopy last year. Have been taking finasteride for past 8 months but haven't seen any effect.

@amishboy51

Technology and Technique

Aquablation: Employs a high-velocity, heat-free water jet guided by real-time ultrasound and robotic programming to remove obstructing prostate tissue.

HoLEP (Holmium Laser Enucleation of the Prostate): Uses laser energy to meticulously peel (enucleate) the entire inner adenoma block from the surgical capsule, akin to peeling an orange.

Sexual Function and Ejaculation
Aquablation: Superior rates of preserving antegrade (normal) ejaculation because the heat-free mechanism and robotic mapping protect the vital structures and ducts near the verumontanum.

HoLEP: Carries a significantly higher risk of retrograde ejaculation (dry orgasm) or loss of normal ejaculation due to the complete sweep of tissue at the bladder neck.

Efficacy and Prostate Size
Aquablation: Highly predictable and effective for small-to-very-large prostates, though extremely massive glands (>150 ml) can sometimes carry higher retreatment considerations depending on study parameters.

HoLEP: Considered the ultimate size-independent "gold standard" for massive prostates, completely clearing out tissue so that regrowth or secondary operations are exceptionally rare (<2%)

Tissue-Removing Surgical OptionsTURP (Transurethral Resection of the Prostate): Cuts away excess prostate tissue blocking the urine path.GreenLight Laser: Melts and vaporizes the blocked tissue and can remove previous UroLift metal clips.HoLEP: Uses a laser to precisely shell out and remove large amounts of obstructive prostate tissue.Minimally Invasive OptionsAquablation: Uses a robot-controlled water jet to remove tissue, safely performed even after prior UroLift.Rezūm Therapy: Uses water vapor (steam) to shrink extra prostate tissue if the gland size is still appropriate.

DO NOT : TURP and Greenlight.
Why? TURP, by 2026 standards is BARBARIC, painful, and relatively longer recovery-very old school technology with high bleeding - unsuitable for those on blood thinners.
GREENLIGHT: Outdated. I had Greenlight in 2012. Easy procedure, Went home same day, no catheter. But prostate will REGROW, so I had HOLEP on June 19 this year. Finishing week 6 of recovery. BEEN 100% PAIN FREE AND TEXT BOOK RECOVERY.

Whatever you do, stay away from outdated TURP and even Greenlight has been superseded by more advanced procedures. TURP is still around because it is a simple, unsophisticated procedure taught to all medical students. It is a very cheap procedure that does not require expensive modern equipment.

HOLEP was in its infancy in 2012 when I had Greenlight. In 2026, HOLEP is arguably the new GOLD STANDARD. But it requires very expensive robotics equipment, and urologists have a steep learning curve to master this technique. My urologist on June 19 this year, is one such GENIUS.

See attachment below: I submitted a summary report to the urologist, of my textbook recovery, over 5 weeks since my Holep on June 19.

@amishboy51

One factor that can determine choice of procedure is whether patient is on blood thinners. Ask your doctor. I had to stop my blood thinners for a total of 10 days, starting, 5 days before procedure then another 5 days after procedure.

When I had Greenlight in 2012, I wasn’t yet on blood thinners.
Since having Holep, on June 19, I have resumed running, on July 17( 4 week ban on exercise post Holep) with NO side effects - no bleeding. No wetting of pants.

Whatever you do, stay away from TURP, or even Greenlight. TURP is old school method, very cheap requiring no special equipment, and taught in medical school. All other methods like Holep, Aquablation, Rezum, etc require extensive training for already qualified doctors/ urologists to master. Holep, for example require very expensive, advanced robotic equipment for the surgeon to perform it. Not taught in the basic medical degree. Practising surgeons have to learn it.

I think that the first procedure that should be considered is the prostate artery embolization. It is performed by an interventional radiologist…not a urologist. Which is probably why the urologist does not recommend it.

@heath2026 Thank you for your very informative replies. At the moment, I've recently started on Finasteride, which hopefully will make surgery unnecessary. However, as I've said, my urologist in South Florida only referenced aquablation and HoLEP, never mentioned Greenlight, TURP, or Urolift (in fact, he didn't even mention PAE until I, alerted by a friend, inquired about it).

Regardless, thanks for sharing, and best wishes for continued good health!

@heath2026 Greenlight may not be state of the art today, but I had it in 2005 and no issues since.