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

I had Aquablation five months ago. One of my stated goals to the UR surgeon was that I wanted to preserve ejaculation and this procedure gave me the best chance for that. I worked.

HoLEP will not preserve ejaculation for sure, its one of the drawbacks of this procedure

Congratulations!!! Yes, I think this facility is training Aquablation. but another does have it. I would travel, be in a trial for the best outcome. Went out of state for a less invasive wrist procedure a doctor developed, preserved some movement. This surgeon believes more in the total clearing out prostate and not reoccurring. His concern is regrowth and that permanently damaging bladder function. He is good with 2nd opinions, but he presents a scary picture. Surgery in 2 days. I have appt in a month with other surgeon but everything became more rushed when hospitalized. Plus don't want catheter any longer than necessary. I want to do what the pro says is best but I was hoping for reducing prostate. I want all function like you. He thinks this is best because I have a catheter already some other guy put in. Online every option has a doc saying it is the best. How to decide? First urologist had me on flomax but no reduction med. This could have been delayed. Thank you for your experience

Chicago has multiple hospitals/doctors that are experts in Aquablation. It is a well studied procedure and there was a multi center study recently published that you may find interesting. Unfortunately not all doctors know or share this info.

Search for the Water III study In the Urology Times. It was published in 2025.

Wow - sorry to hear of all your serious medical needs. A catheter is no fun but try to choose what's best for you and not rush. I'm 72, last June had severe retention, catheter then HoLEP. My results are excellent. I do have retrograde ejaculation but I knew I would going in -- pretty much a guarantee with HoLEP. If you choose it, you need a surgeon that does them all the time with 500 or more to reduce complications. If I was younger, Aquablation would have been my first choice. But be aware that there is no guarantee you won't have RE with Aqua - Many on this forum have it but it's your best chance you won't. If you want durability, minimal complications, little to no bleeding and tissue for Histopathology then HoLEP is a good choice - with the right surgeon. If ejaculation is your goal, Aqua gives the best chance. With your bladder thickness you have lots to consider. Best wishes...

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

@learning123 I had a PAE/Aquablation procedure 4.5 months ago. The procedures are done back to back. It reduces bleeding (I only had catheter 24 hours) and I think allows the regrowth of the prostate. Doctor said it could last me 10-15 holes. In hindsight not sure i would go through the trouble of the PAE part again, but every time I read about guys having catheters for a week and trips to the ER post surgery I rethink it. There's a study out there is you want to just Google "PAE aquablation combination study". Aqua has about a 20% RE result. One thing I can tell you is don't delay, the thickening of one's bladder wall will have significant impact on your results. Aqua gas a pretty great record of results and grows in popularity every day. My results were good, but could have been even better had i had treatment 5 years ago. I don't know much about holep, but doctors tend to recommend the procedure their practice is qualified in our that they're familiar with so get a second opinion, it can't hurt.

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!

@vtredwolf pardon the typos. Corrections: the PAE "SLOWS" the regrowth of the prostate (i think), and doctor said the procedure should last me 10-15 "years". Fat fingers and spell check did me in.

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