Article Archive
May/June 2020

Surgery for Enlarged Prostate
By Amy E. Krambeck, MD
Today’s Geriatric Medicine
Vol. 13 No. 3 P. 22

Safe, minimally invasive procedures are changing the outlook for millions of men.

By age 50, men have a roughly 50% chance of having an enlarged prostate, or benign prostatic hyperplasia (BPH)—a number that rises with every year of age to reach about 90% at age 80.1 Because an enlarged prostate can squeeze the urethra, narrowing or blocking urine flow, the most common symptoms are problems urinating, which affect nearly 34 million American men between ages 40 and 79.2 Men with BPH experience urinary urgency, full bladder sensation, weak or inconsistent urine flow, difficulty urinating, or even the inability to urinate, which is a medical emergency.

The goal of BPH treatment is to alleviate urinary symptoms and prevent complications such as urinary tract or kidney infections, or even a decrease in the kidneys’ ability to function.

Patients with BPH are evaluated on a variety of factors, including prostate size, overall health, age, and kidney function, but the nature and severity of their symptoms are central to the assessment. BPH is staged as mild, moderate, or severe based on symptoms, which do not have a direct relationship with prostate volume. Some people with minor enlargement can have symptoms that disrupt their lives, whereas others with very large prostates can have relatively minor symptoms.

Although most men can control BPH symptoms with medication and changes to eating and drinking habits, BPH is the most common reason for urological surgery. Surgical advances have made treatment for BPH less invasive. In early stages, some procedures can be performed in a doctor’s office. Even in more advanced stages or with very large prostates, options such as advanced laser surgeries have reduced pain and recovery time.

Treatment Options Before Surgery
In mild cases of BPH with no symptoms, doctors continue to monitor the problem over time. If symptoms are mild, such as minor urinary frequency or urgency, patients can improve them by altering how much and what kinds of fluids they drink and how they schedule eating, drinking, and bathroom trips. Exercising regularly, following healthy eating habits, and limiting caffeine intake also can improve symptoms.

Because all treatments have potential risks and side effects, treatment with medication or surgery is generally limited to patients with significant symptoms.

For mild to moderate cases, patients can combine lifestyle changes with medication. Alpha blockers relax the prostate and bladder neck to make urination easier, while 5-alpha reductase inhibitors inhibit prostate growth, resulting in some shrinkage of the prostate over a prolonged period of use. Patients are sometimes prescribed a combination of both medications. Chronic use of these medications can cause side effects such as dizziness and retrograde ejaculation. The 5-alpha reductase inhibitors also can result in erectile dysfunction, breast growth or tenderness, and increased hair growth.

Traditional BPH Surgery
Surgery has long been an option for patients with moderate to severe BPH, particularly if they cannot urinate, have blood in their urine, or have bladder or kidney problems. Patients with such severe symptoms need surgical procedures to open the urethra by reducing the bulk of the prostate that is compressing the urethra and/or removing the intrusion of tissue into the urethra and bladder. Because of the risks associated with surgery, it traditionally was reserved for more advanced stages of BPH.

The oldest surgical option for BPH, open prostatectomy with an abdominal incision, is rarely performed today because there are so many less invasive options. Robotic laparoscopic techniques for prostate resection can be used in some complex cases, but most often, surgeons rely on minimally invasive transurethral techniques.

The most common BPH surgery performed today is transurethral resection of the prostate (TURP), a less invasive technique that has been performed for decades. There are several terms for TURP: button TURP, plasma electrode TURP, and bipolar TURP. These terms all describe the same type of procedure with different energy sources.

In TURP, the surgeon shaves down the prostate from inside the urethra, removing most of the prostate and opening the urethra. Patients spend one or two nights in the hospital, require a urinary catheter for a few days to a week, may require irrigation for bleeding, and may need a blood transfusion if bleeding is severe. Postoperatively, patients can experience a urinary tract infection as a result of catheterization, and they may require retreatment for BPH symptoms because the prostate tissue is not entirely removed and the prostate will continue to grow throughout their lifetimes. TURP is not a recommended BPH procedure for large prostates.

New Treatments for Small Prostates
BPH procedures undergo continual innovation, with new and improved devices and procedures emerging regularly. BPH can be treated effectively at any stage, and because newer procedures can minimize complications, catheterization, prostatic bleeding, pain, and recovery time, the threshold for surgery is changing to include patients with earlier-stage BPH.

Newer minimally invasive surgical treatment may now be appropriate for patients with mild BPH who are not improving on medication or who would rather have a low-risk procedure than take medication for the rest of their lives. Now there are many office-based minimally invasive therapies for the treatment of BPH that are generally meant for men with mildly enlarged prostates. For appropriately selected patients, these procedures, which can be performed safely in the office, can improve voiding symptoms in the short term. As with any newer procedure, data on long-term effectiveness are limited.

One example is steam therapy of the prostate. Steam is applied to the lobes of the prostate, destroying the tissue, which is then resorbed by the body over time. The patient may require a catheter for several days until swelling resolves. Some men require additional surgery to relieve symptoms when they reoccur.

Another in-office procedure called prostatic urethral lift (PUL) is a transurethral surgery for patients with mild to moderate BPH and a prostate volume under 100 cc. In PUL, the surgeon separates the right and left lobes of the prostate and attaches bands to both enlarged lobes, lifting them away from the urethra to open it for easier urination.

Another newer minimally invasive procedure performed in the operating room is water ablation (aquablation) of the prostate, which also opens up the urethra in less severe cases.

Advanced Laser Surgeries for Larger Prostates
In general, men with severe symptoms or significantly enlarged prostates tend to require physical removal of prostate tissue through procedures performed in the operating room, where advanced laser procedures have emerged as alternatives to TURP. Laser surgery has undergone changes recently with the development of new lasers and laser fibers.

Laser procedures for BPH have been in use for decades. For example, ablative procedure such as photoselective vaporization of the prostate (PVP, aka green light) and holmium laser ablation of the prostate (HoLAP) have long been used to burn away prostate tissue around the urethra in individuals with small prostates (less than 80 cc). These patients often need additional treatment later.

A newer advance in laser surgery called holmium laser enucleation of the prostate (HoLEP) has significant advantages over TURP, laser ablative procedures, and office-based procedures. In the HoLEP procedure, a high-powered holmium laser is used to core out the prostate, peeling it from the inside. A morcellator then chews up the tissue so that it can be removed through the urethra. Because a laser is used to perform all of the cutting, both enucleating the prostate and cauterizing blood vessels, the approach produces significantly less bleeding than TURP does. This improves safety for the many older patients who take blood thinners.

Patients rate their postoperative symptoms as much improved after HoLEP compared with TURP, and their ability to urinate is markedly better.3 Because all the abnormal growth is removed down to the thin rim of capsule (similar to the rind of an orange), HoLEP patients rarely need retreatment. Ten years after HoLEP surgery, only 1% to 4% of patients need retreatment,4 whereas 30% of TURP patients need additional surgery after just five years.3

HoLEP can be performed at all BPH stages and on prostates of any size, including very large prostates over 80 cc that would traditionally be treated with open or robotic prostatectomy. With transurethral HoLEP, patients have lower morbidity, blood loss, and catheter time compared with those procedures.5 HoLEP’s reduced catheter time lowers the risk for urinary tract infection compared with TURP.6

Next-Level MoLEP Treatment
A recent advance in the HoLEP procedure—Moses laser enucleation of the prostate (MoLEP)—takes all the advantages of standard HoLEP and adds the unique power of a 120-watt holmium laser with a modulated pulse (“the Moses effect”) and new fibers that make surgery far more efficient in several ways. First, the laser energy is very stable, and the fibers rarely break. MoLEP also enables surgeons to cut adenoma tissue more efficiently to reach the target plane. Also key to MoLEP’s efficiency is the focused, modulated laser pulse, which cuts through and coagulates tissue concurrently. With standard HoLEP, the surgeon controls the laser with two pedals set at different powers, an incision setting and a cautery setting. The surgeon cuts tissue and then cauterizes it. When the surgeon does both at the same time with MoLEP, surgery time is reduced. These efficiencies translate to shorter procedure times with less anesthesia, which is beneficial for patients, particularly those with cardiovascular or pulmonary problems. Furthermore, the shorter operating time results in health care savings for the hospital and allows surgeons to help more people by being more efficient with their time.

By cauterizing as it cuts and instantly controlling bleeding, MoLEP is safe for patients taking anticoagulants. Less bleeding also means better visibility for the surgeon. And limited bleeding after MoLEP can actually negate the need for the overnight irrigation used for TURP and other procedures. Patients can be discharged with a catheter, sleep in their own beds at home, and return the next day for follow-up and catheter removal. In some especially blood-free cases, patients can even have their catheters removed the same day as the procedure. Thus, laser technology and technique have advanced so far as to begin making laser surgery an outpatient procedure.

Minimally Invasive Options for Everyone
Advances in BPH surgery are shaping a very promising future for the millions of men with enlarged prostates at all stages. Rather than taking daily medications for the rest of their lives, men can opt for a safe procedure that will control their BPH symptoms over the long term. Patients with more advanced BPH can have minimally invasive surgery, possibly on an outpatient basis. Less bleeding means faster recovery and less need for the catheter, which is one aspect of surgery patients universally dread.

New BPH procedures also have the potential to drive earlier detection and treatment. As more men realize just how safe and effective today’s BPH procedures are, they may be more likely to seek help earlier, thus averting the most serious complications of BPH, such as kidney damage. Men can have safe, effective BPH surgery, quickly get back on their feet, and return to their normal lives.

— Amy E. Krambeck, MD, is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis. She is a consultant for Lumenis Surgical, maker of the Lumenis 120-watt holmium laser with MOSES Technology.


1. What is benign prostatic hyperplasia (BPH)? American Urological Association website. Updated May 2019.

2. Ulchaker JC, Martinson MS. Cost-effectiveness analysis of six therapies for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Clinicoecon Outcomes Res. 2018;10:29-43.

3. Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012;109(3):408-411.

4. Elmansy HM, Kotb A, Elhilali MM. Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol. 2011;186(5):1972-1976.

5. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008;53(1):160-166.

6. Cornu JN, Ahyai S, Bachmann A, et al. A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. Eur Urol. 2015;67(6):1066-1096.



Case 1
Benign prostatic hyperplasia (BPH) treatment with transurethral resection of the prostate (TURP)

Patient: The 63-year-old patient had moderate BPH with no major comorbidities.

Symptoms: Urinary frequency and urgency, weak urine stream, difficulty starting urination, pain while urinating, and urinary tract infection

Prostate size: 57 cc

Treatment: TURP

Postoperative care and recovery: The patient spent two nights in the hospital, with catheterization and irrigation. During the recovery period, one urinary tract infection was treated with antibiotics. He also had bleeding for two weeks.

Outcomes: TURP alleviated the patient’s BPH symptoms, but they began to return after three years. He was retreated with TURP.

Case 2
BPH treatment with Moses laser enucleation of the prostate (MoLEP)

Patient: The 69-year-old patient had severe BPH. His history included cardiovascular disease and current anticoagulant therapy.

Symptoms: Urinary frequency and urgency, difficulty starting urination, weak urine stream, urinary retention, urinary tract infection, and kidney inflammation

Prostate size: 92 cc

Treatment: MoLEP

Postoperative care and recovery: The patient did not need irrigation and was discharged the same day with a catheter. It was removed at an office visit the next morning at 8 am. He was able to stay on his anticoagulant medication for the procedure and his bleeding resolved in seven days. He was able to return to exercise after the bleeding stopped.

Outcomes: MoLEP alleviated the patient’s BPH symptoms. At five years, there’s been no need for retreatment and no change in his urinary symptoms.