Treatment for Prostate Enlargement
By Dr Simeon Ngweso, Urological Surgeon
As men get older, the prostate commonly becomes enlarged. This is called benign prostatic enlargement (BPE). An enlarged prostate can narrow the urinary passage and cause bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS), including:
weak urinary stream
difficulty starting urination
a feeling of incomplete bladder emptying
increased urinary frequency
urgency
getting up frequently at night to urinate.
Complications from long term onstruction can cause urinary retention, recurrent urinary infections, blood in the urine or kidney failure.
Treatment options
For men with mild or moderate symptoms, lifestyle changes and medications may be sufficient.
Alpha-blockers, such as tamsulosin or silodosin, relax the muscles around the prostate and can improve symptoms relatively quickly. 5-alpha-reductase inhibitors, such as dutasteride, gradually shrink the prostate and reduce the risk of urinary retention and future surgery.
Medications can work very well, but generally need to be taken long term and may cause side effects such as dizziness, reduced libido, erectile or ejaculatory problems. Dutasteride also lowers PSA levels, which needs to be considered when monitoring for prostate cancer.
When is a procedure recommended?
A procedure may be considered when:
symptoms remain troublesome despite medication
medication causes unwanted side effects
you prefer a procedural treatment rather than long-term medication
you develop complications such as recurrent urinary retention, urinary infections, bladder stones or deterioration in kidney function.
There are several effective procedures for BPE. The best option depends on your prostate size, general health, bladder function, severity of obstruction and whether preserving ejaculation is a priority for you.
HoLEP – A gold-standard treatment
Holmium Laser Enucleation of the Prostate (HoLEP) is a modern, highly effective and durable treatment for an enlarged prostate. It is particularly useful for men with larger prostates and is the most versatile surgical option available.
HoLEP removes the enlarged inner portion of the prostate while leaving the outer prostate capsule intact.
A simple way to think about this is peeling an orange. The outer capsule is like the skin of the orange and the enlarged prostate tissue is like the fruit inside. Rather than shaving away small pieces of prostate, HoLEP follows the natural plane between the enlarged tissue and the capsule and removes the obstructing tissue.
The removed tissue is then removed through the urinary passage and sent to the laboratory for examination.
Why choose HoLEP?
Suitable for prostates of almost any size
Excellent and durable improvement in urinary flow and symptoms
Low risk of significant bleeding
Allows earlier catheter removal and hospital discharge
Very low rates of needing repeat prostate surgery
Removed prostate tissue is available for laboratory examination
Bladder stones can be treated during the same procedure.
For men with very large prostates, HoLEP can provide a less invasive alternative to open or robotic simple prostatectomy, with a shorter recovery.
Rezūm – a minimally invasive option
Rezūm Water Vapour Therapy is a minimally invasive treatment for an enlarged prostate that uses targeted steam energy to treat the prostate tissue causing obstruction.
Rezūm is particularly attractive to men who want to improve their urinary symptoms while preserving sexual and ejaculatory function. Unlike HoLEP and TURP, it does not remove the prostate tissue immediately. Instead, the treated tissue gradually shrinks over the following weeks and months.
The procedure is performed through the urinary passage and does not require an incision. Recovery is generally quicker and less invasive than traditional prostate surgery, although urinary symptoms can temporarily worsen before they improve.
Rezūm is best suited to carefully selected men with suitable prostate size and anatomy. It may not be appropriate for men with very large prostates or severe obstruction.
For the right patient, Rezūm provides an attractive balance between meaningful symptom improvement, a minimally invasive procedure and preservation of ejaculation.
How do other treatments compare?
TURP is a well-established and effective treatment, particularly for small to moderate-sized prostates. It provides excellent symptom improvement and remains widely available.
GreenLight laser surgery vaporises prostate tissue and can provide good symptom improvement with a low bleeding risk. HoLEP also uses laser technology but HoLEP removes the enlarged tissue through enucleation, allowing it to be examined and providing better long-term durability.
UroLift uses small implants to hold the prostate open without removing tissue. Its main advantage is preservation of ejaculation and a relatively rapid recovery. It is suitable only for selected prostate anatomies.
Robotic simple prostatectomy can provide excellent results for very large prostates. HoLEP offers an endoscopic alternative without an abdominal operation and can provide equivalent relief of obstruction with faster recover.
Are there disadvantages to HoLEP?
HoLEP is not right for everyone.
Retrograde ejaculation is very common after HoLEP. Temporary urgency, frequency and urinary leakage can also sometimes occur during recovery. Persistent, significant urinary incontinence is uncommon.
HoLEP is a technically advanced procedure requiring specialised training, experience and equipment and is therefore not available at every hospital.
Which treatment is right for me?
There is no single treatment that is best for every man.
For men seeking definitive and highly durable relief of bladder outlet obstruction, particularly those with larger prostates, HoLEP is a gold-standard surgical option.
For men who prioritise preservation of ejaculation and a minimally invasive approach, Rezūm can be an excellent option when the prostate size, anatomy and degree of obstruction are suitable.
TURP, GreenLight, UroLift and robotic simple prostatectomy also have an important role in selected patients.
The best treatment depends on your prostate, symptoms, bladder function, general health and personal priorities. Your urologist can discuss the advantages and limitations of each option and help you choose the treatment that best fits your circumstances.
Dr Ngweso is a high volume HoLEP surgeon with local and international training and performs high volume cases within both public and private hospitals.
Dr Ngweso is also happy to offer Rezūm and performed the first Rezūm case at St John of God, Berwick.
This information is intended as a general guide and does not replace individual medical assessment.
| Procedure | Re-operation rate | Transfusion rate | Time to IDC Removal | Histopathology | Can be performed on anticoagulated patients |
|---|---|---|---|---|---|
| Holmium Laser Enucleation of Prostate (HoLEP) | ~1-2% | <1% | 1 Day | Yes | Yes |
| Transurethral Resection of Prostate (TURP) | ~5-10% | ~2-7% | 2 Days | Yes | No |
| Greenlight Laser | ~5-15% | <1-2% | 1-2 Days | No | Yes |
| Robotic Simple Prostatectomy | ~1-2% | ~1-5% | 7 Days | Yes | No |
| Open Simple Prostatectomy | ~1-10% | ~5-15% | 7 Days | Yes | No |
| Urolift | ~13-20% | ~0% | 0 Days | No | Yes |
| Rezum Water Vapor | ~4-7% | ~0% | 3-7 Days | No | Yes |
