Many men reach a point where tablets no longer feel sufficient, or where the thought of taking medication indefinitely starts to wear thin. That is usually when procedural options come into view — and the names can sound more confusing than helpful: HoLEP, Aquablation, Rezum, TURP.
All four are established treatments for urinary symptoms caused by benign prostate enlargement, known as BPH. They are not the same, they are not interchangeable, and the "best" one depends less on marketing language and more on your anatomy, symptoms, health, and priorities.
A very good operation in experienced hands is often better than a theoretically ideal procedure offered only occasionally. Surgeon volume and centre experience matter as much as the choice of technique — always ask how many of the recommended procedure the team performs each year.
How treatment decisions are usually made
Treatment decisions are based on symptom burden and urinary obstruction — not prostate size alone. A man with a large prostate may cope well on medication, while someone with a smaller gland may have debilitating frequency, poor flow, night-time trips to the toilet, or recurrent retention.
Clinicians look at the whole picture: symptom scores, urine flow measurement, post-void residual, PSA, prostate size and shape, and any complications such as recurrent infections, bladder stones, bleeding, or kidney effects. Your own priorities matter just as much as the clinical picture.
The questions that usually frame the decision are:
- How severe are the symptoms, and how much are they affecting quality of life?
- What is the prostate size, and does its shape suit any particular technique?
- What is the risk of urinary retention if treatment is delayed?
- How important is preserving ejaculation — and has this been discussed honestly?
- What are the expectations around recovery time and duration of catheter use?
- What is the surgeon's experience with each available option?
The four procedures compared
| Treatment | What it does | Best suited to | Symptom relief | Ejaculation | Retreatment risk |
|---|---|---|---|---|---|
| Rezum | Water vapour (steam) shrinks prostate tissue over weeks | Moderate symptoms, selected anatomy, men prioritising lighter recovery | Good, not immediate — improvement builds over weeks | Often better preserved | Higher than HoLEP or TURP |
| TURP | Endoscopic resection of obstructing prostate tissue | Small to moderate prostates, reliable surgical standard | Strong | Retrograde ejaculation common | Low |
| Aquablation | Robotically guided waterjet removes tissue without heat | Moderate to large prostates, men seeking strong relief and a modern approach | Strong | May preserve ejaculation better than TURP in selected men — not guaranteed | Low — long-term data still growing |
| HoLEP | Laser enucleation removes the obstructing core of the prostate | Any prostate size — particularly suited to large glands | Very strong — most complete tissue removal | Ejaculatory dysfunction common | Very low |
Each procedure explained
Considering a procedure for prostate enlargement?
Mr Sri offers all four options and will recommend the one best suited to your prostate size, anatomy, and priorities. Same-week appointments available.
The ejaculation conversation — why it needs honesty
Sexual side effects from BPH surgery are often feared more broadly than they are actually experienced in practice — but ejaculation is a different matter. The distinction between erectile function and ejaculatory function needs to be made clearly at every consultation.
Erectile dysfunction after BPH surgery is relatively uncommon and is not a primary risk of most of these procedures. Men are often surprised to find their erections are unchanged.
Ejaculatory dysfunction — specifically retrograde ejaculation, where semen travels back into the bladder at climax rather than forward — is much more common after tissue-removing procedures. This does not affect the sensation of orgasm for most men, but semen is not produced during intercourse. This change should be discussed openly before any procedure is chosen.
- HoLEP: ejaculatory dysfunction is common — similar to TURP or more
- TURP: retrograde ejaculation is common — typically affects 65–80% of men
- Aquablation: may offer a better ejaculation profile than TURP for selected patients, though outcomes vary and this cannot be guaranteed
- Rezum: best ejaculatory preservation of the four — but not universal
If preserving ejaculation is important to you, say so explicitly at your consultation. It is a legitimate clinical priority and should shape the recommendation.
Matching the procedure to your priorities
Questions to ask your urologist
A good consultation should make the decision clearer, not more complicated. Arriving with specific questions moves the conversation from generalities to something clinically useful for you.
- What is my prostate size, and does its shape rule any option in or out?
- Do my symptoms reflect mainly obstruction, bladder overactivity, or both — and does that change the recommendation?
- Which of these procedures do you think best fits my anatomy and symptom pattern?
- What is the chance of retrograde ejaculation or dry orgasm with each option you're recommending?
- How quickly should I expect improvement, and how long is catheter use likely to be?
- What is the likelihood of needing another procedure in five or ten years?
- How many of the recommended procedure does this centre perform each year?
- If my prostate is large, are all four options equally suitable — or are some less likely to give adequate relief?
If answers feel vague, or if only one procedure is recommended without a clear reason specific to your anatomy and priorities, a second opinion is entirely reasonable. That applies especially when the prostate is large, anatomy is unusual, ejaculation is a major concern, or prior retention has occurred.