Last updated: March 2026
When a patient is told they need prostate surgery, the first thing they do is search for information. And they encounter a bewildering array of options: TURP, GreenLight, HoLEP, Aquablation, Rezum, UroLift, open surgery, robotic surgery… How do you choose?
In this article, I will compare the main surgical techniques for benign prostatic hyperplasia (BPH), based on published scientific evidence and over 20 years of experience with laser prostatectomy. My aim is to give you the information you need to make an informed decision together with your urologist.
Why are there so many techniques for the same condition?
BPH affects approximately 2 out of every 10 men over the course of their lifetime, making it an enormous market for the medical device industry. Each company develops its own technology and invests heavily in demonstrating that its method is superior. This has a positive side — more innovation, more options — but it also generates confusion, as each manufacturer naturally presents its results in the most favourable light.
What does not change, regardless of technology, is the anatomy. And the fundamental principle is this: the more completely the prostatic adenoma is removed, the better and more durable the results will be.
HoLEP vs transurethral resection (TURP)
TURP has been the "gold standard" for surgical treatment of BPH for decades. An electrical loop cuts the adenoma into small chips from the urethra. It is a well-known, widely available technique that is effective for small to medium-sized prostates.
However, it has significant limitations:
- Size limit: TURP becomes risky and less effective in prostates over 80 grams. Beyond that size, surgical time becomes excessively long, increasing the risk of bleeding and fluid absorption syndrome (TUR syndrome).
- Incomplete removal: TURP never removes the entire adenoma. Remnants are always left behind that can regrow over time.
- Retreatment rate: Between 10 and 15% of patients treated with TURP will require a repeat procedure in the following years. With HoLEP, that figure is below 2%.
- Bleeding: TURP carries a higher risk of bleeding and transfusion, particularly in patients on anticoagulants.
HoLEP outperforms TURP on all these parameters. Multiple meta-analyses confirm that both techniques produce comparable symptomatic improvement, but HoLEP offers less bleeding, shorter hospital stay, shorter catheterisation time, and a definitive solution regardless of prostate size. The EAU and AUA guidelines have recognised this for years.
HoLEP vs GreenLight laser (PVP)
The GreenLight laser vaporises prostatic tissue using a side-firing fibre. I have extensive personal experience with this technique — I actually developed the en bloc enucleation technique with GreenLight laser (GreenLEP) before evolving towards HoLEP.
GreenLight has genuine advantages: minimal bleeding during surgery and the ability to safely treat patients on anticoagulants. However:
- No tissue specimen: Since the tissue is vaporised, there is no sample for laboratory analysis. This means that incidental prostate cancer — found in up to 5–6% of cases — will not be detected.
- Slow in large prostates: Vaporising 100 or 150 grams of tissue takes a very long time.
- Incomplete removal: It is difficult to know when you have reached the capsule with vaporisation. Residual adenoma may remain, potentially requiring retreatment.
- No clear anatomical reference: Vaporisation works from the inside out, without a defined anatomical plane. The risk of capsular perforation or under-treatment is higher.
HoLEP, by contrast, follows the natural anatomical plane between adenoma and capsule, removes all the tissue (which is sent for histological analysis), and works with equal efficiency regardless of prostate size. In our published series of 754 patients, enucleation efficiency actually increased with larger prostates.
HoLEP vs Aquablation
Aquablation is a relatively new technique that uses a high-pressure water jet, guided by ultrasound and artificial intelligence, to destroy the prostatic adenoma. Its main selling point is ejaculatory preservation, with reported antegrade ejaculation rates of approximately 90% in the WATER and WATER II trials.
It is an interesting technology, but several points deserve consideration:
- Postoperative bleeding: The WATER and WATER II trials reported significantly higher rates of postoperative bleeding compared to other endoscopic techniques. The water jet destroys tissue but does not coagulate, requiring additional haemostasis with electrocautery.
- Size range: Aquablation is approved for prostates between 30 and 150 ml. HoLEP has no size limit.
- Cost: The device is expensive, with a high per-procedure disposable cost.
- Retreatment: Long-term data remain limited. It is not an enucleative technique — it does not remove the entire adenoma, but destroys a portion of it. Long-term follow-up studies will determine whether retreatment rates are acceptable.
Ejaculatory preservation is a legitimate consideration for certain patients. But it must be weighed against overall treatment efficacy, bleeding risk, and the potential need for retreatment.
HoLEP vs open surgery
Open simple prostatectomy — opening the abdomen to remove the adenoma with the surgeon's fingers — was for over a century the reference standard for large prostates. It is extraordinarily effective: the entire adenoma is removed, just as with HoLEP.
But the price the patient pays is substantial:
- Abdominal incision with significant postoperative pain
- Higher risk of bleeding and transfusion
- Hospital stay of 5–7 days (vs 24–48 hours with HoLEP)
- Longer catheterisation time
- Full recovery in 4–6 weeks
HoLEP achieves exactly the same result — complete enucleation of the adenoma — but without incisions, with minimal bleeding, and with discharge the following day in most cases. It is, quite literally, an open prostatectomy performed through the urethra.
What about minimally invasive treatments? (Rezum, UroLift, iTIND)
These treatments are aimed at patients who wish to preserve ejaculatory function and avoid major surgery. Each has its own mechanism: Rezum uses steam, UroLift places implants that separate the prostatic lobes, and iTIND is a temporary device that reshapes the bladder neck.
I must be straightforward: these procedures have a role, but they are not comparable to enucleation in terms of efficacy and durability. The objective improvement in urinary flow is much smaller and far less predictable. When you are accustomed to seeing happy patients after enucleation, with flow rates of 25–30 ml/s and complete bladder emptying, it is frustrating to find that these minimally invasive treatments offer modest improvements and a significant probability of retreatment.
I believe they should be considered more as an alternative to medical therapy than as an alternative to definitive surgery. And they should be performed at experienced centres, because despite their apparent simplicity, appropriate patient selection is crucial for good outcomes.
Comparison table
| Parameter | En Bloc HoLEP | TURP | GreenLight | Aquablation | Open surgery |
|---|---|---|---|---|---|
| Size limit | None | ~80 g | ~80–100 g | 30–150 ml | None |
| Adenoma removal | Complete | Partial | Partial (vaporises) | Partial (destroys) | Complete |
| Tissue for pathology | Yes | Yes (fragmented) | No | No | Yes |
| Long-term retreatment | <2% | 10–15% | 5–9% | To be determined | <2% |
| Transfusion rate | <1% | 2–5% | <1% | 3–6% | 5–10% |
| Hospital stay | 24–48 h | 2–3 days | 24–48 h | 1–2 days | 5–7 days |
| Antegrade ejaculation | 10–30% | 20–30% | 20–30% | ~90% | 10–20% |
| EAU/AUA guidelines | Recommended (any size) | Recommended (<80 ml) | Recommended (<80 ml) | Option (30–150 ml) | Recommended (>80 ml) |
What do the clinical guidelines say?
Both the European Association of Urology (EAU 2025) and the American Urological Association (AUA 2024) guidelines recognise HoLEP as a recommended technique for the surgical management of BPH, regardless of prostate size. It is the only endoscopic technique with this unrestricted recommendation.
This is not opinion — it is Level 1 evidence, based on multiple randomised trials and meta-analyses. Enucleation delivers the same outcomes as open surgery with the safety profile of a minimally invasive procedure.
The right question is not which technique, but who performs it
A skilled surgeon experienced in TURP will achieve better outcomes than an inexperienced surgeon with HoLEP. Technique matters, but the hand that executes it matters more. If your urologist is highly experienced in TURP and your prostate is moderate in size, you may well get a good result. But if your prostate is large, if you are on anticoagulants, if you are looking for the most definitive solution with the best published data — enucleation is the answer.
At ICUA we evaluate each case individually. In-person consultation in Madrid or international video consultation.
📞 +34 91 435 28 44 · ✉ icua@icua.es
Scientific references
- Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
- Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? World J Urol. 2015;33:539-547. DOI (Open Access)
- Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
- Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to BPH: AUA guideline amendment 2023. J Urol. 2024;211:11-19. DOI
- Juliebø-Jones P, Gauhar V, Castellani D, et al. Real world propensity score matched analysis: en-bloc vs non en-bloc for large and very large prostates. World J Urol. 2024;42:299. DOI
- Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
- Rücker F, Lehrich K, Böhme A, et al. A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe. World J Urol. 2021;39:2337-2345. DOI
