Last updated: March 2026
It is a more common situation than you might think: you had your prostate treated — with TURP, GreenLight laser, Rezum, UroLift, iTIND — and now the symptoms have returned. Or they never fully improved. Your stream is still weak, you are getting up at night again, perhaps you have had an episode of urinary retention. You were told the procedure would fix the problem, and for a while it seemed to. But now you are back where you started, or worse.
If this sounds familiar, you are not alone. And most importantly: there is a solution.
Why does a prostate treatment fail?
"Fail" is not always the most accurate word. In many cases, the procedure was technically correct — the issue is that the technique used has inherent limitations that prevent a durable result.
Incomplete resection (TURP, GreenLight)
TURP works by shaving prostatic tissue from the inside. The surgeon removes tissue until the channel seems wide enough, but the entire adenoma is not removed — a variable amount of living tissue remains, capable of growing. The same applies to GreenLight vaporisation: it vaporises the surface, but the depth is limited, particularly in large prostates.
The retreatment rate after TURP is estimated at 10–15% at 8–10 years. I have seen many patients who had TURP at 55–60 and who, at 75–80, develop severe obstruction from adenoma regrowth. It is what I call "the prostate that complicates old age".
Minimally invasive treatments that do not solve the problem (Rezum, UroLift, iTIND, stents)
I am seeing an increasing number of patients who have been through one or more minimally invasive treatments before reaching us. It is a growing phenomenon that deserves an honest explanation.
These treatments are commercially positioned as alternatives that preserve ejaculation and allow rapid recovery. And it is true that they offer those advantages. But the objective improvement in urinary flow is significantly less than with enucleation, durability is limited, and many patients will eventually require retreatment.
Personally, I have so far limited my practice to enucleation and have not adopted any minimally invasive treatment. One consequence of performing enucleation regularly is that you become accustomed to seeing happy patients after surgery, with excellent flow rates and complete bladder emptying. When you see the results of these minimally invasive treatments, the objective improvement is much smaller and much less predictable.
The treatment cascade: It is not uncommon — particularly in the United States, where economic incentives favour outpatient procedures — to see a patient who first had an iTIND, then a few months or years later required a first UroLift, and when the result was unsatisfactory had a second UroLift (sometimes ending up with an absurdly high number of staples), then had a GreenLight vaporisation, and subsequently a TURP. It is the living expression of failure in our goal as urologists, where the patient becomes a victim of the system.
When a patient insists on one of these methods, I refer them to colleagues experienced in that specific procedure. It would not be the first time they come back to my clinic months or years later, asking me to resolve their urinary problem. After suffering poor results and failing to achieve their quality-of-life goals, they often put the ejaculation issue in perspective and tell me they would rather not ejaculate but solve the problem once and for all.
HoLEP as a definitive solution after any previous procedure
After TURP or GreenLight vaporisation
The prostatic capsule — the "peel of the orange" — remains intact after these techniques, and the dissection plane between the adenoma and the capsule is still there. HoLEP works along that capsular plane: we find the capsule and peel away all the residual adenoma. There may be areas of scarring that make dissection slightly more challenging, but it is manageable for an experienced surgeon.
After UroLift
The UroLift system does not remove tissue — it leaves metallic staples within the prostate that mechanically retract the lobes to open the channel. When the effect is insufficient or fades over time, enucleation is perfectly feasible. The capsular plane is usually good. During surgery, we encounter the sutures connecting the metallic elements — they cut easily with the holmium laser — and the staples themselves, which must be managed during morcellation. The metal can damage the morcellator blade, but these are technically straightforward cases.
After Rezum
Rezum injects steam into the adenoma, producing tissue necrosis. Over time, a cavitation forms within the adenoma. But often this cavitation is not uniform: some areas of tissue have been destroyed while others persist intact. Some patients experience insufficient improvement or, worse, recurrent infections from the presence of necrotic tissue. En bloc enucleation removes all remaining adenomatous tissue without difficulty, completely cleaning the area.
After iTIND or other temporary devices
The iTIND is placed temporarily in the prostatic urethra to remodel tissue. When removed, it leaves marks on the adenoma but does not extract tissue. Subsequent enucleation presents no special technical challenges. The same applies to prostatic stents: the adenomatous tissue remains in place, the capsule is intact, and enucleation proceeds normally.
After an incomplete enucleation at another centre
If you had a complete enucleation (HoLEP, ThuLEP) at an experienced centre, the retreatment rate is below 2%. But if it was incomplete — something that can happen at centres with less experience — the residual adenoma continues to cause problems and the enucleation can be completed.
This is not a second chance — it is a definitive solution
Many patients who arrive after a failed procedure do so with resignation: "I was already treated and it didn't work — why would it work this time?" The answer: because this time, the entire adenoma will be removed.
The difference is conceptual. TURP shaves from the inside, leaving residual tissue. Vaporisation evaporates the surface. Devices like UroLift and iTIND remove no tissue at all. Rezum destroys tissue partially. Stents simply hold open a channel that closes again. Enucleation peels the entire adenoma from the capsule, complete. It is the only approach that ensures no tissue remains to regrow.
Request a second opinion. We will explain whether HoLEP can resolve your case definitively.
📞 +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
- Rücker F, Lehrich P, Gilfrich C, et al. HoLEP in three different techniques: a comparison of 600 patients. World J Urol. 2021;39:4063-4069. DOI
- 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
- Tricard T, Xia M, Trambert C, et al. Open prostatectomy is dead — long live endoscopic enucleation of the prostate! World J Urol. 2023;41:1457-1463. DOI
