The prostate gland surrounds the urethra just below the bladder. As the prostate enlarges — a near-universal process in ageing men — it can compress this channel like a hand squeezing a garden hose. The result is reduced flow, difficulty starting urination, incomplete emptying, and the constellation of symptoms we call lower urinary tract symptoms (LUTS).

Obstruction has two components: static obstruction from the physical bulk of enlarged tissue, and dynamic obstruction from smooth muscle tension in the prostate and bladder neck. Medications like the alpha-blockers primarily address the dynamic component; 5ARI primarily the static; surgery addresses both.

Left untreated, significant obstruction can lead to complications beyond bothersome symptoms. The bladder muscle may thicken and eventually weaken from working against resistance. Incomplete emptying increases infection risk. In severe cases, back-pressure can affect the kidneys. These complications, when present, often strengthen the case for surgical intervention.

Before recommending surgery, I assess the degree of obstruction through flow rate measurement (uroflowmetry), post-void residual volume (how much urine remains after voiding), symptom questionnaires, and sometimes pressure-flow studies (urodynamics) that directly measure the relationship between bladder pressure and urine flow. This assessment helps determine both whether surgery is appropriate and which procedures are most suitable.

One of the most important things to understand is that LUTS surgery is rarely an emergency. This matters because it allows space for proper assessment, reflection, and unhurried discussion. Rushing into the wrong procedure can be more harmful than taking time to choose the right one.

In most cases, delaying surgery by weeks or even months while you consider options does not reduce future success. The exception is when complications are present — retention, significant kidney impairment, or recurrent infections warrant more prompt attention.

I encourage patients to use the time available to understand their options thoroughly. A decision made with confidence and realistic expectations leads to better outcomes and greater satisfaction than one made under pressure.

Uncertainty is entirely reasonable. Surgery involves trade-offs, and the "right" decision depends on factors that only you can weigh — how much symptoms bother you, how important sexual function preservation is, how you feel about the various risks and benefits.

My role is to provide information and guidance, not to push you toward any particular choice. If you're uncertain, we can discuss your specific situation, clarify what each option would mean for you personally, and — if helpful — revisit the decision after a period of reflection.

Is surgery inevitable if I have an enlarged prostate?

Will waiting make surgery more difficult later?

Can I try a less invasive option first and have more surgery later if needed?

Procedures differ in how much tissue they can effectively address. Some work well across all sizes; others are optimised for specific ranges. Very small prostates causing obstruction may not need tissue-removing surgery at all. Very large prostates may exceed the capacity of some techniques while being ideal for others.

During assessment, I'll determine your prostate volume through ultrasound or other imaging. This measurement — typically expressed in cubic centimetres or grams — helps narrow the suitable options.

The prostate has several lobes, including lateral lobes on either side of the urethra and a median (middle) lobe that can project upward into the bladder. A prominent median lobe can be particularly obstructive and influences procedure selection — some minimally invasive options are less effective when significant median lobe enlargement is present.

Many men are surprised to learn that ejaculation and orgasm are separate physiological processes. Ejaculation involves the expulsion of semen; orgasm is the pleasurable sensation that typically accompanies it. Some procedures affect the direction of semen flow — causing retrograde ejaculation where semen flows backward into the bladder — without affecting the sensation of orgasm.

Whether this matters depends entirely on your priorities, fertility plans, and personal sense of what's important. For some men, preserving normal ejaculation is paramount; for others, it's a minor consideration compared to urinary improvement. There's no universally "correct" view — only what's right for you.

Erectile function — the ability to achieve and maintain erections — is generally preserved well across most BPH procedures. The risk of erectile dysfunction is relatively low with modern techniques, though not zero. Procedures that preserve ejaculation also tend to have favourable erectile function profiles, but the two are not identical.

A specialised instrument called a resectoscope is passed through the urethra to reach the prostate. Through the scope, I can see the obstructing tissue and use an electrically heated wire loop to shave it away in small chips. These chips are washed out and collected.

One advantage of TURP is that the removed tissue can be examined under a microscope. This occasionally identifies unexpected pathology — including, rarely, prostate cancer that wasn't detected beforehand. While this isn't the primary purpose of the procedure, it provides diagnostic information that tissue-destroying techniques cannot.

The electrical current simultaneously cuts tissue and seals blood vessels, but some bleeding is inevitable. A catheter remains in place after surgery to allow the surgical site to heal and to wash out any blood clots. Once the urine runs clear and you're comfortable, the catheter is removed and you can go home.

TURP delivers substantial symptom relief for the large majority of patients — approximately 80–90% report significant improvement. Urinary flow rates typically increase dramatically. Bothersome symptoms of hesitancy, weak stream, incomplete emptying, and frequency generally improve markedly.

These improvements tend to be durable, lasting many years for most patients. However, the prostate tissue that remains can continue to grow, and some men eventually require retreatment — though this typically takes a decade or more if it occurs at all.

Ejaculatory changes are the most common lasting effect, occurring in approximately 65–75% of patients. Retrograde ejaculation — where semen flows backward into the bladder rather than being expelled — results from necessary tissue removal at the bladder neck. This doesn't affect orgasmic sensation and isn't harmful, but it's permanent and eliminates fertility through intercourse.

Erectile function is preserved in most patients, though approximately 5–10% report changes. The mechanism isn't entirely clear and may relate to thermal effects on nearby structures.

Bleeding during and after surgery requires careful management. Blood in the urine for several weeks during healing is expected and normal. More significant bleeding occasionally requires intervention.

Other potential complications include urinary tract infection, temporary incontinence (usually resolving within weeks to months), and scarring causing urethral stricture or bladder neck contracture in a small percentage of cases.

Traditional TURP uses glycine solution for irrigation, which in rare cases can be absorbed into the bloodstream causing a complication called TUR syndrome. Bipolar TURP uses saline irrigation instead, eliminating this risk entirely.

Bipolar technology may also reduce bleeding and potentially allows treatment of somewhat larger glands with improved safety. Many centres now use bipolar as standard, though clinical outcomes are broadly similar to traditional monopolar TURP.

Using holmium (HoLEP) or thulium (ThuLEP) laser energy, the entire inner prostate gland — the adenoma — is separated from its surrounding capsule, much like peeling an orange. The adenoma is then pushed into the bladder and removed using a morcellator, which cuts it into small pieces for extraction.

Because the entire adenoma is removed rather than just part of it, regrowth requiring retreatment is exceptionally rare — among the lowest of any BPH procedure.

Unlike TURP, which becomes less practical as prostate size increases, enucleation works effectively across all sizes — including very large glands that would traditionally have required open surgery. This versatility represents a significant advantage, offering a single approach regardless of prostate volume.

Symptom relief is excellent, comparable or superior to TURP, with particularly impressive long-term durability. The comprehensive nature of tissue removal means the retreatment rate over subsequent decades is very low.

Ejaculatory changes occur at rates similar to TURP — this reflects the thorough nature of adenoma removal rather than any deficiency of the technique. Temporary urgency and occasional incontinence during healing are common but typically resolve.

Surgeon expertise significantly influences outcomes. Enucleation has a substantial learning curve, and results from experienced centres consistently exceed those from lower-volume practitioners.

A high-powered laser (producing characteristic green light) is directed at prostate tissue through an endoscope. The laser energy is selectively absorbed by blood, instantly vaporising targeted tissue while simultaneously sealing blood vessels. The result is efficient tissue removal with minimal bleeding.

The exceptional haemostasis (bleeding control) makes vaporisation particularly suitable for patients on anticoagulant medications who face higher bleeding risks with other procedures. Many such patients can undergo GreenLight surgery without stopping their blood thinners — an important advantage when anticoagulation is medically necessary.

Because tissue is destroyed rather than removed, no pathological specimen is obtained — the diagnostic opportunity that TURP and enucleation provide is lost.

Post-operative irritative symptoms — burning, urgency, frequency — may be more pronounced and prolonged than with other techniques, likely reflecting thermal effects on surrounding tissue.

The technique is best suited for small-to-moderate sized prostates. Very large glands are better addressed by enucleation.

Long-term retreatment rates may be slightly higher than with enucleation, though for most patients this difference is not clinically significant.

Open prostatectomy is now typically reserved for extremely large prostates exceeding the capacity of even enucleation techniques, or when concurrent procedures (such as bladder stone removal or bladder diverticulum repair) are needed at the same time.

The procedure involves an abdominal incision, removal of the adenoma through the bladder or prostate capsule, and several days of hospital recovery. It's highly effective but substantially more invasive than endoscopic alternatives.

Robotic-assisted and laparoscopic versions of this surgery can reduce invasiveness while achieving similar outcomes, though availability varies.

Is TURP still relevant with newer options available?

How do I know if laser surgery is better for me than TURP?

Will I definitely lose normal ejaculation with these procedures?

Small implants are delivered through a cystoscope, passing through the obstructing prostatic tissue and anchoring on the outer capsule. When tensioned, these implants pull the lateral lobes apart, creating an open channel through the prostatic urethra.

Because no tissue is removed or destroyed, healing is rapid and the procedure's effects are immediate — many patients notice improved flow within days.

The defining feature of UroLift is its minimal impact on sexual function. Ejaculatory dysfunction is rare — dramatically different from the 65–75% rate with TURP. Erectile function is similarly well preserved.

For men who place high priority on maintaining normal ejaculation — whether for fertility, relationship, or personal reasons — this represents a transformative advantage. NICE has recognised this value and recommends UroLift as an option for suitable patients.

UroLift provides meaningful symptom improvement for most patients, with rapid onset of benefit. Quality of life improvements are substantial, and patient satisfaction is consistently high.

However, the magnitude of improvement in symptoms and flow rates is generally less than achieved with TURP or enucleation. For patients with severe obstruction seeking maximum possible urinary improvement, this difference may be significant. For those prioritising sexual function preservation, the trade-off may be entirely acceptable.

UroLift works best for prostates in the 30–80cc range without a large obstructing median lobe. The technique mechanically retracts lateral lobes; it's less effective when median lobe enlargement is the primary source of obstruction.

Retreatment rates are higher than with TURP or enucleation over extended follow-up. The prostate continues to grow around the implants, and some patients eventually require additional procedures. This doesn't preclude UroLift as an excellent initial choice, but realistic expectations about potential future treatment are important.

Recovery is typically rapid. Some temporary discomfort, urgency, and blood in the urine are common immediately after the procedure but usually resolve within days to weeks. Most patients return to normal activities very quickly — often within a day or two.

A specialised device inserted through a cystoscope delivers precise nine-second bursts of steam directly into targeted areas of prostate tissue. The thermal energy from the steam causes cell death within the treatment zone.

Over the following weeks to months, the body's natural processes break down and reabsorb this dead tissue, reducing prostatic volume and relieving obstruction. This gradual process means improvement develops over time rather than immediately.

Like UroLift, Rezūm demonstrates excellent preservation of both ejaculatory and erectile function — markedly superior to traditional surgery. Studies consistently show low rates of sexual side effects, making it an attractive option for men prioritising this aspect of their outcome.

NICE has recommended Rezūm as a cost-effective option for suitable patients, recognising its value in the treatment landscape.

Symptom improvement develops gradually as tissue reabsorption occurs. Most patients notice significant benefit by three months, with continued improvement potentially extending to six months. The degree of improvement is meaningful for most patients, achieving substantial reductions in symptom scores and improvements in quality of life.

Unlike UroLift, Rezūm requires a temporary catheter. The steam treatment causes initial tissue swelling before the resorption process begins, and this swelling can temporarily worsen obstruction. A catheter remains in place — typically three to seven days — until swelling subsides sufficiently for voiding to resume.

For some patients, this catheter period is a significant consideration. For others, a few days of catheterisation is an acceptable trade-off for the procedure's benefits.

During the weeks following treatment, as tissue resorption occurs, some patients experience temporary symptoms including urgency, frequency, blood in urine or semen, and occasionally urinary tract infection. These healing-phase effects resolve as the process completes.

The delayed onset of benefit — in contrast to the immediate improvement with UroLift — requires patience. Full assessment of outcome should wait until at least three months post-procedure.

Before treatment begins, real-time ultrasound creates a three-dimensional map of the prostate. I define the treatment boundaries on this image — specifying exactly how much tissue should be removed and where. The robotic system then executes this plan using a high-velocity water jet that precisely ablates tissue within the defined zone.

The non-thermal mechanism — using water pressure rather than heat — may contribute to the favourable sexual function outcomes observed with this technique.

Aquablation achieves symptom improvement and flow rate increases comparable to TURP, even in larger prostates. The robotic automation provides consistency that may reduce operator-dependent variability.

Particularly notable is the lower rate of ejaculatory dysfunction compared to TURP. While not as low as with UroLift or Rezūm, the reduction is clinically meaningful — positioning Aquablation as an option for patients seeking TURP-level efficacy with reduced (though not eliminated) sexual function impact.

Bleeding risk may be somewhat higher in the immediate post-operative period compared to TURP, occasionally requiring intervention. This reflects the non-thermal mechanism — water jet cutting achieves tissue removal without the simultaneous cauterisation that electrical or laser energy provides.

As a newer technology, very long-term outcome data (decades) don't yet exist, though medium-term results are encouraging.

Specialised equipment requirements mean availability is limited to centres with the necessary infrastructure.

Working through a small puncture in the groin or wrist artery, an interventional radiologist navigates tiny catheters into the arteries supplying the prostate using X-ray guidance. Microscopic particles are then injected to block these vessels, cutting off blood supply.

Deprived of its blood supply, prostate tissue gradually dies and shrinks over subsequent weeks to months, reducing obstruction.

PAE avoids urological surgery entirely — an appealing prospect for some patients. No instrument enters the urinary tract. General anaesthesia is not required. Sexual function is typically preserved. Recovery is rapid, usually without any catheter.

For patients who prefer to avoid surgery, those medically unfit for other procedures, or those simply wanting an alternative approach, PAE offers a genuine option.

Results are more variable than with surgical approaches. While many patients experience good improvement, response is less predictable than with tissue-removing procedures, and some patients do not achieve adequate relief.

Long-term durability is less established than for surgical options. Some patients eventually require additional treatment.

The procedure requires specific radiological expertise and equipment, limiting availability.

Post-embolisation syndrome — temporary flu-like symptoms with pelvic discomfort — commonly occurs as tissue responds to reduced blood supply.

Several guidelines consider PAE somewhat investigational, often recommending it within clinical trials or at experienced centres rather than as routine first-line treatment.

A compressed nitinol (nickel-titanium alloy) device is placed in the prostatic urethra via cystoscope under local anaesthesia. Once positioned, the device expands, exerting sustained pressure on prostatic tissue for five to seven days. This pressure creates ischaemic changes that remodel and reshape the channel. The device is then removed during a second brief procedure.

The appeal lies in achieving tissue remodelling without permanent implants, ongoing medication, or extensive surgery. Sexual function is preserved. The procedure is minimally invasive.

However, tolerating the device for several days can cause discomfort. Symptom relief is generally less robust than with tissue-removing procedures. Long-term data remain limited.

Are minimally invasive procedures as effective as TURP?

How do I choose between UroLift and Rezūm?

Will I need repeat treatment after a minimally invasive procedure?

Can I have TURP later if a minimally invasive procedure doesn't work well enough?

Botulinum toxin blocks nerve signals that cause involuntary bladder muscle contractions — the overactivity driving urgency, frequency, and urge incontinence. By partially paralysing the overactive muscle, Botox reduces these abnormal contractions and increases the bladder's functional capacity.

For patients with refractory overactive bladder, Botox injections are highly effective — often providing dramatic relief when other treatments have failed. Many patients report transformative improvements in their quality of life.

The effect is temporary, typically lasting six to nine months before gradually wearing off. Ongoing repeat injections are required to maintain benefit.

By reducing bladder contractility, Botox can impair the bladder's ability to empty completely. Approximately 5–10% of patients experience temporary urinary retention requiring self-catheterisation until the effect partially wears off.

This possibility is a firm requirement for discussion before treatment. Patients must be willing and able to perform self-catheterisation if needed — this isn't optional. If you're unable or unwilling to catheterise yourself, Botox may not be appropriate for you.

A small device similar to a cardiac pacemaker is implanted under the skin in the buttock region. A thin electrode positioned near the sacral nerves delivers continuous low-level electrical pulses that modulate the nerve signals controlling bladder function.

Treatment proceeds in two stages: a trial phase with an external stimulator assesses your response; if successful (at least 50% improvement), permanent implantation follows.

Once implanted, sacral neuromodulation provides continuous therapy without repeat procedures. There's no risk of retention requiring catheterisation. The device can be adjusted and reprogrammed as needed.

Surgical implantation carries associated considerations including potential lead migration, infection risk, and eventual battery replacement. Not everyone achieves adequate response during the trial phase. However, for appropriate candidates, it offers durable relief from severe symptoms.

No procedure guarantees a perfect outcome. Statistics describe averages across populations; your individual result may be better or worse. Some uncertainty is unavoidable.

What you can control is making a well-informed decision that reflects your priorities. A choice made with understanding and realistic expectations — whatever that choice is — tends to lead to greater satisfaction than one made hastily or without full information.

If you're uncertain, that's fine. We can discuss further, you can take time to reflect, and the decision can wait until you feel ready.