Surgery for Benign Prostatic Hyperplasia (BPH): What You Need to Know

“Do I need surgery?” This is both the most common and the most worrying question among patients who visit the clinic with symptoms caused by prostate enlargement. If you are asking yourself the same question, you are not alone.

This article explains as simply and transparently as possible how the decision for surgery is made, why one method may suit you better, what to expect afterward, and which risks are possible. Our goal is to help you speak with your physician more comfortably and knowledgeably during the decision-making process.

It is important to clarify at the outset: surgery is not the first-line treatment for BPH. It is an effective and safe next step when needed, performed in millions of patients worldwide with well-established results.

1. The Decision for Surgery: When and Why Is It Necessary?

Not every patient with prostate enlargement needs surgery. Many live comfortably for years with lifestyle changes or medication. Surgery is considered for certain medical indications or according to the patient’s informed preference.

Situations in which surgery is clearly required

If any of the following apply, surgery is no longer merely a preference but a necessary step to protect health:

• Inability to urinate (recurrent urinary retention): You cannot empty the bladder independently and require a catheter.

• Impaired kidney function: Obstruction caused by the enlarged prostate places pressure on the kidneys.

• Recurrent urinary tract infections: Infections recur because the bladder does not empty completely.

• Bladder stones: Retained urine creates conditions in which stones can form.

• Recurrent or severe bleeding: Repeated blood in the urine originating from the prostate.

Quality-of-life reasons

Even without the mandatory indications above, surgery may be a reasonable option when:

• Medication does not provide sufficient benefit

• Side effects prevent continued medication

• You prefer a lasting solution to lifelong medication

Remember: The decision is based not only on prostate size but also on symptom severity, impact on quality of life, and medical indications, and it is made through shared discussion with you.

2. Choosing a Method: Which Operation Is Suitable for You?

There is no single answer to “Which operation is best for me?” The right method is selected by evaluating several factors together. The methods are first summarized in the table and then explained individually:

What is the difference between TUIP and TURP?

In TURP, enlarged tissue is cut into small pieces and removed. In TUIP, no tissue is removed; one or two small incisions are made in the bladder neck and prostate tissue to relieve narrowing. TUIP is therefore a simpler, shorter procedure that may be preferred in patients with a small prostate who prioritize preservation of sexual function.

Main factors considered when choosing the method

• Prostate volume: TUIP may be considered for small glands, particularly without a median lobe. TURP remains reliable for small-to-medium glands. HoLEP and ThuLEP stand out for large and very large glands because their effectiveness is independent of prostate size.

• Age and overall health: Coexisting diseases and anesthesia risk influence the duration and choice of surgery.

• Use of blood thinners: Laser techniques with stronger bleeding control, such as HoLEP or ThuLEP, are often preferred when anticoagulants cannot be stopped safely. Taking these medications does not mean you cannot undergo surgery.

• Your expectations: Hospital stay, speed of recovery, and concerns about sexual function are considered with your physician.

• Experience of the center and surgeon: Access to laser technology and surgical expertise also influence practical selection.

3. Minimally Invasive Treatment Options

In selected patients, less invasive, short procedures are available in addition to the surgical techniques above. They are generally considered for medium-sized prostates and especially when preserving sexual function is a priority:

• Prostatic urethral lift (UroLift): Small implants compress prostate tissue without cutting it, widening the urinary channel and largely preserving ejaculation and erectile function.

• Water vapor therapy (Rezum): Controlled steam is delivered into the prostate to shrink enlarged tissue. It offers advantages for preserving sexual function.

• Aquablation (robotic waterjet tissue removal): Tissue is removed with an image-guided robotic waterjet. This newer method can also be used for larger prostates and is reported to preserve sexual function better than TURP.

An important balance must be understood: Because less tissue is removed with these methods, sexual side effects are lower; however, symptoms may be somewhat more likely to recur and require additional treatment than after HoLEP, ThuLEP, or TURP, which remove more tissue. Current guidelines do not yet recommend some methods, such as prostatic artery embolization (PAE), for routine use outside clinical trials.

Suitability depends on prostate volume, your priorities—rapid recovery or the most durable result—and overall health, and should be evaluated with your physician.

4. What Should You Expect After Surgery?

The improvement after successful surgery is generally very noticeable. You may expect:

• A strong, comfortable urinary stream without straining or interruption

• A marked reduction in nighttime toilet visits

• A feeling that the bladder empties completely

• No longer needing daily medication

• A lasting, meaningful improvement in quality of life—studies show surgery produces stronger and more durable improvement in symptom scores than medication

5. Risks and Possible Complications

As with any operation, prostate surgery has risks that should be understood. The aim is not to alarm you but to provide realistic, transparent information so you can feel more secure throughout the process.

Retrograde ejaculation

This is the most common effect of prostate surgery and may occur frequently after TURP, HoLEP, and ThuLEP.

• Semen flows backward into the bladder instead of outward and later leaves the body with urine.

• It is not harmful to health.

• It does not remove the sensation of orgasm; only the visible amount of semen changes.

• If you plan to have children, discuss this with your physician before surgery. Some centers use special ejaculation-preserving techniques.

• Because TUIP removes no tissue, it can substantially reduce this risk compared with TURP in suitable patients with a small prostate.

Erectile function

This is a major concern for many patients, but the available evidence is reassuring:

• Current studies show that modern techniques largely preserve erectile function; some comparative studies find no meaningful deterioration in erectile-function scores after surgery.

• In this age group, erectile problems are more commonly related to age, vascular health, or diabetes than to the operation itself; surgery does not markedly increase the risk.

Temporary urinary incontinence

• Mild leakage may occur during the first days or weeks, particularly after enucleation techniques such as HoLEP.

• It is usually temporary and resolves as the pelvic floor muscles strengthen.

• Permanent urinary incontinence is very rare.

Bleeding

• Some bleeding is expected after any operation and is generally monitored and controlled with a urinary catheter.

• Blood transfusion is rarely required. The risk is inherently lower with laser techniques such as HoLEP and ThuLEP, one reason they are favored in patients taking blood thinners.

Urethral or bladder neck stenosis

• This is a rare late complication that may appear months after surgery.

• It is noticed when a weak urinary stream returns and can be treated with a simple procedure.

Overall assessment: Most risks are either temporary or uncommon. Your physician will select the method that minimizes them according to prostate size, overall health, and your priorities.

Frequently Asked Questions

Will surgery completely resolve my urinary symptoms?

Most patients experience very marked and lasting improvement. The result varies according to prostate size, bladder function before surgery, and the selected method. Your physician will discuss your individual expectations beforehand.

Can retrograde ejaculation be reversed?

It is generally permanent but causes no harm to health. If you plan to have children, discuss it with your physician before surgery.

Is HoLEP/ThuLEP better than TURP?

No method is universally “better.” The main determinants are prostate volume, overall health, use of blood thinners, and the experience of your surgeon and center.

Can minimally invasive methods be used for everyone?

No. They are generally recommended for medium-sized prostates and patients meeting specific clinical criteria. Your physician will assess suitability.

How soon can I return to daily life after surgery?

Most patients resume daily activities within a few days and return to full capacity within a few weeks. The exact time varies by method and overall health.

I take blood thinners. Does that mean I cannot have surgery?

No. Blood thinners are not an absolute barrier. Your physician will assess whether they can be stopped safely and may recommend laser techniques with stronger bleeding control.

This content was prepared for patient information based on the AUA 2026 Guideline on Surgical Treatment of BPH and current comparative clinical studies of HoLEP, ThuLEP, and TURP. The decision for surgery and choice of method require evaluation by a physician.