HoLEP vs TURP: Which BPH Surgery Is Right for You?

Benign prostatic hyperplasia (BPH) is a common condition that leads to urinary symptoms as men grow older. When medication and lifestyle changes no longer provide relief, surgery becomes an option to consider. Two main procedures—Holmium Laser Enucleation of the Prostate (HoLEP) and Transurethral Resection of the Prostate (TURP)—offer effective treatment. This article compares these procedures to help you determine which may be most suitable for your situation.

What is BPH?

Benign prostatic hyperplasia is a non-cancerous enlargement of the prostate gland that commonly occurs as men age. The prostate surrounds the urethra, and as it enlarges, it can compress this tube, leading to urinary symptoms. These symptoms often include frequent urination, difficulty starting urination, weak stream, inability to completely empty the bladder, and nocturia (waking at night to urinate).

TURP: The Traditional Approach

TURP has long been the standard surgical treatment for BPH, offering effective relief from urinary symptoms for many patients.

The Procedure: TURP involves inserting a resectoscope through the urethra to reach the prostate. The surgeon uses an electrical loop to cut away excess prostate tissue that is blocking urine flow. The procedure requires no external incisions, as it works entirely through the natural opening of the urethra.

Recovery Period: Patients typically stay in the hospital for 1-3 days following TURP. A catheter remains in place for 1-3 days to drain urine while healing begins. Most men can return to light activities within 2 weeks, though complete recovery may take 4-6 weeks.

Effectiveness: TURP provides consistent symptom relief for the majority of patients, with most men experiencing significant improvements in urinary flow and reduced symptoms. These improvements generally last for many years, though some men may need additional treatment later as the prostate continues to grow.

Limitations: TURP is generally most appropriate for prostates of moderate size. For very large prostates, other surgical approaches may be recommended. Additionally, TURP carries some risk of bleeding, which can be a concern for patients on blood-thinning medications.

HoLEP: The New Gold Standard 

HoLEP represents an advancement in BPH surgery that utilises holmium laser technology. This approach offers different benefits compared to conventional methods.

The Procedure: HoLEP uses a holmium laser to separate enlarged prostate tissue from the capsule. The surgeon “shells out” the obstructing tissue in larger pieces, which are then pushed into the bladder. A special instrument called a morcellator then breaks down this tissue for removal. Like TURP, HoLEP requires no external incisions.

Recovery Period: Hospital stays following HoLEP are typically shorter than with TURP, often 0-1 day. Catheterisation time is also generally shorter, frequently less than 24 hours. Most patients can resume normal activities within 1-2 weeks.

Effectiveness: The procedure removes more prostate tissue than TURP,  resulting in fewer retreatments over time. Urinary flow improvements are also better than those achieved with TURP.

Prostate Size Range: Unlike TURP, HoLEP can effectively treat prostates of almost any size, including very large glands that may otherwise require open surgery. This makes it an option for a wider range of patients.

Comparing Key Factors

Bleeding Risk and Blood Thinners

TURP: Uses electrical energy that cuts and cauterises simultaneously but still carries a notable risk of bleeding. Patients on blood thinners typically need to stop these medications before surgery.

HoLEP: The laser energy seals blood vessels as it cuts, resulting in minimal bleeding. This makes HoLEP suitable for patients who cannot safely stop blood-thinning medications and those with larger prostates where bleeding risk is higher.

TUR Syndrome Risk

TURP: Uses non-saline irrigation fluid, which can occasionally be absorbed into the bloodstream during longer procedures, causing a potentially serious condition called TUR syndrome (characterised by confusion, nausea, and in severe cases, seizures).

HoLEP: Uses saline irrigation, eliminating the risk of TUR syndrome. This allows for longer operating times when needed for large prostates without this specific complication risk.

Sexual Function Considerations

TURP: This procedure may cause retrograde ejaculation, where semen enters the bladder instead of exiting through the urethra. Generally, erectile function is preserved unless there are pre-existing issues.

HoLEP: Similar to TURP, HoLEP typically results in retrograde ejaculation. Its impact on sexual function is comparable to TURP, with most men maintaining erectile function.

Ideal Candidates for HoLEP and TURP

Both TURP and HoLEP can effectively treat BPH symptoms although HoLEP has some specific advantages. 

TURP may be appropriate for men with moderately enlarged prostates (30-80 grams) who can safely stop blood-thinning medications temporarily. HoLEP offers advantages for patients with very large prostates (over 80-100 grams), those who must continue taking blood thinners, men who wish to minimise hospital stays, and patients looking to reduce the likelihood of needing repeat surgery. Those with urinary retention requiring long-term catheterisation may also benefit more from HoLEP. 

Conclusion

Both HoLEP and TURP offer effective treatment for BPH symptoms. TURP has a long history of successful outcomes, although HoLEP offers advantages in terms of durability and effectiveness and is safer in very large prostates and men on blood thinners. Contact a Singaporean urology for a consultation to determine which BPH surgical approach best suits your condition.