Enlarged Prostate Treatment Options: Aquablation, TURP, HoLEP and PAE Compared

By Mr Neil Haldar, Consultant Urological Surgeon — London, Buckinghamshire, Berkshire, and Oxfordshire.

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In brief

When medication no longer controls the symptoms of an enlarged prostate — also known as benign prostatic hyperplasia, or BPH — there is rarely one single “best” treatment. There are several effective options, each with a different balance of symptom relief, recovery time, anaesthetic requirement, durability and impact on ejaculation.

The main options I discuss with men are:

• Aquablation — a robot-guided, heat-free waterjet procedure, often considered by men who wish to preserve ejaculation.
• TURP — the long-established benchmark operation for BPH.
• HoLEP — a durable laser enucleation procedure, particularly useful for very large prostates.
• PAE — prostate artery embolisation, a non-surgical option performed by an interventional radiologist.

I assess men with enlarged prostate symptoms from across Buckinghamshire, Berkshire, Oxfordshire, West Hertfordshire and the Thames Valley, including Great Missenden, High Wycombe, Beaconsfield, Gerrards Cross, Slough, Windsor, Maidenhead, Marlow, Aylesbury, Amersham, Chesham and Hemel Hempstead.

The purpose of this page is to help you understand how the options differ before your consultation.

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Why there is no single “best” enlarged prostate treatment

It is natural to ask: “What is the best treatment for an enlarged prostate?”

The honest answer is that the best treatment is the one that fits your prostate, your symptoms, your health and your priorities.

A man in his fifties who wants to preserve ejaculation may make a different choice from a man in his eighties who is on blood-thinning medication and wants to avoid a general anaesthetic. A man with a 40 mL prostate may need a different treatment from a man with a 140 mL prostate. A man with severe urinary retention may need a more definitive operation than a man whose main problem is nocturia and urgency.

That is why the consultation matters. The goal is not simply to choose the newest treatment. It is to match the right treatment to the right patient.

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Enlarged prostate treatment options at a glance

Treatment	How it works	Anaesthetic	Ejaculation	Best suited to	Main trade-off
Aquablation	Robot-guided waterjet removes obstructing prostate tissue	General or spinal	Preserved in most men	Men prioritising ejaculation; selected larger glands	Availability varies; not suitable for every anatomy
TURP	Electrical loop removes prostate tissue through the urethra	General or spinal	Often retrograde	Many men with moderate-to-severe BPH symptoms	Ejaculation commonly affected
HoLEP	Laser enucleation removes the obstructing inner prostate	General or spinal	Often retrograde	Large and very large prostates	Technically specialist procedure; ejaculation commonly affected
PAE	Interventional radiologist blocks prostate blood supply so it shrinks	Usually local anaesthetic	Usually less affected than surgery	Men avoiding surgery or unfit for anaesthetic	Improvement may be slower or less complete

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Aquablation — the ejaculation-sparing surgical option

Aquablation is a newer surgical treatment for BPH that uses a robotically controlled jet of sterile water to remove obstructing prostate tissue. The procedure is planned using real-time ultrasound and camera guidance, allowing the surgeon to map the tissue to be removed while aiming to preserve important structures involved in ejaculation and continence.

The main reason many men ask about Aquablation is ejaculation preservation. Traditional prostate operations often cause retrograde ejaculation, where semen passes backwards into the bladder rather than forwards. Aquablation is designed to reduce that risk, although no operation can guarantee normal ejaculation in every patient.

Aquablation may be particularly relevant if:

• You have moderate-to-severe urinary symptoms despite medication;
• Preserving ejaculation is important to you;
• Your prostate is large enough that treatment choice needs careful planning;
• You want to compare modern options before deciding on surgery.

Aquablation is not automatically the best choice for everyone. Suitability depends on prostate size, prostate shape, bleeding risk, medication history, anaesthetic fitness and the amount of tissue that needs to be removed.

You can read more in my dedicated guide: Aquablation prostate surgery for enlarged prostate.

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TURP — the established benchmark operation

Transurethral resection of the prostate, or TURP, has been the reference operation for BPH for many decades. It removes obstructing prostate tissue using an electrical loop passed through the urethra, without any external incision.

TURP remains a reliable and effective operation for many men. It produces strong improvement in urinary flow and symptoms, and it is the benchmark against which many newer BPH procedures are compared.

The main drawback is that TURP commonly causes retrograde ejaculation. For some men, this is acceptable; for others, particularly younger men or men who strongly value ejaculation preservation, it may be a major factor in choosing another option.

TURP may be a good option if:

• Your symptoms remain troublesome despite medication;
• You want a well-established operation with a long evidence base;
• Your prostate size and anatomy are suitable;
• Preservation of ejaculation is not your highest priority.

You can read more about my BPH assessment and TURP pathway here: Enlarged prostate BPH treatment.

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HoLEP — durable and strong for large prostates

HoLEP stands for holmium laser enucleation of the prostate. It uses a laser to separate and remove the obstructing inner part of the prostate. In experienced hands, it is highly effective and durable, particularly for large prostates.

HoLEP is often considered when the prostate is too large for a standard TURP approach or when a very complete removal of obstructing tissue is needed. It is a specialist technique, and outcomes are closely linked to the surgeon’s experience.

Like TURP, HoLEP frequently affects ejaculation. For many men with very large glands, that trade-off may be worthwhile because the urinary improvement can be substantial and durable.

HoLEP may be a good option if:

• You have a large or very large prostate;
• You need a highly definitive operation;
• You are less concerned about preserving ejaculation;
• Your anatomy is better suited to enucleation than resection.

When HoLEP appears to be the most appropriate treatment, I refer to trusted colleagues with specific expertise in HoLEP.

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PAE — prostate treatment without surgery

Prostate artery embolisation, or PAE, is different from the other treatments on this page because it is not performed through the urethra and does not involve cutting or removing prostate tissue directly.

Instead, an interventional radiologist passes a fine catheter into the arteries supplying the prostate and blocks selected small vessels. This reduces the prostate’s blood supply, causing it to shrink over time.

PAE is usually performed under local anaesthesia. It may be attractive for men who want to avoid surgery, are not ideal candidates for a general or spinal anaesthetic, or wish to reduce the risk of sexual side effects.

The trade-off is that symptom improvement may be more gradual and, in some men, less complete than with tissue-removing surgery such as TURP, HoLEP or Aquablation.

PAE may be a good option if:

• You are keen to avoid surgery;
• You are at a higher risk for anaesthesia;
• Preserving sexual function is a major priority;
• You accept that improvement may be slower or less predictable.

Where PAE appears suitable, I assess the urological side of the decision and arrange referral to an appropriately experienced interventional radiologist.

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Which option is most likely to suit you?

If preserving ejaculation is your main priority

Aquablation is often the option most worth discussing. PAE may also be considered, particularly if avoiding surgery is important. TURP and HoLEP are more likely to cause retrograde ejaculation.

If you want the longest-established operation

TURP remains the traditional benchmark for BPH surgery. It has a long track record and remains appropriate for many men.

If your prostate is very large

HoLEP is often a strong option for very large glands. Aquablation also has evidence in larger prostates, but suitability depends on anatomy, local availability and individual risk.

If you want to avoid surgery or anaesthesia

PAE may be the most relevant option, especially for men who are at higher risk for surgery or strongly prefer a non-surgical approach.

If your symptoms are mainly urgency and frequency

It is important to confirm whether your symptoms are truly caused by obstruction. Some men have bladder overactivity, nocturnal polyuria, infection, medication-related symptoms or mixed lower urinary tract symptoms. Treating the prostate alone may not fully resolve these symptoms unless the cause is correctly identified.

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How I assess which treatment is right for you

Before recommending any BPH treatment, I usually consider:

• your symptom pattern and International Prostate Symptom Score;
• urinary flow rate;
• post-void residual urine volume;
• prostate size and shape;
• PSA history and prostate cancer risk;
• whether there is a median lobe or bladder neck issue;
• history of urinary retention, infections, stones or bleeding;
• kidney function and bladder health;
• blood-thinning medication;
• fitness for general or spinal anaesthetic;
• How important is ejaculation preservation to you;
• Your preference for surgery, referral or non-surgical treatment.

Once these factors are clear, the options usually narrow quickly. My role is to explain the trade-offs honestly, including options I perform myself and options I arrange through specialist colleagues.

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Local private assessment across the Thames Valley

I see men with enlarged prostate symptoms from across Buckinghamshire, Berkshire, Oxfordshire, West Hertfordshire and the wider Thames Valley.

My clinic locations include:

• The Chiltern Hospital, Great Missenden — convenient for Amersham, Aylesbury, Beaconsfield, Chesham and the Chilterns.
• The Shelburne Hospital, High Wycombe — convenient for High Wycombe, Marlow, Beaconsfield, Maidenhead and South Buckinghamshire.
• The Princess Margaret Hospital, Windsor — convenient for Windsor, Slough, Maidenhead, Ascot, Berkshire and West London.

Patients also commonly travel from Gerrards Cross, Denham, Stoke Poges, Henley, Thame, Watlington, Hemel Hempstead, Berkhamsted, Rickmansworth and the surrounding M40, M4 and M25 corridors.

If you are unsure whether your symptoms are due to BPH, you may also wish to read about my specialist LUTS and urinary symptoms clinic.

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Frequently asked questions

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Discuss your enlarged prostate treatment options

If you are weighing up treatment for an enlarged prostate, a consultation is the fastest way to turn a confusing set of choices into a clear recommendation.

I can assess your symptoms, prostate size, urinary flow, bladder emptying and priorities, then explain whether Aquablation, TURP, HoLEP, PAE, medication or another approach is most appropriate for you.

Arrange a private urology consultation

Mr Neil Haldar is a Consultant Urological Surgeon (GMC 3683914). This page provides general information and is not a substitute for individual medical advice.

Further Information

NHS BPH advice

British Association of Urological Surgeons BPH procedures advice

NICE guidance on transurethral water-jet ablation

NICE guidance on prostate artery embolisation