Introduction

Men with symptomatic benign prostatic hyperplasia (BPH) are normally treated with medication, but approximately 10% of men with BPH eventually require surgical intervention (British Association of Urological Surgeons, 2025a). 
 
In the past the standard treatment was transurethral resection of the prostate (TURP), although this and other traditional surgical treatments for BPH are associated with side effects such as sexual dysfunction and urinary incontinence. In recent years new minimally invasive treatments have been introduced that are safe, effective and have fewer adverse effects, increasing the treatment options available (Das et al, 2020). 
 
This article, the second in a two-part series, discusses the minimally invasive and invasive surgical options for treating BPH. The first part, which looked at the diagnosis, management and medical treatment of BPH, can be found here.
 

Case study 

Paul Harris is a 79-year-old man*. He had an ischaemic stoke in 2019 which was treated with thrombolytic medication and he made a full recovery. Mr Harris was found to have atrial fibrillation and is now taking an anticoagulant to prevent stroke and bisoprolol to control heart rate. He has lived alone in a flat since his wife died last year. He visits friends for lunch once a week, goes bowling with friends on Tuesdays and visits his sister every Sunday for lunch.
 
Recently he has had problems going out because of bladder symptoms. He was diagnosed as having an enlarged prostate a few years ago and has been taking tamsulosin and finasteride but these don’t seem to be working any more, as he is struggling to empty his bladder and no sooner has he been to the toilet than he needs to go again. He has had two urinary tract infections in 3 months and a post void bladder scan shows a residual urine of 250 ml. Mr Harris does not wish to have a catheter nor does he wish to try intermittent catheterisation. 
 
Mr Harris is seen by urology. His urinary stream is 12 ml/second, whereas the normal stream is around 60 ml/second (Liu et al, 2016), and his prostate volume is 85 g. In the past he might have been treated with a simple prostatectomy but that carries the risk of bleeding and is not recommended for people taking anticoagulants. Mr Harris is very anxious and does not wish to discuss the different types of procedures – he says he wants the surgeon to decide what is best for him. Mr Harris is considered to have capacity to determine if he wishes to have surgery and to decide what he would prefer. The surgeon asks if Mr Harris would like the team to discuss what they consider the best treatment to be and to recommend a treatment. He agrees and says that he does not want the stress of checking all the treatments. 
 
The team recommend green light laser prostatectomy as it is suitable for men with large prostates, use of a laser minimises bleeding and Mr Harris can go home the next day. This is carried out successfully, and Mr Harris is able to get out and about without his life being dominated by his bladder symptoms. 

*Please note a pseudonym has been used and details changed to maintain patient confidentiality

Minimally invasive treatment

The UK population is ageing and the number of older men with BPH and bothersome lower urinary tract symptoms is rising (Speakman et al, 2015; Ye et al, 2024). BPH is normally treated with medication, with surgical intervention considered for men who do not respond to medication or those whose symptoms progress. 
 
Minimally invasive treatments aim to bridge the gap between medication and invasive surgical treatments and to reduce the complications of more invasive treatment (Christidis et al, 2017) (Figure 1, Table 1). Types of minimally invasive treatment include holmium laser enucleation of the prostate, Rezūm steam ablation, stent insertion, prostatic urethral lift, green light laser prostatectomy, prostatic arterial embolisation and bladder neck incision (British Association of Urological Surgeons, 2025a). 
 
It is important for clinicians to determine prostate size as size guides treatment options. Prostate size is usually measured using transrectal ultrasound (TRUS) or magnetic resonance imaging (MRI). TRUS involved inserting an ultrasound probe into the rectum to take images that enable clinicians to measure the length, width, and height of the prostate. A formula is then used to calculate weight and volume – the normal prostate weighs 20–30 g. Transabdominal ultrasound and rectal examination can also be used but these methods are less accurate (Wasserman et al, 2020; Arnold et al, 2023). 




Figure 1. Treatment options for benign prostatic hyperplasia
Table 1. Minimally invasive procedures for benign prostatic hyperplasia
Procedure Suitable for prostate size How long does it take? Day case or overnight Catheter needed post procedure Comments
Green light laser prostatectomy  Up to 150 g 1 hour Day case or overnight stay Yes Suitable for men with large prostates and those taking anticoagulants
Prostate artery embolisation Up to 150 g 2–3 hours Day case No Suitable for men with large prostates
Holmium laser enucleation of the prostate Small and large prostates (20–150 g)  2 hours
 		 Day case or overnight stay Yes, with irrigation Less than 1% of men require further treatment
Rezūm 30–80 g 10–15 minutes Day case Yes 4.4% required further treatment
UroLift 30–80 g 10–15 minutes Day case No 10.7% required further treatment 
Incision of the bladder neck Small prostate (20–70 g) x20–30 minutes Two nights  Yes, with irrigation –
Urethral dilatation Not stated 20–30 minutes Day case No Suitable for frail older men but may need to be repeated

Holmium laser enucleation of the prostate 

This procedure is suitable for men with small, medium or large prostates. It is carried out under general or spinal anaesthetic, and may be carried out as a day case or involve an overnight stay. A probe is passed through the urethra and a laser fibre is used to peel the lobes of prostate tissue from the capsule surrounding it. The peeled pieces are flushed into the bladder where they are chopped into smaller pieces using an instrument known as a morcellator. These are sucked out of the bladder and any bleeding points are lasered to stop bleeding. The bladder is then irrigated via a three-way catheter to remove any clots or blood, with the catheter removed before discharge. Holmium laser enucleation of the prostate is highly effective and less than 1% of men require further treatment (British Association of Urological Surgeons, 2023a). 
 

Rezūm steam ablation

This procedure is suitable for men who have a prostate gland of between 30–80 g and is not suitable for men with very large prostates. The procedure is carried out under spinal anaesthetic, usually as a day case, and takes around 10–15 minutes. An instrument is passed along the urethra and puffs of steam are injected into the prostate. The larger the prostate, the greater the number of times the prostate is steamed during the procedure as the more steam is required. The treatment causes the prostate to shrink over 3–6 months and preserves sexual function (Das et al, 2020; National Institute for Health and Care Excellence (NICE), 2020; British Association of Urological Surgeons, 2023b; Nguyen et al, 2024). A urinary catheter is inserted as the man may develop urinary retention following the procedure, and removed a few days later at a follow-up appointment. Around 4.4% of men who have Rezūm steam ablation require further treatment (Elterman et al, 2021).
 

Green light laser prostatectomy

This procedure is suitable for men who have large prostate glands (up to 150 g). The procedure is carried out under general or spinal anaesthetic, and may be carried out as a day case or involve an overnight stay. It takes around an hour and is suitable for men who are taking anticoagulants and others at high risk of bleeding. An instrument is passed along the urethra and a laser fibre inserted. The laser emits green light and is used to core out the tissue obstructing the urethra. The laser's green light is absorbed by red tissue and this minimises bleeding, making this an excellent choice for men who are taking anticoagulants. It is as effective as a TURP and has fewer side effects. A urinary catheter is inserted as the man may develop urinary retention following the procedure. The catheter is usually removed a few days later at a follow-up appointment (NICE, 2022; British Association of Urological Surgeons, 2023c). 

Stents and implants 

A stent is a tube that is inserted into the prostatic urethra to keep the urethra open and enable the person to void. Permanent stents are rarely used in fit healthy men but are sometimes used to maintain urinary flow in frail older men with multiple medical problems. Common side effects are infection and incrustation (Christidis et al, 2017). 
 
The prostatic urethral lift or UroLift is suitable for men who have prostate glands weighing 30–80 g. It is not suitable for men with large prostate glands or those with a history of urinary retention. The procedure is usually carried out as a day case, under general or spinal anaesthetic. It takes around 10–15 minutes. An instrument is passed along the urethra and between two and four implants are inserted. The implants pull the prostate tissue away from the urethra (Figure 2), leaving a clear channel for urine to drain. A catheter is not usually required and the man can be discharged as soon as he has passed urine (NICE, 2021; British Association of Urological Surgeons, 2023d).

We do not yet know how effective this procedure is long term (Srinivasan and Wang, 2020) – at present around 10.7% of men require further treatment (Elterman et al, 2021). It can be very helpful in treating symptoms in frail older men as it is quick and minimally invasive. 
Figure 2. Prostatic urethral lift, showing implants being used to clear a channel through which urine can drain. 

Prostate artery embolisation

Prostate artery embolisation is suitable for men who have large prostate glands of 80 g or more. The procedure is carried out under local anaesthetic by an expert radiologist. It is usually carried out as a day case and takes around 2–3 hours. 

Under X-ray guidance, the prostate is approached through the left or right femoral artery (Figure 3). Fine microcatheters are used to introduce embolisation agents such as polyvinyl alcohol (PVA) and other newer synthetic biocompatible materials into the small arteries supplying the prostate. These microparticles completely block the prostatic vessels, reducing blood supply to the prostate which causes tissue death and shrinkage. Pelvic pain can occur during the procedure and for up to 3 days afterwards. Lower urinary tract symptoms improve in the weeks and months after the procedure (NICE, 2018; Bibok et al, 2024).


Bladder neck incision

Bladder neck incision is a specialist technique to relieve prostatic obstruction. It is suitable for men who have small prostate glands. The procedure takes around 20–30 minutes and is carried out under general or local anaesthetic. It usually requires a two-night stay in hospital. An instrument is passed into the bladder and incisions are made in the bladder neck to clear obstructions. A laser can be used to make the incisions, which is thought to reduce bleeding and speed recovery. In other cases, electrical energy delivered via a ‘spike’ vaporises obstructing tissue. The bladder is then irrigated via a three-way catheter to remove any clots or blood, and the catheter is removed before discharge (British Association of Urological Surgeons, 2023e).
Figure 3. Prostate artery embolisation, using embolising agents to block prostatic blood vessels and cause the prostate to shrink.  

Urethral dilatation 

Urethral dilatation is a simple procedure that can enable older men to pass urine without needing indwelling catheters. It is suitable for men who have small prostate glands. The procedure takes around 20–30 minutes and is carried out under local anaesthetic with sedation. Urethral dilatation used to stretch the urethra to treat narrowing, or a stricture of the urethra, which obstructs urinary flow. There are two methods. 
  1. Long thin rods, known as urethral dilators are inserted. A small dilator is first inserted and removed and then progressively larger ones, so that the urethra is stretched and the urethra is once more fully patent (British Association of Urological Surgeons, 2024).  
  2. A balloon device such as the Optilume device is inserted into the urethra and inflated to stretch the urethra and restore patency. The balloon is then removed.  
This technique may need repeating. This can be useful in older men who have multiple health problems and those who are unable to tolerate medication (Guo, 2015). 
 

How effective are minimally invasive procedures?

A Cochrane review examined the effectiveness of minimally invasive treatments and concluded that prostatic urethral lift and prostate artery embolisation were as effective as traditional surgery in the short term (up to 12 months) (Franco et al, 2021). Minimally invasive treatments may result in a large reduction in major adverse events. The authors stated that there were limited data on long-term outcomes to determine the effectiveness of treatments and stressed the importance of further research (Franco et al, 2021). 
 
Pham and Sharma (2018) carried out a literature review and examined newly-approved therapies for BPH including Rezūm, aquablation, mechanical stenting (UroLift), prostate artery embolisation, and injectable agents. They concluded that these emerging techniques demonstrated comparable outcomes to traditional therapy. They commented that only prostate artery embolisation has currently been proven effective in patients with prostates of 80 g or more who were not able to have surgery.
 

Invasive procedures

Surgical intervention is reserved for men with moderate to severe symptoms who do not respond to other therapies. Two operations are commonly carried out: TURP and open or laparoscopic prostatectomy.

Transurethral resection of the prostate

TURP is considered the gold standard in prostatic surgery. The number of TURPs performed has declined in recent years as a result of the use of pharmaceutical therapy and minimally invasive procedures (Young et al, 2018). Normally TURP is suitable for men who have large prostate glands of no more than 80 g, but very skilled surgeons can carry out TURP on men who have prostates up to 150 g (Leslie et al, 2023). 

The procedure is carried out is under general or spinal anaesthetic and takes 45–60 minutes. It usually requires a hospital stay of 2–3 nights. TURP is performed using a specially adapted cystoscope with a wire loop and diathermy. It removes the central part of the prostate and sucks these tissues out of the bladder (Figure 4). The bladder is irrigated via a three-way catheter to remove any clots or blood, which is removed before discharge. Complications include blood loss requiring transfusion, transient or long-term urinary incontinence, infertility and erectile dysfunction (Foster et al, 2018; British Association of Urological Surgeons, 2023f). 
 

Open or laparoscopic simple prostatectomy

Open or laparoscopic prostatectomy is also known as Millin’s prostatectomy. It was developed by Millin, a urology surgeon, in 1945. It is suitable for men who have large prostate glands of 80 g or more. The procedure is normally carried out under general anaesthetic and takes 2–4 hours. The man normally stays in hospital for 7–10 days postoperatively. 

The prostate is approached via an abdominal incision and the central lobes of the prostate that are obstructing the urethra are removed. The outer lobes and the capsule of the prostate are left intact, and a drain is left in place for 2–4 days. The bladder is irrigated via a three-way catheter to remove any clots or blood, which normally stays in place for around 7 days and is removed before discharge (British Association of Urological Surgeons, 2025b). 

Open prostatectomy is associated with a number of side effects including blood loss requiring transfusion, transient or long-term urinary incontinence, infertility and erectile dysfunction. It is gradually being replaced with robot-assisted prostatectomy as this is associated with fewer complications (Xia et al, 2021).

Robot-assisted prostatectomy was first reported by Sotelo et al in 2008. This uses a robotic system to guide the surgeon's instruments precisely. It is carried out through small incisions in the abdomen with the surgeon controlling robotic arms from a console, enabling the surgeon to have a magnified three-dimensional view. The surgeon is able to perform more precise movements than are possible with human hands. Surgeons with experience of using robot-assisted surgery can learn how to carry out this procedure quickly (Johnson et al, 2018; Cho et al, 2020). Robot-assisted prostatectomy is associated with fewer initial complications such as blood loss and fewer long-term complications such as urinary incontinence because of the precision of the work (Cho et al, 2020).
 

Figure 4. Processes involved in transurethral resection of the prostate (TURP).

Figure 5. A surgeon performing robotic prostatectomy surgery. 

Conservative treatment 

In some cases, surgical or medical treatment are inappropriate and conservative treatment is indicated. The aim of conservative treatment is to enable the person to void and to avoid complications such as infection and renal problems. There are two treatment options for these patients: intermittent or permanent catheterisation. 
 

Intermittent self-catheterisation 

Intermittent self-catheterisation predates the use of indwelling catheters. Small flexible catheters are used and the patient is taught to use a catheter 4–6 times a day to drain the bladder. The catheter is inserted, urine is drained from the bladder and the catheter removed. This maintains normal bladder tone and reduces the risks of infection. 
 
NICE (2015, 2017) guidance on infection control recommends that, when appropriate, intermittent self-catheterisation should be used in preference to an indwelling catheter. NICE (2017) guidance recommends that the person with bladder dysfunction be offered the option of intermittent self-catheterisation if this is clinically appropriate and practical. In order to manage intermittent self-catheterisation the person needs to be aware of the reasons that this is required, be motivated to carry out intermittent self-catheterisation, have sufficient dexterity and a reasonable bladder capacity. Intermittent self-catheterisation aims to improve the person’s quality of life rather than placing an intolerable burden on the person so it is important to check that intermittent self-catheterisation will suit the person and his lifestyle.
 

Permanent catheterisation 

Permanent catheterisation is used in frail older men with ongoing health problems. A urethral catheter is usually used, although a suprapubic catheter is used when prostatic enlargement makes it difficult to pass a urethral catheter. 

Conclusions

BPH can have a devastating effect on a person’s quality of life and lead to long-term health problems if left untreated (Park et al, 2020). Although there are now many different treatment options men can hesitate to seek treatment or to report when treatment is longer effective. Nurses working in community settings can enquire about lower urinary tract symptoms when seeing older men and can ensure that the person is able to access appropriate treatment. 
 

Resources

NHS (2023) Making a decision about enlarged prostate (BPE). https://www.england.nhs.uk/wp-content/uploads/2023/11/Decision-support-tool-making-a-decision-about-enlarged-prostate.pdf (accessed 31 October 2025)

Key points 

  • Around 10% of men who have symptoms of BPH will require treatment other than medication.
  • In the past the only active treatment options were invasive surgical procedures which carried the risk of life-changing complications.
  • New minimally invasive treatments appear to be safer and have lower rates of complication.
  • Fewer traditional treatments are now being carried out.
  • Conservative treatment is appropriate for some men. 
  • Effective treatment relieves symptoms and improves quality of life. 

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