Getting up several times during the night to urinate, a weakening of the urine stream or a feeling of not emptying the bladder completely are the symptoms of benign prostatic hyperplasia that affect daily life the most. Surgery comes into consideration when medication is not enough, or in cases of recurrent urinary retention, bladder stones, impaired kidney function or frequent infections. At this point, the HoLEP vs TURP comparison is naturally one of the topics patients ask about most often.
Both methods aim to treat the part of the prostate that narrows the urethra. However, the energy used, the way the tissue is removed, effectiveness in large prostates, bleeding risk and some details of the recovery process differ. The right choice is not made simply on the basis of “the newest method” or “the shortest operation.” The volume of the prostate, the medications the patient takes, accompanying conditions, their expectations and the surgeon's experience with the method must be assessed together.
What is TURP prostate surgery?
TURP stands for transurethral resection of the prostate. It is also commonly known as closed prostate surgery. The procedure uses a special optical system advanced through the urethra; the prostate tissue blocking the urinary passage is cut out in small pieces with electrical energy and removed. No incision is made in the skin.
TURP is a method that has been used for many years in the surgical treatment of benign prostatic hyperplasia, and its results are well known. It can be an effective option, particularly in patients with a suitable prostate volume. In current practice, bipolar TURP technology may offer some advantages over classic monopolar TURP in terms of the fluid and energy system used.
The tissue removed during TURP can be sent for pathological examination. This is valuable for detecting an unexpected focus of prostate cancer. A catheter and bladder irrigation may be needed for a while after surgery. The length of hospital stay, the amount of bleeding and the patient's general condition affect this process.
How is HoLEP surgery performed?
HoLEP means holmium laser enucleation of the prostate. In this method, laser energy is used to separate the enlarged inner part of the prostate from the prostate capsule along the anatomical plane. The freed tissue is pushed into the bladder and then broken into small pieces with a device called a morcellator and removed from the body.
The key difference of HoLEP is that, rather than cutting away only the part of the prostate in front of the channel in pieces, the enlarged adenomatous tissue is enucleated more completely. The removed tissue is sent to pathology. Because the laser contributes to bleeding control, less bleeding and a shorter catheter time can be aimed for in suitable patients.
This technique is a closed method that can be an alternative to open surgery, particularly in large prostates. However, HoLEP is a surgery that depends on the surgeon's learning curve as much as on the device used. Finding the correct anatomical plane, preserving the sphincter structure that maintains urinary continence and carrying out the morcellation step safely are important.
HoLEP vs TURP comparison: the key differences
The common goal of both operations is to relieve the urine flow and allow the bladder to empty. The difference lies in how this goal is reached. In TURP, the obstructing prostate tissue is resected in a controlled way. In HoLEP, the enlarged prostate tissue is separated from its capsule and removed.
Prostate volume and choice of method
TURP is one of the methods often preferred for small and medium-sized prostates. As prostate volume increases, factors such as operating time, fluid use and bleeding are considered more carefully. Although TURP can still be performed in some patients with very large prostates, the need for a staged procedure or the possibility of residual tissue may come into consideration.
HoLEP, by contrast, can be performed across a wide range of volumes, from small prostates to very large ones. It can be a strong option for patients with a large prostate who want to avoid the incision, bleeding and recovery burden that open surgery may bring. However, prostate volume alone does not decide the matter. Narrowing of the urethra, the strength of the bladder muscle, the middle lobe structure of the prostate and previous procedures are also assessed.
Bleeding and the use of blood thinners
The ability of laser energy to coagulate blood vessels can contribute to bleeding control in HoLEP. For this reason, HoLEP often comes into consideration in patients who take blood thinners or who need more careful assessment for bleeding. Even so, no surgical method is “bloodless”; whether medications should be stopped and when they should be restarted must be decided individually with cardiology and anesthesia assessment.
Safe results can also be achieved in TURP with modern bipolar systems. Nevertheless, the risk of bleeding varies with the size of the prostate, the patient's clotting status, the medications used and a longer operating time. For this reason, a complete blood count, kidney function tests, urinalysis and other tests considered necessary are planned before the procedure.
Catheter, hospital stay and return to daily life
After HoLEP, the catheter time and hospital stay can be short in many patients. After TURP, the need for a catheter with bladder irrigation may be somewhat more pronounced. However, this is not a fixed rule for every patient. A large prostate, active bleeding, bladder dysfunction, infection risk or additional conditions can change the recovery plan.
After either method, burning on urination, frequent urination, a sudden urge and mildly bloody urine may be seen in the first days. Adequate fluid intake, regular use of the prescribed medications and avoiding heavy physical activity for a certain time support recovery. In case of fever, heavy bleeding with clots, being unable to urinate at all or increasing pain, you should see a doctor without delay.
Durability and the need for repeat surgery
In HoLEP, because the obstructing inner part of the prostate is removed close to the capsule, the need for additional surgery due to regrowth over the long term is expected to be low. This may be meaningful especially for younger patients with a high prostate volume who are looking for a long-term solution.
TURP is also an effective and established treatment. However, because of the amount of tissue removed, the structure of the prostate and continued growth over time, some patients may need another procedure years later. This likelihood is not the same in every patient and should be discussed realistically before surgery.
Expectations regarding sexual life and urinary continence
One of patients' most sensitive questions is the effect of surgery on erection and ejaculation. After HoLEP and TURP, retrograde ejaculation, that is, semen flowing back into the bladder instead of coming out, is a common occurrence. Although the sensation of orgasm continues in most patients, a decrease in semen volume or dry ejaculation may occur. Patients who plan to have children must mention this before surgery.
Erectile function is preserved in most patients; however, age, diabetes, vascular disease, an existing erection problem and psychological factors affect the outcome. It is not right to promise zero risk for any method.
Regarding urinary incontinence, temporary stress incontinence or dribbling may be seen in the first weeks after HoLEP. This period may last somewhat longer, especially in very large prostates and in patients who have had obstruction for a long time. Pelvic floor exercises and regular follow-up provide marked improvement in most patients. Permanent, significant urinary incontinence is rare in experienced centers. Temporary urinary complaints may also be seen after TURP; in both methods, preserving the sphincter is one of the core elements of surgical success.
Which method suits which patient?
It is not right to define a single method as the best option for everyone. In patients with a small or medium-sized prostate who are anatomically suitable and have limited accompanying risks, TURP can be a good solution. In cases of large prostate volume, medication use that requires attention regarding bleeding, or when a more complete removal of tissue is aimed for in the long term, HoLEP may come to the fore.
Before the decision, it is not only the prostate volume measured by ultrasound that is considered. The level of the patient's complaints, the urine flow test, the amount of urine remaining in the bladder, the PSA value, digital rectal examination findings, the presence of a urinary infection and, when necessary, cystoscopy are assessed together. In some patients, the real cause of the complaints may be not the prostate but a weak bladder muscle. In such a situation, even a technically successful operation may not fully meet expectations.
Assoc. Prof. Dr. Uygar Miçooğulları carries out individualized surgical planning in the treatment of prostate enlargement by assessing the patient's anatomical features, life expectancy and post-operative priorities. The aim is not only to open the urinary channel but to improve quality of life in the long term through a safe operation, clear information and an accessible follow-up process.
If your urinary complaints are disrupting your daily routine, do not make your decision based on online comments or a single test result. A detailed urological assessment to determine the method that suits you helps prevent both unnecessary delays and disappointments caused by choosing the wrong method.
