Enlarged Prostate (BPH) - Laser Prostate Surgery - Better Urination After Procedure
- Nikola Stanojevic
- Apr 13
- 7 min read
Updated: Apr 19
Benign prostatic hyperplasia - also called BPH - is a condition in men where
the prostate is enlarged but not cancerous. Other names are benign hypertrophy or benign prostate enlargement.
Benign prostatic hyperplasia affects about 50 percent of men between 51 and 60 years of age and up to 90 percent of men older than 80 years.
As the prostate slowly enlarges over time it presses on the urinary canal - the urethra. Narrowing of the urethral canal leads to reduced urine flow, difficulty urinating and urine retention in the bladder (inability to completely empty the bladder). Typical problems with an enlarged prostate include frequent urination eight or more times a day, nighttime urination (nocturia), weak intermittent urine stream, involuntary wetting (urinary incontinence) and as the most pronounced symptom - inability to urinate (urinary retention - emergency condition).
Over time, due to difficult urine emptying, the bladder wall becomes thicker, the bladder weakens and loses the ability to empty completely. The amount of urine that cannot be emptied is called residual urine (RU). In the worst cases, urine backs up into the kidneys (hydronephrosis) and the kidneys lose their function (urea and creatinine accumulate in the blood).
The goal of any enlarged prostate surgery is to enable better urination without taking medications.
How is benign prostatic hyperplasia diagnosed?
The diagnosis is easily made by examining the prostate with ultrasound. Usually, a certain size limit of the prostate is 40-45 grams (milliliters) when it is said that the prostate is enlarged.
Urethroscopy is planned when a man has a small prostate on ultrasound (up to 40ml) but has difficulty urinating that is not resolved with medication.
A biopsy is performed when there is an altered PSA tumor marker result (especially the PSA index is monitored).
When do I need surgery for an enlarged prostate?
Surgery is planned when medications for BPH no longer resolve urination problems. The indication for surgery is established when urination is poor or when there is a complete cessation of urination.
The decision that prostate surgery is needed is made when one or more of the following conditions exist:
frequent urges to urinate
difficulty starting urination
slow (prolonged duration) urination
frequent urination at night
starting and stopping urination
feeling that you cannot completely empty your bladder
frequent urinary tract infection
kidney or bladder damage
inability to control urination or inability to urinate
presence of stones in the bladder
presence of blood in the urine
Thus, the size of the prostate alone is not the only indicator of whether you need surgery or not.
Sometimes, a very small prostate of about 30 grams can cause major problems, while on the other hand, large prostates over 120 grams sometimes do not cause significant problems.
What type of prostate surgery do I need?
Surgery through the abdomen, the so-called trans-vesical-prostatectomy (TVP), is an outdated procedure, and if someone suggests such surgery to you, I advise you to seek a second opinion.
Nowadays, it is common practice to remove all prostate adenomas regardless of prostate size through the urethra, but prostate surgery can also be performed through the perineal skin without damaging sensitive structures of the urethra and prostate.
The choice of procedure depends on the availability of equipment and the surgeon's/urologist's training.
Depending on the surgical approach and the instrument used, we distinguish the following procedures:
- Monopolar transurethral resection of the prostate (M-TURP)
- Bipolar transurethral resection of the prostate (B-TURP)
- Bipolar transurethral vaporization of the prostate (B-TUVP)
- Bipolar transurethral enucleation of the prostate (B-TUEP)
- Laser transurethral enucleation of the prostate (HoLEP or TuLEP)
- Laser transurethral vaporization of the prostate (L-PVP)
- Transurethral water vapor ablation of the prostate (REZŪM™)
- Transperineal laser ablation of the prostate (TPLA - Elestra EchoLaser or Biolitec Leonardo Laser)
Monopolar transurethral resection of the prostate (M-TURP)
The classic monopolar transurethral resection of the prostate (TURP) is a procedure performed through the urethra using a monopolar instrument. What does this mean? The instrument has one electrode at its tip, and another electrode is placed on the patient's body. During the procedure, electric current flows from the instrument's tip inside the prostate to the electrode usually placed on a large muscle (thigh, shoulder, etc.). The problem with this device design is the occurrence of stray currents that uncontrollably damage tissues in the urethra and around the prostate. Although monopolar devices are very powerful in resecting enlarged prostate tissue, they are far inferior in terms of possible surgery duration due to the risk of TURP syndrome, lack precise bleeding control during surgery, and most postoperative complications are related to stray currents (most common complications include urethral stricture, urinary incontinence due to sphincter damage, and bladder neck contracture). Monopolar TURP is only chosen by urologists if no modern equipment for treating enlarged prostate is available.
Bipolar Transurethral Resection and Vaporization of the Prostate (B-TURP, B-TUVP)
The key difference between bipolar TURP/TUVP and M-TURP lies in precision. Unlike monopolar devices, bipolar instruments feature two electrodes at the tip that generate plasma for tissue resection/vaporization—earning the name "plasma resection/vaporization."
Advantages over M-TURP include:
- No time constraints (eliminating TUR syndrome risk), enabling treatment of larger prostates
- Superior bleeding control (near-zero blood loss)
- Minimal collateral damage (no stray currents)
- Compact design (22-24Fr), offering greater precision and less invasiveness
Bipolar TURP remains the global gold standard for urologists — even when laser systems are available due to:
- Technical superiority in precision
- Cost-effectiveness (significantly cheaper than lasers)
- Equivalent outcomes to laser procedures
- Any enlarged prostate can be treated
- Leads to better urination
Laser Transurethral Vaporization of the Prostate (L-PVP)
This method is similar to B-TUVP, but instead of plasma energy (used in bipolar devices), it utilizes laser energy to remove prostate adenoma tissue. The approach is the same: a precise instrument is inserted through the urethra, using laser energy to vaporize prostate tissue, eliminating the enlarged portion and restoring normal urination. GreenLight and Thulium lasers are typically used for this procedure.
Key Advantages:
Nearly perfect bleeding control (minimal blood loss)
No risk of TUR syndrome
Suitable for prostates of all sizes (only limited by the surgeon’s skill)
Results comparable to bipolar resection/vaporization
Main Drawbacks:
High-power laser use (Thulium lasers can reach 200W)
Possible long-term bladder irritation
Risk of urethral sphincter damage → permanent urinary incontinence (requires highly skilled surgeons to avoid)
Cost Factor:
The primary difference between laser and bipolar methods is equipment cost, which affects the patient’s final bill. Laser surgery is more expensive compared to Bipolar surgery but without superior results.
Laser or Bipolar Prostate Enucleation (HoLEP, ThuLEP, B-TUEP)
This method removes enlarged prostate tissue by precisely separating it from the capsule and cutting it into smaller pieces (morcellation). It's mainly used for very large prostates (200+ ml) or to reduce laser power (80-100W vs. 200W for vaporization).
How it works:
A tool is inserted through the urethra to peel off excess prostate tissue in one piece.
The tissue is then cut (morcellated) inside the bladder for removal.
Energy sources used:
- Holmium laser (HoLEP)
- Thulium laser (ThuLEP)
- Bipolar plasma (B-TUEP)
Pros:
- Complete tissue removal – Low risk of regrowth
- Less laser power needed vs. vaporization
Cons:
- Longer surgery time
- Higher cost
- Few trained urologists available
- Not clearly better than bipolar resection or laser vaporization for most cases
Reality: Most urologists still prefer bipolar resection (B-TURP) or laser vaporization (PVP).
All the aforementioned surgical procedures lead to the removal of prostate tissue and thus enable normal urination. Although these operations achieve good urinary function, nearly 100% of men experience permanent and irreversible loss of ejaculation after these surgeries.
In modern urology practice worldwide, two truly minimally invasive procedures have emerged in recent years that maintain urination quality while preserving ejaculatory function: TPLA (Echo™ and Leonardo™ Laser) and REZUM™.
The most advanced treatments for enlarged prostate are TPLA and REZUM™. These procedures treat prostate enlargement while preserving post-operative ejaculation—a key difference from all other methods, which cause ejaculatory dysfunction in 100% of cases. The distinction between these two lies in their surgical approach and energy source.
REZUM™ Procedure
This method uses steam energy to treat the enlarged prostate. Performed transurethrally, a specialized instrument delivers steam into the prostate to shrink tissue.
However, it carries risks:
Potential damage to the prostatic urethra lining
Uncontrolled injury to surrounding structures (rectum, bladder) due to blind execution (no ultrasound or X-ray guidance)
Limited treatment zones (certain prostate areas remain inaccessible).
Transperineal Laser Ablation of the Prostate (TPLA)
The newest globally recognized and accepted surgical method for BPH treatment is Transperineal Laser Ablation of the Prostate (TPLA). This is the only method among all those mentioned that does not enter the urinary canal to treat prostate tissue. It is also the only procedure performed with millimeter precision under ultrasound guidance. Laser fibers are precisely guided through the perineal skin to the prostate via ultrasound-assisted 19G thin needles. The laser fiber width is 360nm, ensuring extreme precision in treating benign prostatic hyperplasia while virtually eliminating complications common in other procedures. The laser power is reduced to a minimal 5-10W.
This approach treats all prostate segments without damaging the urethra, urethral sphincter, rectum, or bladder, making it far superior to all previously mentioned surgical techniques. This laser prostate surgery improves urination while preserving ejaculation.
Drawbacks:
Longer catheter use compared to other procedures
Possible prostate regrowth 10-15 years post-surgery
Higher cost than bipolar vaporization due to advanced equipment
Top TPLA Devices:
- Echo Laser (Elestra)
- Dual Leonardo Laser (Biolitec)
TPLA - A Millimeter-Precise Laser Placement Technique Inside Enlarged Prostate Tissue for enlarger prostate treatment gives technical advantage and still remains the most minimally invasive surgery as it can be. The procedure uses low power diode laser to reduce enlarged prostate volume and resolve urine flow obstruction, resulting in better urination afterwards but perserving sexual ejaculatory function.
Evaluation & Surgical Procedures for Prostate Adenoma (BPH)
Preoperative Evaluation Includes:
- Detailed medical history + ultrasound examination
- Urine analysis
- Uroflowmetry (urine flow test)
- Urethro-cystoscopy
Surgery Details:
- Anesthesia: Usually general, but spinal/local anesthesia is possible.
- Duration: TPLA: ~30 minutes / Enucleation (HoLEP/ThuLEP): 2-3 hours (depends on prostate size)
- Hospital Stay: discharge next day.
Catheter Use:
- Resection/Vaporization/Enucleation: Few days
- TPLA (Echo Leonardo Laser): 7-10 days
Postoperative Care:
- Regular ultrasound check-ups to monitor urination quality.
- All procedures significantly improve urine flow.
- Only TPLA & REZUM™ preserve ejaculation (other methods damage it).
Results after prostate surgery:
- Better urination
- No urinary infections
- No need for daily prostate medications
