Surgical procedures for problems passing urine at a glance

The table above sets out what each procedure does, but not which one fits you. This guide works through the factors that decide it, drawing on British Association of Urological Surgeons (BAUS) leaflets and noting where a figure comes from the table.

Which enlarged prostate surgery is right for me?

The right procedure is the one whose trade-offs suit you, and that usually comes down to five things: prostate size, how much keeping ejaculation matters, how you feel about a catheter, whether you take blood thinners, and how much anaesthetic you can safely have. Behind them sits a sixth: how much you mind needing another procedure later.

Two things come before any procedure. Medication is often tried first, and your consultant can advise whether that suits your situation. Tests also need to show that the prostate rather than the bladder is the problem: BAUS lists incomplete relief of symptoms after TURP as common, affecting between 1 in 10 and 1 in 2 men. Our problems passing urine page explains how we check.

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When priorities conflict, no option wins on every count; working through that is what the consultation is for.

Does prostate size decide which procedure you can have?

Often, yes — it usually narrows the choice first. Urolift and Rezum work on tissue where it sits: Urolift pins it back with implants, and Rezum shrinks it with steam. BAUS notes that size and shape decide suitability and that they cannot be used in all men; the table above notes they do not suit larger prostates. TURP, HoLEP and Aquablation take tissue away rather than working around it; of these, HoLEP and Aquablation are the options suited to larger glands. Shape matters too: BAUS notes Rezum can also treat tissue bulging into the bladder (the median lobe). Size and shape come from examination and imaging such as MRI, described on our prostate assessment page, not from symptoms.

Which prostate surgery preserves ejaculation?

Urolift and Rezum are the least likely to affect ejaculation, followed by Aquablation; TURP and HoLEP usually leave it dry. When an operation removes tissue to open a wide channel, semen tends to pass backwards into the bladder at orgasm — retrograde, or ‘dry’, ejaculation. BAUS describes dry ejaculation as very rare after Urolift and very uncommon after Rezum, and gives about 1 in 10 after Aquablation, roughly 2 in 3 to 3 in 4 after TURP, and 9 in 10 after HoLEP.

The NHS notes that sex still feels the same after TURP but no semen comes out, which affects fertility. If you may want children, say so early so your consultant can advise before a procedure is chosen; our male fertility page explains how retrograde ejaculation is tested for.

What if you want to avoid a catheter?

Urolift is the procedure most often done without one, though BAUS notes a few men need a temporary catheter if they cannot pass urine afterwards. Everything else involves at least a short spell with one — 24 to 72 hours after HoLEP, a few days after Rezum, and a few days after Aquablation, sometimes at home. For strictures, BAUS gives at least 24 hours after urethrotomy and two to three weeks after urethroplasty. The balance shifts if you already depend on a catheter: BAUS describes HoLEP as very effective for men in retention, so a few days with one afterwards can be the route to living without one.

Can you have prostate surgery if you take blood thinners?

A blood thinner does not in itself rule out treatment, but it needs planning and can narrow the choice. BAUS asks you to tell the team if you take medicines such as warfarin, aspirin, clopidogrel, rivaroxaban or dabigatran. Whether one can be paused is decided by your consultant with the doctor who prescribes it — for some men stopping is unsafe — so never stop it yourself. Bleeding risk differs too: BAUS puts bleeding needing a transfusion or re-operation lower after HoLEP (1 in 50 to 1 in 250) than after TURP (1 in 10 to 1 in 50), and temporary bleeding at about 1 in 4 after Aquablation, lasting up to four weeks.

What if you are not fit for a general anaesthetic?

Then Urolift and Rezum, which can be done under local anaesthetic, move to the front. TURP and HoLEP normally need a general or spinal anaesthetic, and Aquablation a general anaesthetic. For men unfit for any procedure, BAUS describes a long-term catheter, through the urethra or the lower abdomen (suprapubic), or intermittent self-catheterisation, passing a disposable catheter yourself to drain the bladder. A long-term catheter is also an option for men with a stricture and several medical problems.

What does ‘retreatment’ mean?

Retreatment means a further procedure because symptoms return or were never fully relieved — for the prostate, because tissue regrows or the first procedure did not relieve enough of the blockage; for a stricture, because the narrowing comes back.

The figures cover different time spans, so compare them with care. BAUS gives 13% needing further treatment within five years of Urolift, and about 1 in 25 within four years of Rezum and within five years of Aquablation. For TURP, BAUS puts a repeat procedure for regrowth at between 1 in 10 and 1 in 50, with no time span; the table above gives 10–20% at five to ten years after TURP or bladder neck incision (BNI), and notes HoLEP lasts longer than TURP. Newer procedures have shorter follow-up, so their long-term picture is less certain.

What is normal after each procedure, and when should you get help?

Some bleeding, burning and frequency are normal for days to weeks, and a later bleed at home is common after TURP and HoLEP. A high temperature, clots or heavy bleeding are not normal and need urgent advice. Flow usually improves straight away after TURP and HoLEP, though frequency and urgency can take up to three months to settle. After Rezum, the table above notes improvement starts as the prostate shrinks over two to four weeks; BAUS puts the peak at 8 to 12 weeks on average, occasionally six months, and gives the same for Aquablation. Our problems passing urine page covers recovery timescales generally.

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BAUS advises starting pelvic floor exercises early after any prostate surgery to help control. Contact your treating team, GP or NHS 111 urgently if you develop a high temperature, pass clots or bleed heavily. If bleeding is heavy and will not stop, or you feel very unwell, go to A&E or call 999. If you suddenly cannot pass urine and your bladder is full and painful, go to an emergency department.

Why do urethral strictures come back, and how does that change the choice?

They come back because the quicker treatments stretch or cut the scar rather than remove it, so it can narrow again; the key question is whether yours has recurred before. A stricture is a narrowing caused by scarring of the lining of the urethra and the spongy tissue around it. BAUS notes urethrotomy opens but does not remove the scar, and gives a 1 in 2 risk of recurrence after a first urethrotomy and a higher risk after each repeat; the table above puts success for recurrent strictures treated this way below 10%.

So a day-case dilatation or urethrotomy is a common first step, because it may be all you need. After recurrence, the choice usually moves to Optilume or urethroplasty. Optilume’s drug-coated balloon helps hold the stricture open; BAUS notes it is licensed for recurrent bulbar strictures under 3 cm, and the table notes contraception is needed for six months afterwards. Urethroplasty cuts out the scarred segment and rejoins the ends, or widens it with a graft, usually cheek lining; BAUS gives long-term success of more than 85% for bulbar urethroplasty.

In the UK OPEN trial, 222 men with a recurrent bulbar stricture were randomised to urethroplasty or urethrotomy. Both improved symptoms, but the benefit lasted longer after urethroplasty: 15 of the men allocated to urethroplasty needed a further procedure, against 29 of those allocated to urethrotomy. The cost is a bigger operation, and BAUS advises four to six weeks off work after bulbar urethroplasty. If symptoms are mild, monitoring is reasonable — but BAUS warns that a stricture which stops the bladder emptying can lead to infections and stones and, rarely, kidney failure.

How do we help you choose?

We start from your test results, then go through which options genuinely fit you. Our first appointment guide explains what to expect, and fees and insurance sets out costs. Call +44 7889 318584 (Monday to Friday, 8am to 4pm), email contact@theandrologycentre.co.uk or use our contact page.

Frequently asked questions

References and further reading