An enlarged prostate is not cancer, and the choice is no longer just a daily pill or a real operation.
What is happening
The prostate enlarges with age and surrounds the urethra, so growth squeezes the channel urine passes through. That produces a weak stream, starting and stopping, frequency, urgency, and getting up at night.
The part men underestimate is the sleep. Getting up three or four times a night for years affects mood, energy and daytime function, and it is usually what finally brings a man in.
The gap between pills and surgery
Medication helps many men, but relief can be partial, it can fade, and the side effects are real, including sexual side effects that lead plenty of men to quietly stop taking them.
Traditional surgery works but is more of an undertaking and carries a meaningful risk of retrograde ejaculation.
For a long time there was very little in between. That gap is what the minimally invasive treatments were built to fill, and closing it is an active part of my practice.
The minimally invasive options
UroLift places small permanent implants that hold the tissue open without cutting or heating. Rezum uses water vapor to shrink tissue. Prostatic artery embolization blocks the blood supply so the gland shrinks. Optilume is a drug coated balloon that opens the channel, newer than the others and with a lot less data behind it.
Which one suits you depends on the size and shape of your prostate and on what matters most to you, particularly around sexual function.
The more invasive options
TURP, the classic resection through the urethra, remains the benchmark the others are measured against. Robotic simple prostatectomy removes the obstructing core of a very large gland. Aquablation uses a robotically guided water jet, mapped with ultrasound first, and HoLEP removes the obstructing tissue with a laser and handles very large prostates well. These are operating room procedures, and when the anatomy calls for one of them, they work.
What decides the choice
Prostate size and shape matter, and so does anatomy that does not show up until you look. My general leanings: for a small prostate without a median lobe I lean toward UroLift, which carries some of the lowest complication rates of any procedure here. For a larger prostate without a median lobe, prostatic artery embolization. A prominent median lobe, unfortunately, usually needs to be resected in some way. A man whose real problem is bladder function rather than obstruction will not be helped by opening the channel at all, which is exactly why the evaluation matters more than the brochure.