Alternatives to GreenLight laser

HoLEP (Holmium laser enucleation of the prostate)

HoLEP uses a Holmium laser to separate the obstructing inner part of the prostate from the outer capsule, in a way that mirrors an open prostatectomy. The separated tissue is pushed into the bladder and then chopped up (morcellated) so it can be removed through the scope.

• Good for any size prostate, including very large glands where GreenLight would take a long time.
• Lowest long-term retreatment rate of the main transurethral options in published series.⁴
• Produces a specimen for pathology, which is useful if prostate cancer is suspected.
• Usually an overnight stay. Catheter typically 24 hours.

TURP (transurethral resection of the prostate)

TURP is the original transurethral operation for BPH and has been performed for decades. A heated wire loop is used to cut strips of obstructing prostate tissue, which are then flushed out and sent to pathology.

• Still effective for small-to-medium prostates in skilled hands.
• Higher bleeding risk than laser techniques, which is why blood thinners often need to be paused.
• Produces a specimen.
• Usually 1 to 2 nights in hospital. Catheter typically 2 to 3 days.

UroLift (Prostatic Urethral Lift)

UroLift is a minimally invasive mechanical treatment. Small permanent implants are placed to hold the two lobes of the prostate aside, creating a wider channel for urine to flow. No tissue is removed or heated.

• Preserves ejaculation in most men, which is its main selling point.
• Usually day surgery under light sedation. No catheter in many cases.
• Best for small-to-medium prostates without a large middle lobe.
• Higher long-term retreatment rate than HoLEP or GreenLight in published series.

Rezum (water vapour therapy)

Rezum delivers short bursts of steam into the prostate tissue. The steam condenses inside the tissue, and over a period of weeks to months the treated tissue is absorbed by the body, leaving more room in the channel.

• Performed under light sedation, often in an office-type setting.
• Preserves ejaculation more often than tissue-removing operations.
• A catheter is needed for a few days while the initial swelling settles.
• Full benefit takes 2 to 3 months as the treated tissue is absorbed.
• Higher retreatment rate than HoLEP in published series.

iTind (temporary implantable nitinol device)

iTind is a small nitinol device placed inside the prostatic urethra via cystoscope. Over 5 to 7 days it expands to create three channels, then it is removed. Nothing is left behind permanently.

• No permanent implant, no tissue cut or burned.
• Preserves ejaculation in treated series.
• Usually day surgery under light sedation. Device removal is a short second procedure.
• Suited to small-to-medium prostates.

Aquablation

Aquablation uses a high-pressure, imaging-guided water jet to remove obstructing prostate tissue. The water jet is controlled robotically based on ultrasound imaging.

• Robotic, imaging-guided delivery of the water jet.
• Usually an overnight stay. A separate haemostasis step is used after the ablation, because the water jet itself does not seal bleeding.
• Can be used for larger prostates.
• Availability in Australia is still growing, and access depends on the hospital.

Medication and watchful waiting

Not every man with BPH needs surgery. Alpha blockers (for example tamsulosin), 5-alpha-reductase inhibitors (finasteride, dutasteride) and combination tablets are often tried first. Surgery is usually considered when symptoms are not controlled on medication, when medication is not tolerated, or when complications develop (urinary retention, recurrent UTI, bladder stones, upper-tract change).