It is the question I am asked most often in clinic when I suggest an operation, and it is a reasonable one. Most men who reach this point have been taking tablets for years, have got used to getting up two or three times every night and have put it down to getting older.
The short answer: an operation is considered when the problem is no longer just a nuisance and has started to have consequences, or when medication no longer gives you what you need.
The long answer is this article.
What is happening inside
From a certain age, the prostate grows. The growth is benign (it has nothing to do with cancer), but it causes a mechanical problem: the prostate surrounds the tube that urine passes through, and as it grows, it narrows it.
At first the bladder compensates. It contracts harder to overcome the resistance, and for years a man may notice almost nothing, or just that his stream is weaker. The price of this effort is that the bladder muscle gradually thickens and loses its elasticity.
Hardly anyone explains this, yet it is what matters most: the aim of treating the problem in time is to protect the bladder, as well as to help you pass urine more easily. A bladder that has been under strain for too many years does not always fully recover, even once the blockage has been removed.
When medication is enough
In many cases it is, and there is no hurry at all to operate.
Medication works well when the symptoms are moderate, there are no complications and the patient is happy with the result. Some drugs relax the muscle in the area and others shrink the prostate, and they are often combined.
If that is your situation and you feel well, the answer is to carry on as you are and have regular check-ups.
When surgery is no longer optional
In some situations surgery is the recommended treatment rather than one option among several. The main ones are:
- Acute urinary retention: at some point you have been unable to pass urine and needed a catheter. Once this has happened, there is a high chance it will happen again.
- Repeated urine infections, because the bladder does not empty completely.
- Repeated episodes of blood in the urine coming from the prostate.
- Bladder stones, which form because urine is left sitting in the bladder.
- Effects on the kidneys: when the blockage gets to the point of stretching the urinary tract or affecting kidney function.
- A significant amount of urine left in the bladder after passing urine.
In these cases, carrying on with tablets does not solve the underlying problem.
And the most common case: when medication is no longer good enough
Apart from the complications above, there is one reason that in practice is the most common: the patient is no longer happy living this way.
Getting up three times every night, never sleeping through, working out where the toilets are before going out, not being able to last a car journey or a long meeting. None of that shows up in a test, but it limits everyday life.
If your symptoms persist despite treatment, or the side effects of the medication are not worth it to you, that is a perfectly valid reason to consider surgery. You do not have to wait for a complication.
What happens if you decide to wait
Waiting is a legitimate option, as long as it is an informed decision and you have regular check-ups.
What you should be clear about is that benign prostatic hyperplasia (BPH) generally progresses. Regular check-ups, with a urine flow test and an ultrasound scan, are there precisely to show whether your bladder is coping well or is starting to pay for the extra effort. If any of the signs I described above appear, there is no point in waiting any longer.
What I do not recommend is waiting without check-ups.
Not every case needs the same technique
This is where the result is really decided, and where it is worth being selective about who operates on you.
No single technique is best for everyone; the right one depends on the prostate and on the patient. These are the techniques I perform:
- HoLEP (holmium laser enucleation of the prostate). It separates and removes the inner part of the prostate that causes the blockage, leaving the outer capsule. It allows large prostates to be treated endoscopically, without open surgery. I consider it from about 30 grams, and there is no upper size limit: it is the technique that deals with the large prostates that used to need open surgery.
- Green laser (photoselective vaporisation of the prostate, PVP). It vaporises the tissue causing the blockage. Particularly useful for patients taking blood thinners (anticoagulants).
- Rezum. A minimally invasive water vapour treatment for smaller prostates in selected patients.
- TURP (transurethral resection of the prostate). The classic technique, still appropriate in certain cases.
Below about 30 grams, other options are usually a better fit. The choice depends on the size of your prostate, its anatomy, the medication you take, your medical history and what concerns you most, including sexual function, which is a legitimate factor in the decision and is best raised before the operation rather than after.
My experience with all four techniques allows me to offer you personalised treatment for your particular case.
What to ask at your appointment
If an operation has been suggested to you, these questions will help you decide:
- How big is my prostate, and how does that affect the choice of technique?
- Which techniques are reasonable in my case, and why are you suggesting this one?
- What will happen to my ejaculation? And to my erections?
- How long will I have a catheter, and how long will it take to get back to normal?
- What happens if I decide to wait six months or a year?
If any of these questions does not get a clear answer, ask for a second opinion.
In short
- Surgery is no longer optional when there is retention, repeated infections, bladder stones, bleeding or an effect on the kidneys.
- The most common reason, though, is that medication no longer gives you the quality of life you need. That is reason enough.
- Treating in time aims to protect the bladder before the damage becomes hard to reverse, as well as to improve the flow.
- There is no technique that is best for everyone, only the right one for your case.
If you have been on tablets for years and are not sure whether they are still the right choice, an appointment with a urine flow test and an ultrasound scan will give you an answer based on facts. You can also read what HoLEP laser surgery involves and what to expect after the operation.
If an operation has been suggested to you and you would like your case assessed, you can book an appointment. I see patients in Palma (Quirónsalud Palmaplanas) and Manacor (Més Consultes Mèdiques), in English or Spanish.
Appointments: +34 971 918 000 (Palma) · +34 971 559 000 (Manacor). You can call in English.
This article is general information and does not replace a medical consultation. Each case needs to be assessed individually.
