TURP, HoLEP, and the Future of Minimally Invasive BPH Therapy

Rahul Mehan, MD, is candid about where traditional resective procedures still have a clear edge. For patients further along in the disease process—very low flow rates, large residuals, recurrent retention, bladder stones, or a significantly decompensated—he favors a definitive, tissue-removing procedure over a minimally invasive option. Prostate size matters too: Transurethral resection of the prostate (TURP) remains effective in appropriately sized glands, and holmium laser enucleation of the prostate (HoLEP) extends that reach to very large glands where office-based options simply can't remove enough tissue. He also points to durability as a differentiator—decades of TURP data and mature long-term HoLEP and waterjet data outweigh the encouraging but still-developing 3- and 4-year evidence for newer drug-coated balloon therapy.

On the learning curve, Mehan says the technical skills are familiar to any urologist comfortable with office-based cystoscopy; the real learning is in patient selection, balloon sizing based on prostatic urethral length, and recognizing a well-executed anterior commissurotomy. He contrasts the recovery with transurethral resection of the prostate and waterjet therapy: Because tissue isn't resected or ablated, patients avoid the prolonged healing of more invasive procedures, though he counsels them to expect hematuria, dysuria, and irritable symptoms for several weeks as the paclitaxel coating does its work.

He also cites 3-year PINNACLE data—IPSS improvement sustained near 13 points and Qmax nearly doubled from baseline, with only 6% of patients going on to another surgical procedure—and details the counseling he gives around hematuria (reported in approximately 40% of PINNACLE patients, mostly mild to moderate) and the contraception guidance tied to paclitaxel exposure. In his own practice, he says, careful post-procedure protocols have kept the safety profile favorable, with no transfusions to date.

In the next episode, Mehan discusses where TURP and HoLEP still outperform office-based options, offers practical advice for urologists just starting to adopt drug-coated balloon dilation, and looks ahead to emerging minimally invasive technologies.

For colleagues on the fence about adopting drug-coated balloon dilation, or with only a case or two of experience, Mehan's advice is to make the first several cases easy ones: Choose patients with moderate-sized, predominantly lateral lobe anatomy and a clearly obstructed urethra rather than trying to prove the technology can handle difficult cases. He argues the procedure itself isn't technically difficult and that a good result is achievable from the first case, provided urologists respect the anatomic landmarks and stack the deck in their favor with patient selection.

Looking ahead, Mehan says most minimally invasive benign prostatic hyperplasia technologies are still relatively new, with long-term durability data still accumulating. He's watching next-generation versions of existing water-based and thermal technologies, including AI-assisted refinements, and previews an upcoming trial of the ALPFA GRAIL Pulsed Field Ablation System using electrophoresis, which he describes as a quick, catheter-free procedure with no impact on sexual function, heading toward an FDA pivotal study.