Clinical Report: HoLEP versus Rezum System Outcomes in BPH Treatment

Overview

This matched pair study compared holmium laser enucleation of the prostate (HoLEP) and the Rezum system in patients with benign prostatic hyperplasia (BPH) and prostate volumes between 50–150 mL. Both treatments demonstrated efficacy in improving urinary flow and symptom scores, with Rezum offering a minimally invasive option preserving sexual function. The study provides comparative data on perioperative parameters, functional outcomes, and complication rates over 12 months.

Background

Benign prostatic hyperplasia is a common cause of lower urinary tract symptoms in men over 50 years. Surgical intervention is indicated when medical therapy fails, with HoLEP considered the gold standard due to its size-independent efficacy and reduced morbidity. However, HoLEP is associated with a high incidence of retrograde ejaculation. The Rezum system, a minimally invasive water vapor thermal therapy, has emerged as an alternative that preserves antegrade ejaculation and is recommended for prostate volumes under 80 g, though data on larger glands are limited. This study aims to compare the safety and efficacy of Rezum versus HoLEP in prostates larger than 50 g.

Data Highlights

Key Findings

• Both HoLEP and Rezum significantly improved maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and post-void residual volume (PVR) at 6 and 12 months postoperatively.
• Rezum was performed under local anesthesia with sedation as a day case, whereas HoLEP required spinal anesthesia and longer hospitalization.
• Rezum preserved antegrade ejaculation better than HoLEP, which had a high prevalence of retrograde ejaculation (65–90%).
• Perioperative morbidity was lower in the Rezum group, with fewer complications and shorter catheterization duration.
• Both procedures were effective in patients with prostate volumes greater than 50 mL, including those up to 150 mL.
• Patient Global Impression of Improvement (PGI-I) and International Index of Erectile Function (IIEF-5) scores favored Rezum for sexual function preservation.

Clinical Implications

Rezum offers a minimally invasive alternative to HoLEP for patients with BPH and prostate volumes between 50 and 150 mL, especially for those prioritizing preservation of sexual function. It can be performed under local anesthesia with shorter catheterization and hospitalization times, reducing perioperative morbidity. HoLEP remains a highly effective surgical option but carries a higher risk of retrograde ejaculation and requires spinal anesthesia.

Conclusion

Both HoLEP and Rezum effectively improve urinary symptoms and flow metrics in patients with moderate to large prostate volumes. Rezum provides a less invasive option with favorable sexual function outcomes, supporting its use in appropriately selected patients.

References

1. 1 -- BPH as primary cause of LUTS in males >50 years
2. 2,3 -- HoLEP efficacy and perioperative benefits
3. 4 -- Long-term HoLEP outcomes vs TURP
4. 5,6,7 -- Retrograde ejaculation prevalence post-HoLEP
5. 8 -- Rezum system and AUA guidelines
6. 9-12 -- Rezum efficacy studies
7. 13 -- Rezum mechanism of action
8. 14 -- En-Bloc HoLEP technique