Why HoLEP, TURP, and Aquablation Fail: Field Notes from the AUA 2026 BPH Failure Plenary

Part three of my notes from the AUA 2026 plenary on BPH procedure failure. Part one covered the pattern common to all five technologies. Part two covered UroLift and Rezum. This post covers HoLEP, TURP, and Aquablation.

Same disclaimers. I am not a urologist. This is what I heard in the room.

HoLEP

The HoLEP panelist opened with a claim that could sound like advocacy but was actually a setup for something more interesting. HoLEP, she said, essentially never fails to relieve obstruction when performed correctly. She used that as a premise to make a different point: if HoLEP appears to fail, the cause is almost never the obstruction itself.

Her case made that concrete. A man came to her after a prior UroLift complicated by acute urinary retention. She performed HoLEP, removed the prior implants, and pathology confirmed adequate tissue removal. At three months his symptom score had improved. But his bother score had not moved. He was still waking up four or five times a night and felt no better.

What followed was a year of investigation. Overactive bladder medications did not help. Urodynamics showed minimal abnormality. A voiding diary revealed the actual problem: he was producing an abnormally large volume of urine at night, a condition called nocturnal polyuria. One of his blood pressure medications contained a diuretic. When his primary care physician switched that medication, his nighttime urination dropped to once per night and his bother finally resolved.

The obstruction had been relieved on day one. The symptom bothering him had a cause that no urological procedure was going to fix.

Her list of patients she worries about for HoLEP underperforming: those with urinary retention and a small prostate, particularly where the bladder muscle is weak; patients whose symptoms are mixed and may be driven more by bladder dysfunction than obstruction; and patients whose primary complaint is nocturia. On that last group she was direct. Nocturia as the dominant symptom is unlikely to respond to any bladder outlet procedure, because the outlet is rarely the reason it is happening.

TURP

The TURP panelist described TURP as what he called an extra-anatomic, volume-reduction procedure. You are removing tissue by resection, and the challenge is calibration. Too much and you have complications. Too little and obstruction persists. Enucleation procedures follow the natural boundary between the obstructing inner tissue and the outer gland, removing the adenoma more completely.

He used PSA reduction as a proxy for completeness. Enucleation consistently achieves reductions over 80 percent. TURP ranges from 25 to 58 percent in the data he cited. That gap, he said, explains much of the difference in long-term retreatment rates.

His case: a 77-year-old man who had a TURP performed elsewhere four to five years prior. Cystoscopy showed only a partial resection had been done. An obstructing lateral lobe had been left essentially untouched. The patient had been on medication since and had gone into retention before presenting. The decision was made to perform a thulium laser enucleation, or ThuLEP, as salvage. About 20 grams of tissue were removed. Catheter out the following day. At three months, symptoms, quality of life, and nighttime urination had all improved.

His broader point: salvage enucleation after TURP failure is a growing practice and the long-term data favor it. The decision with the patient, he said more than once, is about symptom reduction. Not about which instrument was used the first time.

Aquablation

The Aquablation panelist opened with a pointed frame: when Aquablation fails, it is not the technology failing the patient. It is the surgeon's failure to understand how the technology works. He was making a specific claim about mechanism, not dismissing the failure.

The most common failure cause he described: not treating the tissue at the front of the prostate near the bladder. The water jet can cover a wide arc of the prostate interior, up to approximately 225 degrees in his description. When anterior tissue gets missed, it is a planning and execution failure, not a device limitation.

On bladder neck management, he was specific. After the water jet, a targeted cautery step is performed at a defined portion of the bladder neck to stop bleeding. This is not a resection step. He was emphatic that approaching it like a TURP risks narrowing the bladder neck over time. Surgeons with a strong TURP background, he implied, sometimes default to more aggressive resection there out of habit.

His number-one cause of failure in experienced hands: under-treatment at the apex. The apex is the lower tip of the prostate, closest to the urinary sphincter. Surgeons treat it conservatively because of incontinence risk. Treated too conservatively, it leaves residual tissue that causes obstruction later. He called this pattern "sneaky" residual.

On salvage: repeat Aquablation is an option but currently not covered for Medicare patients in the US. Only one procedure is reimbursed at present. For commercially insured patients and internationally, a second procedure may be feasible where under-treatment was the cause. Any other salvage path carries a risk of ejaculatory dysfunction. For patients who chose Aquablation partly to preserve that function, he noted, that tradeoff belongs in the consent conversation.

The through-line for all three

These three talks pointed to the same lesson. The procedures are not usually the failure point. What fails is the match between what a procedure does and what the patient actually needs. Or the assumption that fixing the outlet fixes the symptom.

The HoLEP case made that most vivid. A man spent a year being worked up for urological causes of a symptom that had a non-urological cause. That is not a criticism of anyone's judgment. It is a reminder that urinary symptoms run through the entire patient, not just the prostate.

It also circles back to the first post in this series. The early follow-up window is where you find out whether a procedure is doing what it should. Objective, repeatable measurement of flow and symptoms over those first months gives that assessment something to work with. proudP exists in that window, giving clinicians and patients a record of whether things are moving in the right direction, before the question becomes harder to answer.

Corrections welcome. The clinical detail belongs to the panelists.

See how proudP supports objective flow tracking and voiding diary through the post-procedure window.

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Frequently asked questions

Can HoLEP fail even if the procedure was technically successful? 

Yes. The HoLEP panelist made this point directly. HoLEP reliably relieves obstruction when performed correctly, but persistent symptoms after HoLEP are often unrelated to residual obstruction. Storage dysfunction, nocturnal polyuria, comorbidities, and medications are frequent drivers. She presented a case where a medication switch resolved the patient's primary complaint after the procedure had already worked.

Why does TURP have higher retreatment rates than enucleation? 

The TURP panelist described TURP as a calibration-dependent, volume-reduction procedure where completeness of tissue removal varies. Enucleation follows the natural anatomic boundary of the adenoma and removes it more completely, reflected in higher PSA reduction rates and lower long-term reintervention rates.

What causes Aquablation to fail? 

The panelist identified under-treatment as the primary cause in experienced hands. Missed anterior tissue and overly conservative treatment at the apex are the main patterns. Incorrect bladder neck management was cited as a pitfall for surgeons accustomed to TURP technique.

Is a second Aquablation possible after failure? 

It depends on insurance and geography. Medicare currently covers only one Aquablation procedure. For commercially insured patients and internationally, a second procedure may be feasible where under-treatment was the cause.