A man with an enlarged prostate who consults three specialists can receive three different recommendations, each delivered with conviction. This is not usually dishonesty. It is that surgeons think in terms of removing the obstruction, interventional radiologists think in terms of reducing the blood supply, and everyone is most confident about the thing they do most often and do well.
Which means the burden falls on the patient to ask the right questions. This guide is the set of questions.
First: is the prostate even the problem?
Before comparing treatments, establish that a treatment is warranted and that it addresses your symptoms. Symptoms split into voiding complaints — weak stream, hesitancy, straining, dribbling, incomplete emptying — which point at obstruction, and storage complaints — urgency, frequency, waking at night — which point at the bladder and may or may not be caused by the obstruction.
This distinction decides how satisfied you will be afterwards. Relieving obstruction reliably improves voiding symptoms. It improves storage symptoms less reliably, because a bladder that has been remodelling for fifteen years does not always settle when the resistance is removed, and because waking at night frequently has nothing to do with the prostate at all. If your main complaint is getting up twice a night, read why you are awake at three before choosing anything.
Three numbers to know before deciding
Your symptom score, so improvement can be measured rather than remembered. Your post-void residual, which says whether the bladder is emptying. Your prostate volume, which determines which options are technically suitable and puts your PSA in context. A recommendation made without these is a recommendation made without the relevant facts.
The actual trade-offs
Watchful waiting is a legitimate choice for mild symptoms and an empty bladder, and it is not a euphemism for neglect — it means a scheduled review with the symptom score repeated. Medication works quickly, requires taking something daily, and has costs: alpha blockers commonly cause retrograde ejaculation and dizziness on standing, and 5-alpha reductase inhibitors shrink the gland over months while lowering libido in a minority and halving your PSA.
Among procedures, the honest comparison runs like this. The ejaculation-sparing options, prostate artery embolization, Rezum and UroLift, preserve antegrade ejaculation in the large majority of men; none removes tissue the way resection does, so flow improves more gradually. Embolization, Dr. Shusterman's first-line procedure, is performed through a pinhole in the wrist or groin, needs no general anesthetic and no instrument passed through the penis, usually needs no catheter, and works for glands too large for most alternatives. Rezum is the alternative when embolization isn't the right fit; it takes weeks to work and needs a catheter in the interim. UroLift works immediately but suits only smaller prostates, and in Dr. Shusterman's experience symptoms often return, so the practice now rarely recommends it.
TURP and laser enucleation are invasive surgery. They remove the obstructing tissue and give the largest, most durable improvement in flow, but they require general or spinal anesthesia, a catheter and often a hospital stay, and retrograde ejaculation is the usual outcome rather than a risk. Dr. Shusterman reserves them for a minority of men. For a man whose flow is his only priority, that can be a reasonable trade. For most men, it is not.
What makes an option unsuitable
Gland anatomy matters. A large median lobe protruding into the bladder rules out some approaches, UroLift among them. Very large glands narrow the field considerably, and they are where embolization has the advantage; enucleation can handle them too, but it is major surgery with anesthesia, a catheter and a hospital stay. A bladder that has already failed, one that does not contract effectively, will not be rescued by relieving the obstruction, which is why urodynamics is worth doing before a procedure when the picture is ambiguous. Being on anticoagulation favors approaches that do not involve cutting.
The questions to ask
What proportion of my symptoms do you expect this to fix, and which ones will it not touch? What happens to my ejaculation, specifically, and what is the chance? How long until I feel the benefit, and what is the recovery? What is the chance I need a second procedure within five years? What anesthetic is involved, and where is it performed? And — the question that reveals the most — which of the other options did you consider, and why is this one better for me in particular?
A physician who answers all six without defensiveness is giving you advice. One who answers only the success rate is giving you a recommendation you cannot evaluate.
A note on where sedation happens
If a procedure is offered under sedation, it should be performed in a properly equipped and accredited surgical setting with a separate anesthesiologist present whose only job is watching you breathe. The anesthetic determines the requirement, not the size of the operation — a small procedure under deep sedation carries the airway risk of the sedation, not the risk of the incision. This is a standard we hold to, and it is worth asking about wherever you are treated.
The full argument is in Prostate Unlocked, and the practice's general rule — least invasive first, with costs stated before success rates — is set out in how we choose treatments.
Questions patients ask
Which treatment is best?
There is no single best, and anyone who says otherwise is describing what they do rather than what you need. The right choice depends on your gland size and shape, whether your bladder still empties, whether your symptoms are voiding or storage, what your anticoagulation situation is, and how much you value preserving ejaculation.
I want to keep normal ejaculation. What are my options?
Prostate artery embolization, Rezum and UroLift all preserve it in the great majority of men. Say this at the beginning of the consultation rather than at the end. It genuinely narrows the field, and it is the single preference that most changes the recommendation.
How long does each one last?
Resection and enucleation are the most durable, at the cost of invasive surgery. Embolization and Rezum offer good medium-term durability, and because embolization burns no bridges, you lose nothing by trying it first; some men later need further treatment. In Dr. Shusterman's experience, symptoms return often after UroLift, which is why the practice now rarely recommends it. Retreatment is not a disaster; it is a cost to be weighed alongside the others.
Is embolization experimental?
No. It is an established procedure supported by randomised comparisons and guideline recognition, performed by interventional radiologists, and covered by most major insurers for appropriate indications. It is newer than resection and less widely available, which is not the same as experimental.
My prostate is very large. Does that limit me?
It rules out some options and favors others. Embolization handles large glands well, including glands over 80 to 100 grams, without surgery; enucleation can too, but it requires anesthesia, a catheter and a hospital stay. Several office-based approaches, UroLift in particular, have size limits. Very large glands are one of the clearest situations where the choice narrows on technical grounds rather than preference.
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