Two answers for
the big prostate
When a gland passes 80 cc, the office procedures bow out and two operations compete for the job: Aquablation, the heat-free robotic waterjet, and HoLEP, laser enucleation. Dr. Sawkar has performed more than 250 Aquablations, and when HoLEP or open surgery is genuinely the better path for a patient, he says so, so consider this comparison unusually candid.
Medically reviewed by Hari Sawkar, MD, board-certified urologist · Updated August 2026
Side by side
Both remove obstructing tissue and both work at sizes where TURP struggles. The differences that matter to patients: ejaculation, availability, and how much surgeon-to-surgeon variation you are exposed to.
| Aquablation | HoLEP | |
|---|---|---|
| Method | Heat-free robotic waterjet resection | Laser enucleation of the whole adenoma |
| Size range | Proven 30 to 150 cc | Essentially unlimited |
| Tissue removed | The obstructing plan, precisely | The most of any endoscopic option |
| Ejaculation preserved | Most men | Lost for the substantial majority |
| Consistency | Robotic plan, less surgeon-dependent | Long learning curve; results track the surgeon |
| Hospital and catheter | One night, catheter 1-2 days | One night, catheter usually 1-2 days |
| Availability | Growing; established at Providence St. Joseph | Concentrated at high-volume centers |
For glands beyond roughly 150 cc, the candid menu is HoLEP, open surgery, or PAE, which avoids the operating room entirely and has no size ceiling.
The bottom line
If maximal tissue removal is the goal and ejaculation is not a priority, HoLEP in experienced hands is a superb operation. If you want surgical-grade relief with meaningfully better odds of keeping ejaculation, and your gland is under 150 cc, Aquablation earns its place. And if the real question is whether you need an operating room at all, PAE for large prostates deserves a read before you decide anything.
Common questions
Is HoLEP or Aquablation better for a very large prostate
Both are excellent at size. HoLEP removes the most tissue and is essentially size-unlimited; Aquablation is proven to 150 cc with better odds of preserving ejaculation and a shorter learning curve between surgeons. Above 150 cc the honest menu is HoLEP, open surgery, or PAE, and the right answer depends on your anatomy and priorities.
Which preserves sexual function better
Aquablation, on the ejaculation question: most men preserve it, versus a substantial majority losing it after HoLEP, whose enucleation removes the tissue involved. Erections are typically unaffected by either.
Why do academic centers push HoLEP
It is a genuinely durable, tissue-maximal operation, and centers that invested in the long HoLEP learning curve use it broadly. That does not make it the only answer: for many large glands, Aquablation achieves the needed relief while protecting ejaculation, and PAE avoids surgery entirely.
Is there a non-surgical alternative for large glands
Yes, prostate artery embolization. It has no practical size ceiling, requires no general anesthesia, and most men go home the same day without a catheter. For men weighing HoLEP against Aquablation, it is the third option that belongs in the conversation.
Big gland, real options
Bring your measurement, or get one here in minutes, and hear the honest menu for your anatomy. Same-day and next-day appointments, telehealth available, Medicare and most PPO plans accepted.
Chief of Urology, Providence St. Joseph Hospital · 250+ Aquablation procedures, the most in Orange County