There is a conversation I have in almost every new patient consultation that surprises people. I ask: "Do you know that after HoLEP, most patients stop taking all of their prostate medications the same day as surgery — and never need them again?"

Almost universally, the answer is no. They had no idea. They assumed the medication was forever, that surgery was just an additional treatment on top of the pills, or that they'd eventually trade one pill for another. Nobody told them otherwise.

I'd like to change that.

Why men take BPH medications in the first place

Flomax (tamsulosin) and its relatives — alfuzosin, silodosin — are alpha-blockers. They work by relaxing the smooth muscle tissue in the prostate and bladder neck, which reduces resistance and allows urine to flow more easily. They don't shrink the prostate. They don't remove anything. They simply make the opening a little wider by relaxing the muscle around it.

Finasteride and dutasteride are a different class — 5-alpha reductase inhibitors. They work by blocking the hormonal signal that drives prostate growth, which over 6–12 months causes the gland to gradually shrink. They require indefinite use — stop taking them and the prostate starts growing back within months.

Both classes of medication are managing a symptom. They are not treating the underlying condition.

What HoLEP actually does

HoLEP removes the adenoma — the inner obstructing portion of the prostate — entirely. Not partially. Not by shrinking it. By separating it from its surgical capsule using a laser and removing it from the body.

When the obstruction is gone, there is nothing left for alpha-blockers to relax around. There is no enlarged adenoma for finasteride to shrink. The physiological reason for taking these medications has been eliminated.

"After HoLEP, the obstructing tissue is gone. The medications that existed to manage it are no longer needed — and for the vast majority of patients, they are stopped immediately and permanently."

This is not an off-label or experimental approach. It is standard post-operative management following any complete surgical treatment for BPH. Your prescribing physician will be informed and will not renew these medications.

What this means in practice

The day of surgery, or within the first few days of recovery, patients stop taking their BPH medications. Not over weeks. Not gradually. On day one.

Most describe one of several reactions: disbelief ("Are you sure I don't still need these?"), immediate relief ("I've hated taking that pill for years"), or occasionally mild anxiety ("What if my symptoms come back?"). The last concern is understandable but almost never realized — because the tissue causing the symptoms has been removed, not suppressed.

Some patients also notice an improvement in side effects they had attributed to aging or other causes — because Flomax-related dizziness, low blood pressure episodes, and retrograde ejaculation resolve once the medication is stopped.

The side effects you won't miss

Alpha-blockers like tamsulosin are generally well-tolerated, but they carry real side effects that accumulate over years of use. Orthostatic hypotension — a sudden drop in blood pressure when standing — is common and a meaningful fall risk in older men. Retrograde ejaculation (semen traveling backward into the bladder during orgasm rather than forward) affects a significant percentage of men on tamsulosin. Fatigue, nasal congestion, and reduced libido are also frequently reported.

Finasteride and dutasteride carry their own profile: reduced libido, erectile dysfunction, and ejaculatory disorders. There is also ongoing discussion in the literature about a small subset of patients who experience persistent sexual side effects even after stopping the medication — a condition sometimes called Post-Finasteride Syndrome, though its prevalence remains debated.

None of these side effects matter after HoLEP. The medications are gone.

The financial case for stopping medications

This is rarely discussed, but it's real. BPH medications are often not fully covered by insurance. Generic tamsulosin is relatively inexpensive, but patients on branded medications or combination therapy can pay $50–200 per month out of pocket. Over a decade, that's $6,000–$24,000 in medication costs — not counting the annual prescription visits required to renew them.

HoLEP is a one-time procedure that most insurance plans cover. For many patients, the medication savings alone represent meaningful long-term financial benefit.

What patients actually say

In my experience, the medication conversation is often the moment a hesitant patient becomes a committed one. Many men have tolerated their symptoms and their pills for so long that the concept of neither seems almost too good to be true. But it is true — and it is one of the most compelling reasons that HoLEP, when appropriate, is not just a surgical option. It is a quality-of-life upgrade.

If you are taking BPH medications and want to understand whether you might be a candidate for a permanent solution, I would welcome the conversation.

Most men arrive at their urology consultation having done some research online, but not knowing exactly what to ask. They leave having agreed to a procedure they don't fully understand, performed by a surgeon whose experience they never questioned.

That is not a criticism of patients — it is a reflection of how medicine works. Doctors speak with authority, time is short, and it feels awkward to interrogate someone you are trusting with your care. But for a surgical procedure with long-term implications, informed consent isn't just a form you sign. It's a conversation you deserve to have.

Here are the five questions I encourage every patient to ask — whether they are seeing me or any other urologist.

1. "How many of this specific procedure do you perform each year?"

This is the most important question and the one patients are least likely to ask. Surgical volume is the single most consistent predictor of outcomes across nearly every procedure in medicine. For HoLEP specifically — a procedure with a steep learning curve — the difference between a surgeon performing 10 cases per year and one performing 80 is clinically significant.

A high-volume HoLEP surgeon has encountered far more anatomical variation, unusual intraoperative findings, and challenging cases. That accumulated experience translates directly into lower complication rates, shorter operative times, and better outcomes for you.

What to listen for: A surgeon who performs HoLEP as a primary procedure should be able to give you a specific, confident number. Vague answers, or answers that bundle HoLEP together with "all laser prostate surgeries," are worth probing further.

2. "What technique do you use, and why?"

HoLEP is not one technique — it is a family of approaches that has evolved significantly over the past decade. The traditional two- or three-lobe technique, the en bloc approach, and refinements like early apical release all produce different outcomes, particularly around urinary continence and operative efficiency.

A surgeon who can describe their technique specifically, explain why they use it, and discuss how it affects outcomes is demonstrating exactly the kind of deep procedural knowledge that correlates with expertise.

What to listen for: Specific language about their enucleation approach and why they chose it. Comfort discussing the apical dissection — which is where continence outcomes are largely determined. Awareness of the current literature on technique evolution.

3. "What are your outcomes — specifically your retreatment rate and continence outcomes?"

Any surgeon who performs a procedure repeatedly should be tracking their outcomes. For HoLEP, the two most important metrics are retreatment rate (how often patients need another procedure) and temporary urinary incontinence rates.

Published benchmarks for high-volume HoLEP specialists: retreatment rate less than 2% at 5–10 years; temporary incontinence resolving within 3 months in over 95% of patients; permanent stress incontinence in approximately 1–2%.

What to listen for: A surgeon who tracks and can discuss their own outcomes. If the answer is "our results are similar to the published literature" without specifics, follow up by asking what literature they are referring to and whether it reflects their own experience or the studies they cite.

4. "What are ALL my options — including non-surgical ones?"

A surgeon who only performs one type of procedure — or who is employed by a system that only offers certain options — has a structural incentive to recommend that procedure regardless of whether it is the best fit for you. This is not malicious, but it is a real dynamic worth being aware of.

A urologist with genuine expertise across the BPH treatment landscape will be able to discuss HoLEP, TURP, Aquablation, UroLift, Rezūm, PAE, and continued medical management — and explain the trade-offs of each in the context of your specific anatomy, age, and preferences.

What to listen for: Honest discussion of alternatives, including their limitations. Willingness to recommend a less invasive option if it genuinely fits your situation better. If a surgeon dismisses all alternatives without substantive explanation, consider a second opinion.

5. "What does same-day discharge look like at your center — and can I go home without a catheter?"

This question will immediately tell you a great deal about how advanced a program's HoLEP practice is. The traditional approach to HoLEP involves an overnight stay and a catheter left in place for 1–2 days. High-volume specialists have refined their techniques and post-operative protocols to make same-day discharge routine — including catheter removal before the patient leaves the facility.

If a program routinely keeps all HoLEP patients overnight with catheters for multiple days, that is not necessarily a red flag — but it does suggest their protocols may not be as refined as a higher-volume center's.

What to listen for: A clear, specific answer about what their standard approach is. "We aim for same-day discharge and catheter removal for most patients" reflects a different level of experience than "most patients go home the next morning."

"The best surgical consultation is one where you leave with more information than you arrived with — and where the surgeon's answers gave you confidence, not just reassurance."

These five questions will not make you an expert in urology. But they will help you distinguish a thoughtful, experienced specialist from one who is performing HoLEP because it is on the menu — and that distinction matters enormously for your outcome.

If you are preparing for a BPH surgery consultation — with Dr. Childs or with any other urologist — you are welcome to bring this list with you. Good surgeons welcome informed patients.

When patients come to me for a BPH consultation, I show them a single number that changes the conversation: less than 2%. That is the retreatment rate for HoLEP at 10 years — the percentage of patients who need another prostate procedure within a decade of their first.

For context: TURP, the most commonly performed BPH surgery in the United States, has a retreatment rate of 10–15% at 10 years. UroLift reaches 14–20% by 5–8 years. GreenLight laser vaporization approaches 10–20% at 5 years.

These numbers might sound like statistics. They are not. They are the difference between a procedure you have once and never think about again — and a cycle that begins repeating within a few years.

Why retreatment rates matter more than almost anything else

When men choose a BPH treatment, they are usually focused on recovery time, side effects, and what happens in the first few weeks. These things matter — but they are not the right lens for a decision that will affect you for decades.

Think of it this way: if you have BPH surgery at 65, you will likely live another 20–25 years. A procedure with a 15% retreatment rate at 10 years means a meaningful percentage of men will need another surgery before they are 75. That second surgery is more complicated — scar tissue from the first procedure makes the anatomy harder to navigate, increases bleeding risk, and narrows the options available.

The retreatment rate is really a measure of how complete the procedure was. HoLEP removes the entire obstructing adenoma — the inner portion of the prostate that causes the blockage — from its surgical capsule. There is minimal tissue left behind to regrow. That completeness is why the durability is so exceptional.

TURP shaves away tissue piece by piece but cannot remove all of it. GreenLight vaporizes tissue but does not remove it. UroLift moves the prostate out of the way without removing anything at all. Each approach leaves varying amounts of tissue that can, over time, grow back and cause symptoms to return.

What the published data actually shows

The evidence base for HoLEP is extensive and consistent. Multiple large prospective series and randomized controlled trials have now followed patients for 5, 7, and 10 years post-HoLEP with remarkably consistent findings:

• Retreatment rates of 0–2% at 5–10 years across multiple centers and surgical teams
• Sustained improvement in maximum urinary flow rate (Qmax) at all follow-up intervals
• Durable reduction in International Prostate Symptom Score (IPSS) — the standardized measure of urinary symptom burden
• Minimal prostate regrowth on ultrasound at long-term follow-up

By comparison, the most optimistic published 5-year data for UroLift shows a surgical retreatment rate of 13.6% — and real-world data from longer follow-up periods push this figure higher. For GreenLight, multiple series show retreatment rates reaching 15–20% at 5 years, with symptom recurrence often beginning well before formal retreatment is pursued.

The hidden cost of higher retreatment rates

Beyond the obvious inconvenience of needing another procedure, there are downstream consequences to choosing a less durable option that are rarely discussed openly in consultations.

First, repeat procedures are more difficult. Scar tissue from prior surgery narrows the urethra, distorts normal anatomy, and limits options. A patient whose UroLift has failed needs the permanent implants removed before any further surgery — adding complexity and risk. A patient whose GreenLight vaporization has regrown may have enough residual fibrosis to make enucleation more challenging than it would have been as a primary procedure.

Second, repeat procedures carry cumulative risk. Every anesthesia event, every surgical insult to the urethra and bladder neck, and every recovery period adds up. Choosing a durable first procedure reduces lifetime exposure to these risks.

Third, repeat procedures cost more. To the healthcare system, to insurance, and to the patient in time, recovery, and out-of-pocket expense.

The right way to think about this decision

"The best BPH procedure is not the one with the shortest recovery — it is the one you only need to have once."

I tell patients that HoLEP has a learning curve — for the surgeon. But once you are in the hands of an experienced, high-volume HoLEP specialist, you are choosing the most durable solution available in urology today. The recovery is manageable. The results are exceptional. And for the vast majority of men, it is the last prostate procedure they will ever need.

For men who have specific reasons to prefer a MIST procedure — younger age, strong desire to preserve ejaculatory function, medical conditions that preclude surgery — I respect that. But that conversation should happen with full transparency about what you are trading for that convenience.

If you are in Utah and have BPH, I would welcome the opportunity to walk through these numbers with you in person and help you understand exactly what each option means for your long-term future.

One of the most common things I hear from new patients is: "My doctor told me I might not be a candidate for HoLEP." In the majority of cases, when I evaluate those patients, they are perfectly good candidates — sometimes ideal ones.

The reason for this disconnect is usually that the referring physician — or even the urologist who said it — is not deeply familiar with HoLEP and its advantages. HoLEP is genuinely size-independent and broadly applicable. Understanding candidacy properly requires knowing what HoLEP can handle — which is a great deal.

Who is a strong candidate for HoLEP?

The most straightforward answer: most men with symptomatic BPH who have not responded adequately to medication, or who prefer a surgical solution, are candidates for HoLEP. More specifically, HoLEP is particularly well-suited for:

Men with large prostates

HoLEP has no upper size limit. Prostates of 50cc, 150cc, and even 300cc or more can be effectively treated with HoLEP. This is one of its most important advantages over alternatives like UroLift (limited to 100cc), Rezūm (limited to 80cc), and even TURP (which becomes technically more complex and higher risk for very large glands). For large prostates, HoLEP and robot-assisted simple prostatectomy are the two main surgical options — and HoLEP consistently outperforms RSP on safety, recovery time, and complications.

Men on blood thinners

If you take warfarin, apixaban (Eliquis), rivaroxaban (Xarelto), or aspirin for a heart condition, stroke prevention, or a clotting disorder, you have likely been told that surgery is more complicated or risky. TURP and most other surgical options require stopping anticoagulation — which carries its own risks for cardiac and stroke patients.

HoLEP is one of the few BPH surgical procedures that can safely be performed without stopping blood thinners in most patients. The holmium laser's hemostatic properties allow excellent bleeding control even in anticoagulated patients. This is a game-changing advantage for a population that has often been told surgery is not an option.

Men who have had a prior failed BPH procedure

If you had TURP, GreenLight laser, or UroLift and your symptoms have returned, you are often an excellent HoLEP candidate — this is a so-called "salvage" HoLEP. The procedure can be technically more challenging due to scar tissue and altered anatomy, but in experienced hands it is very effective. For patients who have had UroLift, the implants must be removed first — a service I offer directly.

Men in urinary retention

If you are catheter-dependent because you can no longer urinate on your own, HoLEP can be a life-changing procedure. By removing the obstructing tissue completely, HoLEP restores normal voiding in the vast majority of retention patients. For these patients, I prioritize the path to surgery.

Men who have failed medical therapy

If you have been taking Flomax, finasteride, or dutasteride for years and your symptoms are worsening, or if you have been on combination therapy with multiple medications, HoLEP offers a permanent solution that eliminates the need for ongoing BPH medications in most patients.

Who might be better served by a different approach?

HoLEP is not the right answer for everyone. I am transparent about this in every consultation.

Men with small prostates and mild symptoms may not need surgery at all, or may be better served by conservative management or a MIST procedure. I will never recommend HoLEP for a patient who does not clearly need it.

Men with a strong desire to preserve ejaculatory function should have a detailed conversation about the retrograde ejaculation that HoLEP typically causes. For younger men or those planning to father children, alternatives like UroLift, Rezūm, or Aquablation — despite their durability limitations — may be more appropriate.

Men who are high anesthesia risk due to significant cardiac or pulmonary disease may be better suited for PAE (Prostate Artery Embolization), which requires no general anesthesia. Our practice coordinates PAE through the Granger Medical — Summit Urology PAE clinic for these patients.

The best way to know: come in for a consultation

Candidacy cannot be determined from a website. It requires a conversation, a physical examination, a review of any prior imaging, and an understanding of your symptoms and goals. What I can promise is that consultation will be honest, thorough, and unhurried — and that if HoLEP is not the right answer for you, I will tell you that directly.

If you have been told you are not a candidate for HoLEP and are not sure that assessment was right, I welcome second opinions. It is a conversation worth having.

When men in Utah are told they need prostate surgery, the most common next step is a referral to a large hospital system — Intermountain Health, the University of Utah, or another academic medical center. Most patients accept that referral without question, assuming that a well-known institution means they are getting the best care available.

I want to offer a more nuanced view — not to disparage those institutions, which provide excellent care across a broad range of medical needs — but because for a highly technique-dependent procedure like HoLEP, the evidence is clear: the surgeon matters far more than the hospital.

What the research consistently shows

The relationship between surgical volume and outcomes has been studied extensively across virtually every surgical specialty. The findings are remarkably consistent: surgeons who perform a procedure more frequently achieve better outcomes. Lower complication rates. Shorter operative times. Fewer retreatments. Faster patient recovery.

For HoLEP specifically, the learning curve is well-documented. Most experts agree that meaningful technical proficiency requires at least 50 cases, and that outcomes continue to improve significantly well beyond that threshold. The difference between a surgeon on case 20 and a surgeon on case 200 is clinically meaningful — and it affects you directly.

"Volume is not a proxy for quality — it is one of the primary mechanisms by which quality is produced."

This matters because the number of HoLEP cases performed at any given center varies enormously. A large academic medical center may have a HoLEP program staffed by one or two surgeons who perform the procedure among many others in a general urology caseload. A private specialist who has built their practice around HoLEP will accumulate volume — and with it, expertise — at a fundamentally different rate.

The institutional brand problem

Hospital systems spend enormous resources building institutional brand recognition. The result is that patients often conflate the reputation of the institution with the skill of the individual surgeon — which is not always justified.

Consider: a surgeon at a prestigious academic medical center who performs HoLEP 10–15 times per year alongside research responsibilities, teaching duties, administrative commitments, and a broad departmental caseload is practicing at a very different level of procedural mastery than a private specialist who has performed nearly 1,000 HoLEP procedures since 2022 — including close to 200 in the past year alone. That accumulated volume, within a focused private practice, is what produces the pattern recognition and technical fluency that high-volume surgery demands.

The institution's reputation does not perform the surgery. The surgeon's hands do.

What private practice actually means for your care

There is a common perception that private practice physicians are somehow less qualified than those employed by academic medical centers. This conflation of employment model with competence has no basis in fact.

I trained at the same level as any academic urologist — medical school at the University of Vermont, residency at the Lahey Clinic in Boston, with additional training at Beth Israel Deaconess Medical Center, a Harvard Medical School affiliate. I chose private practice not because I could not pursue an academic career, but because private practice gives me the freedom to build something specific: a practice dedicated entirely to producing the best possible outcomes in BPH and HoLEP surgery, without the competing demands of research quotas, teaching schedules, and departmental administration.

What that means in practice for patients:

• You see me at every appointment — not a resident, not a PA, not whoever is available that day
• My livelihood depends on excellent outcomes and patient satisfaction — my incentives are directly aligned with yours
• I am not constrained by what my hospital system offers — I can coordinate the full range of BPH treatments for the right patient
• Appointments are available within weeks, not months
• Consultations are unhurried — I do not have a resident waiting to take the next patient

How to evaluate any surgeon — mine or anyone else's

I want to be clear: I am not telling you to avoid academic medical centers or to simply choose me over anyone else on the basis of this article. I am telling you to ask better questions of any surgeon you see — including me.

Ask how many HoLEP procedures they perform each year. Ask what technique they use and why. Ask about their retreatment rates and continence outcomes. Ask whether you will see them personally at every visit. Ask whether they can offer you alternatives if HoLEP is not the right fit.

A surgeon who is genuinely skilled and genuinely focused on your outcome will welcome these questions. They will answer them specifically and confidently. That response — or the absence of it — will tell you more than any hospital's marketing ever will.

If you are in the Salt Lake Valley and are evaluating your BPH treatment options, I would be glad to meet with you. Come with your questions. I will answer all of them.