To compare the clinical efficacy and functional outcomes of Rezum water vapor therapy versus holmium laser enucleation of the prostate (HoLEP) in patients with large-volume benign prostatic hyperplasia (>80 mL).
We hypothesized that both techniques improve lower urinary tract symptoms, while Rezum provides superior preservation of ejaculatory function.

This prospective randomized controlled trial included 110 men randomized to HoLEP (n=54) or Rezum (n=56). Inclusion criteria were sexually active men, age ≥50 years, IPSS >13, Qmax <15 mL/s, and prostate volume 80–120 mL. The primary endpoint was change in ejaculatory function (MSHQ-EjD) at 12 months. Secondary outcomes included IIEF-15 domains, IPSS, Qmax, post-void residual (PVR), perioperative parameters (operative time, catheterization duration, hospital stay), safety outcomes including complications and retreatmentrates.
Analyses followed the intention-to-treat principle. Continuous and categorical variables were compared using appropriate statistical tests, and longitudinal outcomes were assessed using mixed-effects models.

Both groups showed significant improvement in urinary outcomes (p<0.001). HoLEP demonstrated superior symptom and flow improvement: median IPSS reduction −16.0 vs −10.0 (p<0.001), Qmax increase +13.8±3.8 vs +5.0±4.9 mL/s (p<0.001), and greater PVR reduction (p<0.001). Ejaculatory function declined significantly after HoLEP compared to Rezum (MSHQ-EjD change −3.0±2.5 vs −0.7±2.6; mean difference −2.3, p<0.001), with differences persisting at 12 months. Orgasmic function and intercourse satisfaction favored Rezum (p≤0.02). Erectile function did not differ significantly. HoLEP had longer operative time (117.9 vs 19.6 min, p<0.001) and greater hemoglobin drop (p<0.001), but shorter catheterization (2.7 vs 6.8 days, p<0.001) and lower urinary retention (5.6% vs 13%). Retreatment rates were similar (5.6% vs 8.9%, p=0.72).

HoLEP provides superior relief of bladder outlet obstruction, while Rezum better preserves ejaculatory and orgasmic function with effective relief of urinary symptoms. These findings reflect the trade-off between maximal anatomical debulking and preservation of sexual function in large-volume BPH.

HoLEP achieves greater urinary improvement, whereas Rezum offers superior preservation of ejaculation. Treatment selection should be individualized according to patient priorities.

Özkaptan O, Sevinç C, Çanakci C, Aydogan TB, Türkyilmaz O, Mert MS, et al. Comparison of outcome for holmium laser enucleation prostate and Rezum system in benign prostate hyperplasia: a matched pair analysis. World J Urol. 2025;43(1):242.
Higazy A, Zaza M, Hassan Ali M, Elshahawy M, Salem T, Azazy S, et al. Four-year outcomes of water vapor thermal therapy for benign prostatic hyperplasia. Prostate International. 2025.
McVary KT, Rogers T, Mahon J, Gupta NK. Is Sexual Function Better Preserved After Water Vapor Thermal Therapy or Medical Therapy for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia? J Sex Med. 2018;15(12):1728-38.

Continence 19S (2026) 102716
DOI: 10.1016/j.cont.2026.102716