Historically, operative management of large prostates via TURP presented challenges with regard to operative time, bleeding, and durability of results or retreatment rates. Simple prostatectomy has a long history in the enucleation of large prostates and also affords the ability to address concomitant pathologies, including bladder stones and/or bladder diverticula, or other reconstructive needs. In RCTs, OSP achieved better quality of life and superior PVR bladder volume compared to TURP, but with potential for more bleeding.293, 335 Similarly, in an RCT, LSP compared to TURP after three years achieved better PVR bladder volume, as well as IPSS and uroflowmetry results, but without differences in quality of life or sexual function scores.336 Retrospective data found TURP was associated with 2.35-2.45 times greater risk of urethral stricture than OSP.337 In comparison to RWT in smaller prostates, OSP achieved significantly better IPSS at 1 year but with a higher risk of blood transfusion.338 Newer RASP techniques, compared to other forms of simple prostatectomy, have further advanced the procedure through facilitating same-day discharge, less blood loss, and expanding access to the procedure through extraperitoneal or transvesical, single-port surgery.339, 340 Beyond simple prostatectomy, AEEP are well established as effective treatments for large prostates. Studies comparing HoLEP to LSP and/or RASP in patients with a mean prostate volume >144 cc identified no differences in quality of life, urinary function outcomes, or adverse events at three months or two years.318 A more contemporary series comparing HoLEP and single-port RASP identified greater rates of transient stress urinary incontinence in HoLEP but longer catheterization durations after RASP.341 Comparing ThuFLEP and RASP found differences in 3-month uroflowmetry and PVR bladder volume, but did note IPSS was superior after RASP.342 The use of bipolar energy to perform AEEP is another technique, which can achieve similar IPSS outcomes compared to OSP with no difference in adverse events.293  Non-operative treatment of large prostates with PAE has been compared to OSP in RCTs. Treatment with PAE compared to OSP provided significantly less improvement in IPSS and quality of life scores at 6 and 12 months.343, 344 Objective measures of PVR bladder volume and uroflowmetry were also significantly worse after PAE compared to OSP in these studies.343, 344 A systematic review of retreatment rates estimated 23.8% of PAE and 4.4% of OSP patients underwent retreatment by 5 years.258