Objective: The aim of this study was to compare the efficacy or transurethral resection of the prostate (TURP) versus four less invasive treatment options during a 2–year follow–up.Material and Methods: 95 elderly men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) were assigned prospectively to the following five treatment arms; transurethral resection of the prostate (TURP; n = 28), transurethral electrovaporization (TUVP; n = 17), visual laser ablation of the prostate (VLAP; n = 17), transrectal high intensity focused ultrasound (HIFU; n = 20) and transurethral needle ablation (TUNA); n = 15). Preoperative workup included the International Prostate Symptom Score (IPSS), uroflowmetry, post–void residual volume (PVR), prostate volume determined by transrectal ultrasonography and a multichannel pressure flow study. Postoperative follow–up at 6, 12, 18 and 24 months included assessment of IPSS, PVR and uroflowmetry.Results: At study entry, patients assigned to one of the five treatment arms were comparable with respect to age, peak flow rate (Qmax), IPSS, prostate size and the degree of bladder outflow obstruction. During study, 1 patient in the TURP group (4%) required a secondary TURP, as compared to 23.5% (n = 4) after TUVP, 26.7% (n = 4) after VLAP, 15% (n = 4) after HIFU and 20% (n = 3) following TUNA. In patients not subjected to a secondary procedure, the IPSS decreased a mean 13.9 after TURP, as compared to 12.7 after TUVP, 12.9 after VLAP, 7.0 after HIFU, and 9.8 after TUNA. Qmax increased 11.5 ml/s (mean) after TURP, as compared to 11.1 ml/s after TUVP, 5.6 ml/s after VLAP, 2.5 ml/s after HIFU and 2.3 ml/s after TUNA.Conclusion: In up to a quarter of the patients, a secondary TURP is performed within the first 2 years after ‘less invasive’ procedures. These data underline the need for long–term studies to reliably assess the role of less invasive procedures and to indicate that TURP is still competitive.