In the case of a very severely enlarged prostate, endoscopic treatment (laser therapy, TUR-P) is no longer possible in some cases. In such cases, open prostate surgery through an abdominal incision (suprapubic prostate enucleation (SPE)) can be considered. In this type of surgery, the urinary bladder is opened through an incision in the lower abdomen. Then the surgeon uses a finger to peel out the benign enlarged portions of the prostate. Afterwards, urine must be drained through a catheter for 10 days until the bladder heals.

Suprapubic prostate enucleation is a relatively large surgical procedure with corresponding blood loss and is particularly stressful for older patients. Potency is usually preserved. However, the semen flows backwards into the bladder during ejaculation (so-called retrograde ejaculation or dry ejaculation).

Due to modern forms of resection (TURiS) and laser vaporization, the procedure is now generally unnecessary, as prostate volumes up to 200cc can now be treated endoscopically transurethrally (through the urethra) without any problems.