Background <p>Interest in minimally invasive techniques (MISTs) for treating benign prostatic hyperplasia (BPH) has increased over the years due to their ability to improve symptoms while minimizing complications. Moreover, these procedures can be performed in an outpatient setting, potentially reducing patients’ discomfort. The aim of our randomized trial is to evaluate and compare the efficacy of Transperineal Laser Ablation (TPLA^TM) and Water Vapor Ablation (WVA) in the treatment of BPH.</p> Methods <p>Eighty consecutive patients were randomized 1:1 to the two techniques between January and July 2024. Both procedures were under conscious sedations and patients were same day discharged. All patients underwent standardized follow-up, including International Prostate Symptoms Score (IPSS) and uroflowmetry assessments at 3- and 6-months post-treatment.</p> Results <p>At 6 months, IPSS and Quality of Life (QoL) scores improved significantly from baseline (<i>p</i> &lt; 0.001), in favor of TPLA at both time points (<i>p</i> ≤ 0.03). General Linear Model analysis showed that QoL improvement was faster in the TPLA group (<i>p</i>: 0.005), though no significant difference persisted at 6 months. Uroflow parameters, including maximum flow, average flow, and post-void residual volume, demonstrated significant improvement without notable differences between the two groups (<i>p</i> &lt; 0.001 for all comparisons). All patients were same day discharged, except one who required prolonged continuous bladder irrigation. Postoperative complications occurred in 11 cases, with only one (a prostatic abscess) classified as Clavien-Dindo ≥3. The main limitations of the study are the sample size and short follow-up duration.</p> Conclusions <p>TPLA and WVA are safe outpatient procedures that provide comparable functional outcomes. However, TPLA appears to offer a faster improvement in patient-reported symptoms.</p>