Ejaculation Sparing of Classic and Minimally Invasive Surgical Treatments of LUTS/BPH

The present review explores the evolving landscape of minimally invasive surgical therapies (MISTs) in managing Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH), with a particular focus on their impact on ejaculatory function. It delves into various surgical interventions, ranging from classic endoscopic procedures to emerging techniques like Aquablation, Rezūm, Urolift, and others, while systematically reviewing their efficacy and their influence on ejaculatory function.

We highlighted the paradigm shift in BPH management from a focus on BPH itself to addressing LUTS, emphasizing the importance of sexual function in patients' overall well-being. This shift is underscored by a preference among patients for surgical interventions with lower risks and minimal sexual side effects. Consequently, there's a growing interest in MISTs that offer ejaculation-sparing approaches while effectively alleviating obstructive symptoms associated with BPH.

The systematic review of relevant literature was done with a rigorous approach to evidence synthesis. The inclusion of randomized clinical trials and a meticulous risk of bias assessment enhanced the reliability of the findings. The discussion section critically evaluates the evidence synthesized from the systematic review, acknowledging the positive outcomes of MISTs on both objective parameters like IPSS, QoL, and Qmax, as well as on ejaculatory function.

However, the commentary also recognizes several limitations and challenges. These include variations in study designs, patient cohorts, and follow-up periods, which may influence the generalizability of findings. Additionally, concerns are raised about the lack of specificity in baseline evaluations, the use of validated questionnaires, and the exclusion of individuals who do not engage in sexual activity, highlighting gaps in the literature.

Despite these limitations, we concluded that different MISTs appear to be comparable in their ability to spare ejaculation while effectively managing LUTS/BPH. We emphasized the need for long-term follow-up studies to validate the sustainability of ejaculatory function preservation and called for comparative studies to evaluate the trade-offs between different MISTs and traditional surgical approaches.

Moreover, it underscores the importance of incorporating patient-reported outcomes and quality-of-life assessments into future research. The commentary also advocates for evidence-based practice, urging caution in endorsing new treatments until they meet an agreed minimum threshold of evidence.

Written by: Gian Maria Busetto, Professor of Urology for Medicine and Surgery, Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti, Foggia, Italy

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