Emerging Minimally Invasive Transurethral Treatments for Benign Prostatic Hyperplasia: A Systematic Review with Meta-Analysis of Functional Outcomes and Description of Complications - Beyond the Abstract

Over the years, several minimally invasive surgical treatments (MISTs) have been proposed as alternative therapies for benign prostate hyperplasia (BPH) to allow a significant improvement in lower urinary tract symptoms (LUTS) and a reduction in hospital stay and postoperative complications compared to traditional surgery.


In this meta-analysis, we found that iTIND, Rezūm, and Aquablation were associated with a significant improvement in International Prostate Symptom Score (IPSS) (p<0.001), IPSS-QoL (p<0.001), and Qmax (p<0.001) compared to baseline. A significant reduction of PVR from baseline was described with Rezūm (p<0.001) and Aquablation (p<0.001) but not iTIND (p=0.22). A significant difference in IPSS, IPSS-QoL, and Qmax was shown in favor of Aquablation compared to Rezūm and iTIND (p<0.001). The impact of prostate size on MISTs results still represents a debated topic. Although prostate size is a theoretical limitation of Rezūm, our results showed that it could also be performed effectively in large prostates. Indeed, we found no significant difference in IPSS, Qmax, and PVR between patients undergoing Rezūm with prostate volume < 80 cc and > 80 cc.

One of the most useful indicators to evaluate the efficacy of a surgical procedure is the reoperation rate, which indicates the durability of the improvements achieved in the absence of complications. Reasonably, procedures involving resection of prostatic tissue should have a lower secondary BPH surgery rate, indeed we found that Aquablation had the lowest rate (2%-6.4%) compared to iTIND (4.7%-8.6%) and Rezūm (1.5%-13.1%).

MISTs are overall well tolerated. We found an incidence of serious adverse events (CD ≥ 3) lower than 10% for all procedures. Complications of iTIND and Rezūm were mostly mild to moderate and self-limiting within the first 1-3 months, while a not negligible risk of bleeding (up to 26%) and a relevant rate of transfusion or intervention due to bleeding (up to 9%) were associated with Aquablation. Regarding sexual complications, no case of de novo erectile dysfunction (ED) or ejaculatory dysfunction was reported with iTIND. ED rate after Rezūm ranged from 3.1% to 7.4%, while retrograde ejaculation seemed uncommon but possible (3.1% in a single study). A low incidence of ED (1%-3.4%) and risk of ejaculatory dysfunction extremely variable (but which could reach 27%) were recorded after Aquablation.

Written by:

  • Celeste Manfredi, MD, Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy.
  • Davide Arcaniolo, MD, , PhD, FEBU, Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy.
  • Javier Romero-Otero, MD, PhD, FEBU, FECSM, Department of Urology, Hospital Universitario 12 Octubre, and Unit of Urology, HM Hospitales, Madrid, Spain.


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