In our systematic review, we therefore wanted to provide a clear and structured summary of outcomes across the full range of available MISTs. We examined not only surgical reintervention rates but also the frequency of restarting or initiating medical therapy, both of which represent real indicators of treatment durability. Our analysis covered nearly one hundred studies and more than twelve thousand patients, allowing comparison between therapies under a broad lens.
The findings confirmed what many clinicians already observe in daily practice: the durability of these therapies is highly variable. Aquablation, Water Vapor Thermal Therapy, and the Optilume BPH Catheter System showed relatively stable mid- to long-term outcomes, with reintervention rates approaching those of TURP. It should be clarified, however, that OBCS demonstrated these results in prostate volumes ranging from 35 to 45 cc, whereas Aquablation and WVTT have achieved similarly low reintervention rates in considerably larger prostates, often exceeding 45 cc and in some studies even reaching 100 cc. In contrast, Prostatic Artery Embolization was associated with reintervention in more than one in five patients within two years, while Transurethral Needle Ablation and transurethral Microwave Therapy demonstrated high long-term failure rates, where reintervention became the rule rather than the exception. These differences underscore that MISTs cannot be viewed as a uniform group but must instead be critically assessed on an individual basis.
Equally important was the context in which these results were generated. Our analysis of conflicts of interest revealed that most available studies were supported or influenced by industry. In many cases, study design, patient selection, and reporting practices reflect sponsor priorities rather than real-world conditions. Positive results were often more visible, while limitations and failures were less clearly described. This makes interpretation difficult and underlines the need for independent, long-term studies that include diverse patient populations.
For clinicians, this dual message is essential. On the one hand, MISTs provide genuine options for men who value shorter recovery and preservation of sexual function. On the other hand, enthusiasm must always be balanced with critical judgment, careful patient counseling, and awareness of economic and ethical dimensions. Only by keeping both aspects in mind can we place these therapies in their correct place within the treatment landscape of BPO.
Beyond the abstract, it is important to highlight the team behind this work. The leading author, Burak Akgül, drove the project with great dedication, while senior colleagues contributed their expertise and leadership. Young residents and junior urologists also joined, learning systematic review methodology, bias assessment, and critical data interpretation. The guidance of Christopher Netsch and Thomas Herrmann was particularly decisive, shaping the direction of the study at key stages. This paper also reflects three years of collaboration with Kamran Ahmed, carried out together with residents from our Department of Urology at Necmettin Erbakan University in Konya, as well as enthusiastic young urologists who are close friends and colleagues. They advanced through a process of “learning by doing,” working side by side with experienced clinical researchers such as Theodoros Tokas, Javier Romero-Otero, and Jens Rassweiler, gaining invaluable first-hand experience in methodology and critical analysis. Over time, what began as a focused research exercise grew into a wider international effort, uniting colleagues from both well-established and lesser-known institutions. For many younger contributors, especially those from centers without global visibility, this became a formative academic journey. Today, they are ready to carry this experience forward, contributing not only to their local practice but also to the global discussion.
The message beyond the abstract is threefold: first, minimally invasive therapies for BPO continue to appear as promising alternatives, but their durability remains variable and requires further confirmation through long-term follow-up; second, much of the current evidence has been shaped by industry sponsorship, which has supported innovation but may also introduce bias, underlining the importance of independent trials; and third, our responsibility as urologists is to communicate these findings with balance and transparency, so that patients receive both realistic information and fair access to treatment. Beyond the numbers, these lessons guide how MISTs should be positioned within the evolving management of BPO.
Written by:
- Burak Akgül, MD, Indiana University School of Medicine Indianapolis, US
- Prof. Selçuk Güven, Necmettin Erbakan University, Department of Urology, Konya, TR