Transperineal laser ablation versus trans-urethral resection of prostate for benign prostatic obstruction: A randomized trial

Introduction & Objectives: Trans-urethral resection of prostate (TURP) is the reference-standard procedure for surgical treatment of benign prostatic obstruction (BPO), but is burdened by the consistent risk of permanent retrograde ejaculation. This study aimed to evaluate the reliability of trans-perineal laser ablation of prostate (TPLA) in preserving the ejaculation compared to TURP. Materials & Methods: In this single-center, prospective, randomized, open-label study, consecutive patients with indication to surgical treatment for BPO were enrolled between January 2020 and September 2021 (NCT04781049). Randomization defined two treatment arms: Group A: patients assigned to TPLA (experimental); Group B: patients assigned to TURP (standard). Primary endpoints included comparison of visual analogue scale (VAS), change in ejaculatory function (by EJ-MSHQ), and changes in sexual function (by IIEF-5) at 1 month after surgery. Secondary endpoints included ΔIPSS and ΔQoL, and Qmax improvement at 6 months. Results: Fifty-one patients (26 TPLA versus 25 TURP) were analyzed. No differences were found in the perception of pain assessed by VAS. No differences in IIEF-5 score were found between groups. Distribution of ejaculatory function assessed by the EJ-MSHQ remained unmodified after TPLA (p=0.2) while a median 31% decrease in EJ-MSHQ score (IQR -67;-14%) was observed after TURP (p=0.01). Retrograde ejaculation was reported in one patient within the TPLA group (18 patients s/p TURP). A statistically significant difference between the treatment groups was found in terms of postoperative Qmax (15.2 (IQR 13.5–18.3) versus 26.0 (IQR 22.0–48.0) ml/s, TPLA versus TURP, p<0.001). Qmax was statistically significantly improved with respect to baseline after TPLA (%ΔQmax +42 (+24;+76), p<0.001). Both treatments significantly improved IPSS and QoL with respect to baseline, with TURP impacting more significantly (%ΔIPSS -35.9 (IQR -54.5;-1.3) versus -66.7 (- 82.8;-46.7) and %ΔQoL -33.3 (-50;-8) versus -60.0 (IQR -80;-33), TPLA versus TURP, all p-values<0.03). Conclusions: TPLA allowed for maintaining ejaculation in 96% of the cases, confirming to be valid option in patients seeking for pairing the relief from BPO to the high probability of preserving ejaculatory function.