Systematic Review and Pooled Analysis of Functional and Sexual Outcomes of Minimally Invasive Surgical Treatments for Benign Prostatic Obstruction

Background and objective: Minimally invasive surgical treatments (MISTs) for benign prostatic obstruction have been developed with the aim of providing superior symptom relief in comparison to pharmacological treatment, while minimizing the impact on sexual function. The aim of our study was to assess key MIST outcomes and to propose a definition of procedural success. Methods: A systematic literature search was conducted in February 2025 in the PubMed, Scopus, Web of Science, and Cochrane Library databases. The protocol, which follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and PICOS (Population, Intervention, Comparator, Outcomes, Study design) criteria, was registered on PROSPERO as CRD42024543361. The review focused on randomized controlled trials and prospective studies evaluating surgical and functional outcomes of MISTs (Rezūm, UroLift, temporary implantable nitinol device [iTind], transperineal laser ablation [TPLA], Optilume) for BPO. We assessed the risk of bias and graded the certainty of evidence from the articles included. Pooled analyses were performed to compare perioperative and functional outcomes between study groups. Key findings and limitations: The 24 studies included in the review found that most MISTs were effective, showing improvements at 12 mo of ≥50% in the International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax), and of ≥1 point for at quality of life (QoL) questionnaire. Anejaculation rates were 5% with TPLA, 3% with Rezūm, 1% with iTIND, and 0% with UroLift and Optilume. Complication and retreatment rates were low, although the follow-up duration was inconsistently reported and mainly limited to 24 mo. On the basis of these results, we propose a definition of procedural success that comprises achievement of all the following outcomes: IPSS reduction of ≥50%, Qmax improvement of ≥50%, QoL improvement of ≥50% (or ≥1 point), the absence of intraoperative complications and Clavien-Dindo grade ≥III postoperative complications, and preservation of erectile function and of antegrade ejaculation. Conclusions and clinical implications: MISTs represent a promising tool for benign prostatic obstruction management and provide effective symptom relief while preserving sexual function.