BENIGN prostatic hyperplasia (BPH), characterised by lower urinary tract symptoms, is a common condition among middle-aged and older men. By the age of 50, approximately 50% of men experience BPH, with prevalence rising to 80% in men over 80. While medications such as alpha-1 blockers and 5α-reductase inhibitors alleviate symptoms, severe cases often necessitate surgical intervention.
Traditionally, monopolar transurethral resection of the prostate (M-TURP) has been the gold standard. However, transurethral holmium laser enucleation of the prostate (HoLEP) has emerged as a leading alternative. HoLEP demonstrates superior efficacy in reducing symptoms, enhancing urinary flow, and removing prostate tissue, especially for larger prostates. Additionally, it offers reduced complication rates compared to M-TURP.
Despite its advantages, HoLEP is associated with retrograde ejaculation (RE), affecting quality of life in sexually active patients. Research indicates that 92.5% of HoLEP patients report RE, leading to dissatisfaction with their sexual life. To address this, innovative surgical techniques have been developed to preserve ejaculatory function, such as Urolift, iTIND, and Aquablation. These methods show promise but require further research, especially for patients with enlarged prostates.
Recent advancements in ejaculation-preserving techniques during HoLEP have yielded encouraging results. Studies reveal that preserving the urethral mucosa and ejaculatory ducts improves outcomes. For instance, patients undergoing advanced tissue-sparing procedures report anterograde ejaculation rates of 45.5% within 12 months post-surgery.
Similarly, research on preserving key anatomical structures, such as the pelviperineal muscles and ejaculatory ducts, highlights their role in maintaining ejaculatory and erectile functions. Techniques like Bozzini’s “Omega sign,” which involves extensive tissue preservation, demonstrate comparable success in safeguarding ejaculation.
These advancements reflect a paradigm shift in BPH treatment, focusing not only on symptom relief but also on quality-of-life considerations. By combining innovative surgical methods with established procedures, physicians can offer improved outcomes, ensuring effective symptom management while prioritising patients’ sexual health and overall satisfaction.
Katie Wright, EMJ
Reference
Gao Z et al. Technological innovation of HoLEP: a multicenter, randomized, controlled study for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. World J Urol. 2025;43(1):64.
