Several procedures defined as minimally invasive surgical treatments (MISTs) have emerged, including water vapor thermal therapy (wVTT, Rezum), prostatic urethral lift (PUL, Urolift), prostatic artery embolization (PAE), the Optilume BPH catheter system, the temporary implantable nitinol device (iTIND), and transperineal laser ablation (TPLA). These procedures are performed on an outpatient basis, offer shorter recovery, and most importantly, seek to preserve sexual function. Research has shown that the majority of patients with BPH prioritize preservation of erectile and ejaculatory function regardless of their age or fertility status, making MISTs an appealing option. We aimed to perform an updated and comprehensive analysis of the impact of MISTs on sexual function.
We performed a systematic review and meta-analysis of studies on MISTs for BPH assessing sexual function outcomes 12 months post-procedure, specifically, ejaculatory and erectile function. For ejaculatory function, outcomes included the rate of retrograde ejaculation (RE) and Male Sexual Health Questionnaire (MSHQ-EjD) function and bother scores. For erectile function, outcomes included various iterations of the International Index of Erectile Function (IIEF).
Our initial search yielded 2646 studies, and after screening and full-text review, 77 studies met the inclusion criteria. Based on pooled analyses, for erectile function, IIEF scores at 12 months significantly improved after both Rezum and Urolift. Pooled analyses for PAE and TPLA showed no significant impact on erectile function. For ejaculatory function, based on pooled analyses, Urolift significantly improved both MSHQ-function and bother scores, while Rezum improved MSHQ-bother score only. Due to the limited number of studies, heterogeneity in follow-up, and lack of use of standardized questionnaires, formal meta-analyses could not be performed for ejaculatory function for PAE and TPLA, and for both erectile and ejaculatory function for iTind and Optilume BPH. However, a systematic review of the literature showed generally maintained erectile function and significantly lower rates of ejaculatory dysfunction than traditional surgical procedures.
Our findings demonstrate that overall, both erectile and ejaculatory function are either preserved or improved across several MISTs. Given the variety of surgical options, it remains important for urologists to perform a careful preoperative assessment that can guide patients in their choice based on individual preferences, anatomy, and medical history. We also recommend the utilization of standardized questionnaires for both erectile and ejaculatory function tracking in these patients to improve the quality and generalizability of outcomes assessment. Additionally, with the rising popularity of MISTS, future directions should include comparative research of sexual outcomes across various MIST procedures to assist patients and surgeons with decision-making.
Written by: Ellen M. Cahill,1 Marcelo Mass Lindenbaum,2 Alexander Estright,3 Bernardita M. Ljubetic,2,4 Vivek Aslot,5 Neil Nero,6 Smita De,2 Petar Bajic,2 Raevti Bole,7
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA.
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
- Department of Urology, Doctors' Hospital at Renaissance, McAllen, TX, USA.
- University of Toledo, School of Medicine, Toledo, OH, USA.
- Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland, OH, USA.
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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