Stesura Seveso


Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

1

LETTER TO EDITOR

KEY WORDS: Prostatic hyperplasia; Minimally invasive surgical procedures; Lower urinary tract symptoms; Sexual dysfunction;
Urologic surgical procedures.

Submitted 19 October 2023; Accepted 16 November 2023 

To the Editor, 

In recent years, alternative solutions have been proposed to obtain effective results comparable to TURP, which is cur-
rently considered the gold standard, and laser vapo-enucleation techniques (1, 2), but with the possibility of maintain-
ing sexual functions. In recent years there has been a growing trend towards ejaculation preservation. Although the
results of TURP (3), and most laser enucleation techniques are undoubted in the Benign Prostatic Hyperplasia (BPH) and
Lower Urinary Tract Symptoms (LUTS) management, they often lack in the preservation of ejaculation. All the alternative
recently proposed interventions (Rezum, AquaBeam, Urolift, TPLA, i-TIND, LEST) are procedures considered by some
authors to be promising in both managing BPO and preserving sexual functions. However, all these methods are limited
by a lack of long-term follow-up that would evaluate the efficacy over time, possible complications related to the method
and the correct patient selection for a specific method. 
The aim of this letter is to summarize the available evidence and provide clinicians with practical recommendations on
the use of the brand new minimally invasive techniques for the management of BPO.

LEONARDI EJACULATION SPARING TECHNIQUE (LEST)
The LEST is an ablative technique fully described in 2019 (4). It is the evolution of a technique described in 2009 (5)
that achieved outcomes similar to TURP, while expanding the indication to larger prostates and preserving ejaculation.
This is a debulking laser technique with the aim of preserving the “genital sphincter” (anatomical structure that include
the para-urethral musculature, distinguished in proximal and distal portion, and in part the musculature of the bladder
neck). Other anatomical landmarks, essential to preserve ejaculation, are the orifices of ejaculatory ducts and the floor of
prostatic urethra. The preliminary results showed an IPSS improvement of about 59% (p < 0.001) at 3 months follow-
up and 67% (p < 0.001) at 12 months follow-up. Similarly, the Q max improvement was about +179% (p < 0.001) and
+163% (p < 0.001) at 3- and 12-months follow-up, respectively (5). The Quality of Life (QoL) was 3.5+/-1.2 at the base-
line while 1.3+/-1.2 and 1.2+/-0.4 at 3 and 6 months, respectively. An antegrade ejaculation is maintained in about 80%
of cases in patients without a middle lobe, although in the presence of a middle lobe this rate drops to about 50% (5).
In the beginning, prostates with a size of no more than 60 grams were included (5). Currently, the technique is proposed
for any prostate size, with pure vaporization for a small prostate and enucleation for a large prostate (4, 5). No severe

New minimally invasive solutions for Benign Prostatic
Obstruction (BPO) management: A position paper from
the UrOP (Urologi Ospedalità Gestione Privata)

Rosario Leonardi 1, 2, Francesca Ambrosini 3, Rafaela Malinaric 3, Angelo Cafarelli 1, 4, 
Alessandro Calarco 1, 5, Renzo Colombo 1, 6, Ottavio de Cobelli 1, 7, Ferdinando De Marco 1, 8, 
Giovanni Ferrari 1, 9, Giuseppe Ludovico 1, 10, Stefano Pecoraro 1, 11, Domenico Tuzzolo 1, 
Carlo Terrone 3, 12, Guglielmo Mantica 1, 3, 12

1 Urologi Ospedalità Gestione Privata (UrOP);
2 Casa di Cura Musumeci GECAS, Gravina di Catania, Italy;
3 IRCCS Ospedale Policlinico San Martino, Genova, Italy;
4 Urology Unit, Villa Igea, Ancona, Italy;
5 Villa Pia Hospital, Via Folco Portinari 5, Rome, Italy;
6 Department of Urology, Vita e Salute San Raffaele University, Milan, Italy;
7 Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy;
8 I.N.I. Grottaferrata, Roma, Italy;
9 Hesperia Hospital, Modena, Italy;
10 Ospedale Miulli, Acquaviva delle Fonti, Bari, Italy;
11 NEUROMED, Avellino, Italy;
12 Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy.

DOI: 10.4081/aiua.2023.12003



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R. Leonardi, F. Ambrosini, R. Malinaric, et al.

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complications were described, except for minor bleeding at the beginning of urination, which usually occurs for 40 days
after surgery. The reason for this lies in the preservation of mucosal areas of the prostatic urethra, that obviously must
not be coagulated, that cover the structure to be preserved and that represent the key points of the technique. The
authors are working to a variation of technique for the treatment of prostates with median lobe and the preliminary
results show an increasing preservation of anterograde ejaculation compared to the past.

AQUABEAM/AQUABLATION
Aquablation, first described in 2015, uses a heat-less robotic system called AcquaBeam (AcquaBeam®, Procept BioRobotics,
Redwood Shores, CA, USA), which combines ultrasound-guided waterjet technology with advanced planning software for
precise ablation of prostate tissue and real-time monitoring during the procedure (6). 
The technique is recommended for patients with desires of preservation of sexual function and in case of moderate, to
severe LUTS secondary to benign prostatic enlargement (volume 30-80 gr) and/or obstruction with underlying BPH (7).
The procedure is performed under loco-regional or general anesthesia and 2-4 days of hospitalization are usually
required (7-9). One of the main advantages of Aquablation is the short median operative time and resection time [30.5,
IQR (24-35) and 4, IQR (3.1-4.9), respectively (10)]. Sexual outcomes are promising with de novo ejaculatory dysfunc-
tion observed in 26.7% of patients and absence of de novo erectile dysfunction (10).
The efficacy of Aquablation was demonstrated in the United States (U.S.) cohort of the Waterjet Ablation Therapy for
Endoscopic Resection of prostate tissue (WATER) study, a double-blinded, multicenter, prospective, randomized controlled
trial (RCT) comparing TURP vs. Aquablation in patients with moderate-severe LUTS and a prostate size of 30-80 mL (8).
The hypothesis of non-inferiority of Aquablation in improving IPSS was demonstrated at 6 months (8) and 1 year (11).
The benefits in symptom relief were not at the expense of sexual dysfunction. Among sexually active men, patients treat-
ed with Aquablation experienced statistically significant lower rate of anejaculation (at 6 months: 10% vs 36% in TURP,
p = 0.0003; at 1 year: 9% versus 45% in TURP, p = .0006) (8, 11). Symptom reduction and Qmax improvement results
were maintained at 2 years (12) and 3 years of follow-up (9), with statistically comparable improvements in IPSS scores
between groups (3-year improvement difference: 0.6 points, 95% CI -3.3-2.2, p = 0.7) (9). The same results were report-
ed in patients with large prostates (80-150 mL) (8) at 1 year and 2 year follow-up (WATER II) (13-15). The non-inferi-
or efficacy of Aquablation was objectively demonstrated in another RCT (Aquablation vs. TURP), were bladder outlet
obstruction was measured at 6-month follow-up by using the urodynamic test (16). Bhojani et al. reported an increase in
Qmax of 14.3 ml/sec and a IPSS decrease of 15.6 points (17). Enthusiasm for the functional outcomes is tempered by con-
cerns about its effectiveness in achieving hemostasis. After ablation, haemostasis is usually achieved using a Foley bal-
loon catheter on traction or diathermy or low-powered laser (18). Because of the risk of bleeding, hospitalization for
monitoring and bladder irrigation is usually required (19). In the WATER II trial, 7.9% of the patients required transfu-
sion and/or reintervention due to postoperative bleeding (15). The 6-month rates of grade 2 and 3 Clavien-Dindo events
account for 13.3% (10). Most authors found no significant change in IIEF-15 at 1 year follow-up (20, 21). In most series
0% to 2% of patients required surgical reintervention (i.e. TURP/HoLEP) for unsuccessful therapy (15, 21). According
to the EAU and AUA guidelines (2, 22), Aquablation should still be considered under investigation considering the lack
of long term follow-up and the uncertainties about bleeding risk. 

REZŪM
In the Rezūm system, thermal energy obtained with high frequency is released in the form of water vapor when the vapor
changes from the gaseous to the liquid phase upon contact with the tissue. After the injections, the steam at 107°C dis-
tributes into the interstitial tissue spaces and releases stored thermal energy to the prostate tissue, causing cell necrosis.
The procedure can be performed in an out-patient setting, using a local transurethral anesthesia. Transrectal prostatic
block can be performed, if required (23).The operative time is usually less than 1 hour (23, 24) The efficacy of Rezūm
has been evaluated in RCTs and systematic reviews (24-30). McVary at al. reported the results of a blinded trial in which
patients were randomized 2:1 between Rezūm System thermal therapy and control (they received no treatment other
than rigid cystoscopy simulating surgery) up to 4 years of follow-up. They found symptom relief at three months follow-
up which was confirmed after 12 months, 2 years and 4 years (25, 26, 28). Only the Rezum group was followed up. No
de novo erectile dysfunctions were recorded at one year while erectile and ejaculatory functions were preserved (25).
Antegrade ejaculation is maintained between 100% and 96.6% (31, 32). Patients with troublesome LUTS but low
prostate volume (< 30 g) also experienced significant relief of LUTS (33). The Rezūm could effectively treat patients with
median lobes (25, 34, 35), urinary retention (36, 37) and large prostate volumes (≥ 80 g) (31, 33, 35, 38, 39).
Nevertheless, the improvement of Qmax, IPSS and QoL was assessed only in an early to intermediate follow-up period
(maximum 5 years). The gold standard TURP improved IPSS, QoL, and Qmax at 3 months and maintained its effect for
at least 10 years (40). Medical and surgical retreatment rates for Rezūm were reported up to 18.9% at 5 years (26) and
10.8% at 2 years (41), respectively.The Rezūm system could be a viable alternative option for the treatment of LUTS due
to BPO leading to an improvement in BPH symptoms, preserving sexual function with a 3%-6% risk of developing ejac-
ulatory dysfunction, and being associated with a low surgical recurrence rate over five years (26, 29). Nevertheless, the
level of evidence is low and impaired by several limitations (27) including the lack of a RCT directly comparing the
Rezūm system with the gold standard, and providing a long-term follow-up. 



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New minimally invasive solutions for Benign Prostatic Obstruction

TRANS-PERINEAL LASER ABLATION OF THE PROSTATE (TPLA)
TPLA is one of the most recent ‘ultra-minimally invasive’ ablative surgical treatment available. It uses a low-power diode-
laser as the energy source and a small needle is inserted percutaneously transperineally (usually one needle for each lobe)
(42), preserving the urethra as opposed to the more traditional transurethral approaches. According to the studies avail-
able in literature, TPLA was recommended in case of moderate-severe LUTS with an IPSS above 8 or 12 (43, 43-45) and
prostate volume > 30 mL. There is one series which did not include patients with a median lobe (46). The procedure can
be performed in an ambulatory surgical center, with a relative short operative time [mean setting time 21.33 ± 7.59 and
lasing time 8.43 ± 0.79, respectively (44)]. TPLA resulted in statistically significant improvement in IPSS and QoL scores
from baseline in most of the available studies (43, 45-48), with Frego et al. observing the greatest reduction in IPPS score
(Δ = −16.0 at 12 months) (48). The longest follow-up reported in literature is 3 years, with a significant improvement in
IPSS (-37.2%; p < 0.01), Qmax (+ 45.8%; p < 0.01) and median MSHQ-EjD (60%; p < 0.01) (49). A recent series pub-
lished by Minafra et al. reported that TPLA results are acceptable even after 3 years (49). The results in terms of ejacula-
tory function are impressive (43, 47, 48, 50). In particular, in some cases, ejaculatory function assessed by the MSHQ-
EjD questionnaire was not only preserved but even improved (44, 46, 51). No de novo erectile dysfunction was report-
ed (51) The complication rate is generally low and not severe with a 6-month rates of grade 2 Clavien-Dindo events of
4.6% (44). A case of prostatic abscess was reported by De Rienzo et al. and by Manenti et al. (4.8% and 4.9%, respective-
ly) managed with percutaneous drainage and antibiotic therapy (44, 46). Bertolo et al. recently reported for the first time
the results of the comparison between TPLA and the gold standard (TURP) (52). They found a preservation of the ejac-
ulatory function in 96% of cases of TPLA. Both treatments significantly improved the median Qmax, but the main advan-
tage was observed for TURP (TPLA vs TURP: 15.2 mL/s vs 26.0 mL/s; p < 0.001) (52). More research is needed to eval-
uate the rate of pharmacological or surgical re-intervention in the long term after TPLA. Overall, all available data come
mainly from a few pilot studies with short follow-up (maximum 3 years) and a limited number of patients, the strength
of evidence for which is low and insufficient to make a recommendation. TPLA remains under investigation, but it could
be considered for people interested in preserving sexual and ejaculatory function.

UROLIFT
The prostatic urethral lift (PUL, Urolift, Neotract Inc. Pleasanton, CA, USA) has passed the test of clinical evaluation with-
in 4 years after introduction and was approved by Food and Drug Administration in the 2013 (2). This tissue retracting,
permanent implant has a capsular, external tab made of nitinol connected to the plyethylene terephtalate monofilament
and a urethral end piece made of stainless steel (53). During urethroscopy, in the ambulatory setting, the tissue-retract-
ing implants are placed at the 2 and 10-o'clock positions guaranteeing integrity of the neurovascular bundle and dorsal
plexus. Another advantage that Urolift offers is tailoring the implants based on the patients' anatomy, regulating the
monofilaments' length and tension (54). Ideal candidates are patients with prostatic volume between 20 and 70 cc, with
'kissing' lateral lobes of the prostate, IPSS > 12, Qmax < 15 mL/s and with less than 350cc of post-void residual volume.
To deploy the device, the operator uses a needle that is then anchored, with the internal side in the urethra, and with the
outer side on the surface of the prostatic capsule. Usually, catheterization is not necessary following this procedure.
Contraindications are men with prostatic volume over 80-100 gr, voluminous median lobe and history of urinary reten-
tion (55). The recent evidences did not show superiority of the Urolift when compared to the gold-standard (56-58),
TURP, but it does, however reduce severity of LUTS. Currently, the largest RCT available (the L.I.F.T. study) comparing
PUL vs. a sham control reported durable improvements in IPSS (36%), QoL (50%), and Qmax (44%) at 5-years (58). Also,
an increase in maximum urine flow-rate (Qmax) from 7.88 to 11.08 was evidenced in the same period. Some compara-
tive studies described superiority of the Urolift to other minimally invasive techniques when it comes to erectile dys-
function. Actually, Sexual Health Inventory for Men (SHIM) scores were greater in the Urolift (14.8) versus other groups
(9.2) (59). Moreover, new generation of the PUL, marketed as Urolift 2, was launched in March 2022. There are some
drawbacks to PUL technique, like reported adverse events and high costs. The majority of adverse events were mild, such
as transient hematuria, dysuria, pelvic pain, blood clots and incontinence (60), but some Authors reported formation of
pelvic hematoma (61), one of which needed surgical intervention (62), and another that resulted in acute kidney injury
and progression of chronic kidney disease (63). Also, the LIFT trial reported the need for retreatment or surgical inter-
vention in 13.6% of patients (54). On the other hand, at longer follow-up (5 years), there were no adverse event report-
ed related to sexual function (58). Currently, the Urolift is recommended as an alternative non-ablative technique to men
with LUTS interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe by the guidelines
of the European Association of Urology (2).

TEMPORARILY IMPLANTED NITINOL DEVICE (ITIND)
The temporary implantable nitinol device (first generation: TIND; second generation: iTind) (Medi-Tate®; Medi-Tate Ltd.,
Or Akiva, Israel) is a recent promising non ablative minimally invasive solution for the management of LUTS/BPH (64).
One of the advantages of the technique is the fact that most cases can only be achieved with the use of local anesthetic,
with light intravenous sedation if required (65). Similarly, most patients can be managed with a day-surgery hospital
access. Another advantage, comparing to implantable devices, is that iTind is a temporary device which avoids the poten-
tial complications associated with a permanent device. The iTind seems to be of particular benefit to LUTS/BPH patients



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(IPSS > 12 points and Qmax ≤ 12 ml) seeking a minimally invasive treatment associated with a significant improvement
in symptoms with the preservation of sexual function. ITind could be also recommended in case of BPH and sclerosis of
the bladder neck. In most series, prostate size was quite small (less than 60-75 cc). Porpiglia et al. showed an IPSS and
Qmax improvement by -45% and +67% respectively, at 12 months follow-up (66). Similar results were found in the MT-
02 study, a single arm multicentric study involving 81 patients (67). Other series are published, with good results but
with shorter follow-up (68). The device and the procedure appear to be moderately safe, with a low number of compli-
cations (mostly urinary retention, UTIs, device displacement, hematuria) and in particular not high grade according to
the Clavien-Dindo classification. A randomized trial based on 175 patients showed no de novo ejaculatory or erectile
dysfunction (69). At two-year follow-up, 4 of 81 patients required subsequent surgery (TURP/HoLEP) (70). The longest
published follow-up is 36 months (71). Currently, the iTind is not recommended in the guidelines, even though con-
sidered a promising technique, waiting for the results of ongoing randomized controlled trials comparing iTind to a ref-
erence technique.

DISCUSSION AND CONCLUSIONS
All the new minimally-invasive techniques for the treatments of LUTS due to BPO were developed because of the neces-
sity to offer a patient-tailored, successful, viable treatment for BPH while maintaining sexual and ejaculatory function (4,
6, 42, 58). Now more than ever, the patients are well informed about all the possibilities that new technologies can offer
and how can we, as urologists, improve their quality of life by maintaining good both functions, urinary and sexual. Also,
quick recovery period and rare serious adverse effect of these minimally invasive technologies make them even more
attractive (24). Seemingly, they are a relatively easy choice to make when compared to the gold standard, TURP, and
maybe should be the first one at some point in well selected candidates, but there are some drawbacks to take in con-
sideration such as, in some cases, higher costs, availability, surgical experience of the operators and higher rates of retreat-
ments (24). These are major reasons why urologists should be very careful when proposing new techniques to the
patients, choosing the right candidates for the right procedure, and giving them all the necessary information regarding.
Some of the most important parameters to consider are patients' general health status, prostate volume, and strong desire
to preserve ejaculation (2, 72, 73). The doctor-patient relationship, patient-tailored therapy, shared decision, and correct
informed consent are more important than ever.
From the national health-care institutions' prospective these treatments, if preformed in ambulatory setting, can be
extremely useful as they can alleviate the long waiting lists for surgical treatments that require surgical staff, hospitaliza-
tion, and post-operative care. For example, Rezum, iTind and Urolift can all be offered to the patients in 'day surgery'
regime (36, 55, 69). This can be an important advantages for healthcare systems in the post SARS-CoV-2 era (74, 75).
On the other hand, to be able to offer these kinds of services, urologists preforming them must be adequately prepared
and trained, and not only on the procedure itself, but on adverse events and complications. The scarcity of specialized
training centers and fairly limited diffusion of these novel techniques pose quite an important obstacle in using them,
especially in the smaller, more peripheral hospitals. 
In addition to that, it should be mentioned that some of these techniques did never undergo randomized trials (i.e.
iTind), and the outcomes of these studies never systematically evaluated using validated outcome measures, therefore the
rate of retreatments is still quite uncertain. Furthermore, there is a lack of long-term follow-up results, and for that man-
ner it could be difficult to give the patients precise and complete information. Nevertheless, minimally invasive treat-
ments are on the rise, especially Urolift in the United States (76). 
One of the greatest benefits of minimally invasive techniques is the preservation of sexual function. De novo erectile func-
tion is anedoctal and ejaculatory dysfunction is generally low (15.4% with LEST, 3-6% in Rezum, 26.7% in Aquablation
(24, 30). ITind and Urolift had no impact on ejaculatory dysfunction. 
It is worth noting that all minimally invasive techniques are relatively young and have a short follow-up, with the excep-
tion of LEST (Laparoscopic Endoscopic Single-Site Surgery), which has a follow-up of up to 12 years (4, 5). This remark-
able longevity of follow-up data for LEST sets it apart from other procedures and underscores its potential and reliabili-
ty. In addition, LEST provided immediate relief of LUTS after catheter removal, whereas Rezum, Urolift, and iTind pro-
vided good results only after some time (2 weeks to six months). 
Obviously, the incorporation in the guidelines and insurance companies are also important factors to consider when
implementing them. Moreover, Urolift is mentioned as the valid alternative in some guidelines, while others are not men-
tioned or are discouraged because of higher retreatment rates (73) Also, not all guidelines agree on the recommendations
[NICE vs. AUA (72, 73)]. The need for cautious interpretation of current analytical results stems primarily from the ever-
evolving landscape of safety and efficacy data on these innovative techniques. Currently, ongoing studies are comparing
these procedures not only with transurethral resection of the prostate (TURP) (NCT05762198, NCT05840549) but also
with various alternative treatments, including purely medical interventions. Pending the results of these ongoing stud-
ies, these techniques are very promising and appear to be attractive alternative options for future treatment of the dis-
ease in selected patients.
In conclusion, we would like to provide our position related to each one of the techniques presented. 
The LEST showed promising results in terms of functional outcomes with significant improvements in IPSS and Qmax,
while preserving sexual function.
Aquablation shows efficacy in improving IPSS and Qmax with favorable sexual outcomes. Concerns about hemostasis and



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New minimally invasive solutions for Benign Prostatic Obstruction

bleeding risk remain, but the short operative time and the possibility of an outpatient setting make it a valuable option
for patients seeking both symptom relief and preservation of sexual function.
Rezūm provides significant relief for LUTS, with a low risk of ejaculatory dysfunction. Nevertheless, the level of evidence
remains low, and further long-term studies are needed to prove its efficacy compared to the gold standard TURP.
TPLA shows a remarkable improvement in IPSS and QoL scores, with impressive results in ejaculatory function preser-
vation. Due to the limited short-term data and the small number of patients, TPLA should remain under investigation. 
Urolift proves effective in reducing LUTS severity with durable improvements in IPSS and Qmax, and shows superiority
in preserving erectile function. Despite the reported adverse events, its outpatient nature and the easy implantation make
Urolift an attractive option for selected patients.
iTind is a promising non-ablative solution, that offers significant improvement in symptoms with minimal impact on sex-
ual function. Its temporary nature and low complication rates are the main advantage, especially for patients seeking a
minimally invasive treatment approach.
In conclusion, all of these minimally invasive techniques offer multiple options for patients with BOO, balancing effica-
cy, preservation of sexual function, and potential benefits to the healthcare system. As ongoing studies continue to vali-
date their long-term outcomes and cost-effectiveness, urologists must carefully consider patient preference and individ-
ual health context when recommending these innovative approaches.

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Correspondence
Rosario Leonardi, MD 
leonardi.r@tiscali.it
Casa di Cura Musumeci GECAS, Gravina di Catania, Italy

Francesca Ambrosini, MD (Corresponding Author)
f.ambrosini1@gmail.com
Rafaela Malinaric, MD
rafaela.malinaric@gmail.com
Carlo Terrone, MD
carlo.terrone@hsanmartino.it
Guglielmo Mantica, MD
guglielmo.mantica@gmail.com
IRCCS Ospedale Policlinico San Martino, Genova, Italy
Largo Rosanna Benzi 10, 16132, Genova, Italia

Angelo Cafarelli, MD
info@angelocafarelli.it
Urology Unit, Villa Igea, Ancona, Italy

Alessandro Calarco, MD
info@alessandrocalarco.com
Villa Pia Hospital, Via Folco Portinari 5, Rome, Italy

Renzo Colombo, MD
colombo.renzo@hsr.it
Ottavio De Cobelli, MD
ottavio.DeCobelli@unimi.it
Department of Urology, Vita e Salute San Raffaele University, Milan, Italy

Ferdinando De Marco, MD
info@clinicavillamargherita.it
I.N.I. Grottaferrata, Roma, Italy

Giovanni Ferrari, MD
visite@giovanniferrariurologo.it
Hesperia Hospital, Modena, Italy

Giuseppe Ludovico, MD
g.ludovico@miulli.it
Ospedale Miulli, Acquaviva delle Fonti, Bari, Italy

Stefano Pecoraro, MD
cup@diagnosticamedica.org
NEUROMED, Avellino, Italy

Domenico Tuzzolo, MD
info@casadelsole.it
Urologi Ospedalità Gestione Privata (UrOP)

Conflict of interest: The authors declare no potential conflict of interest.