Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(3):14296 1 ORIGINAL PAPER disorders, and a consequent reduction in quality of life (6-8). Benign prostatic hyperplasia (BPH) is one of the most prevalent conditions in aging men, with a significant impact on the quality of life and often significant lower urinary tract symptoms (LUTS), impaired voiding efficien- cy, and associated complications such as acute or chronic urinary retention and recurrent Urinary Tract Infections (UTIs). Surgical management is recommended when con- servative or pharmacological treatments fail (5). The transurethral resection of the prostate (TURP) has historical- ly represented the gold standard. Over the last years, endoscopic enucleation techniques using different energy sources (holmium, thulium, green laser, diode lasers) are progressively replacing TURP in the management of medium and large prostates (9-13). In parallel, the last decades have also witnessed the incredibly rapid expan- sion of robotic surgery, progressing up to single-site plat- forms, which now provide additional minimally invasive options for the surgical management of BPH (14, 15). However, one of the main issues of endoscopic enucle- ation of the prostate is the significant risk of loss of ante- grade ejaculation, reported in up to 70% of patients after some endoscopic procedures (16, 17). The ejaculatory dysfunction has a substantial impact on patients’ sexual satisfaction and quality of life. The fear of postoperative sexual side effects is one of the leading rea- sons why many men delay or refuse surgical intervention for BPH. In the contemporary medical practice, which is patient-centered, techniques that ensure both effective relief of obstruction and preservation of sexual function are increasingly demanded. The Leonardi ejaculation-sparing technique (LEST), previ- ously described in 2019 (18), was specifically developed to preserve the anatomical structures involved in the ejac- ulatory mechanism, including the verumontanum, geni- tal sphincter, and selected bladder neck fibers, allowing, at the same time, complete adenoma enucleation using diode laser and a dedicated fiber (Twister). Initial feasibility reports suggested promising results, with high rates of preservation of antegrade ejaculation with- out compromising voiding outcomes. However, evidence Introduction: Benign prostatic hyperplasia (BPH) significantly impairs quality of life and may lead to complications such as urinary retention and recur- rent infections. While endoscopic enucleation techniques provide effective relief, they are frequently associated with loss of ante- grade ejaculation. The Leonardi ejaculation-sparing technique (LEST) was developed to preserve ejaculatory function during diode laser enucleation of the prostate (DILEP). Methods: We conducted an observational, retrospective analysis of 99 men undergoing DILEP with LEST between January 2018 and June 2020. Inclusion criteria were symptomatic BPH refrac- tory to medical therapy, prostate volume ≥ 40 mL, and suitabili- ty for endoscopic surgery. Functional outcomes (IPSS, Qmax, PVR), erectile function (IIEF-5), and ejaculatory status (MSHQ- EjD) were assessed preoperatively and at 6 months. Patient sat- isfaction was evaluated with a dedicated 5-item questionnaire. Results: Mean age was 48.1 years, and median prostate volume was 67 mL. At 6 months, IPSS decreased from 21.6 to 3.8, Qmax improved from 9.1 to 25.7 mL/s, and PVR decreased from 103 to 6.8 mL (all p < 0.01). Erectile function showed modest improve- ment (IIEF-5: 14.4 to 16.2; p < 0.01). Antegrade ejaculation was preserved in 94.1% of patients. Satisfaction was high, with > 80% willing to repeat the procedure and denying regret. No major complications occurred. Conclusions: DILEP with LEST provides excellent functional results with high rates of ejaculatory preservation and patient satisfaction. This technique may represent a patient-centered alternative for BPH surgery, especially in younger men prioritiz- ing sexual function. KEy WORDS: DILEP; BPH; Ejaculation sparing surgery; Antegrade ejaculation; Prostate. Submitted 1 September 2025; Accepted 3 September 2025 INTRODUCTION The management of prostatic diseases, whether malignant (1-3) or benign (4, 5), medical or surgical, is not only cru- cial for reduce urinary symptoms and the related compli- cations but also has a significant impact on men’s sexual health, often leading to erectile dysfunction, ejaculatory Diode laser enucleation prostate for benign prostatic hyperplasia: Outcomes of the Leonardi ejaculation sparing technique Rosario Leonardi 1, Guglielmo Mantica 2, Francesca Ambrosini 3, Antonio Tufano 4, Gabriele Iacona 5, Alessandro Calarco 4 1 Department of Medicine and Surgery, University of Enna "Kore", Enna, Italy; 2 Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genoa, Genoa, Italy; 3 IRCCS San Martino Polyclinic Hospital, Genoa, Italy; 4 Department of Urology, San Carlo di Nancy Hospital, Rome, Italy; 5 Casa di Cura Musumeci GECAS, Gravina di Catania (CT), Italy. DOI: 10.4081/aiua.2025.14296 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(3):14296 R. Leonardi, G. Mantica, F. Ambrosini, et al. 2 is still limited, particularly in men with very large middle lobes and very high-volume prostates, where surgical dis- section is more challenging and the risk of functional impairment is higher. In this light, the aim of the present study is to report the outcomes of a larger size cohort of men undergoing diode laser enucleation with the LEST approach. We aimed to evaluate standard functional outcomes but also ejaculato- ry preservation and patient-reported satisfaction at 6 months, using a dedicated questionnaire. This represents one of the largest and most comprehensive cohorts of LEST-treated patients reported to date, providing impor- tant insights into the feasibility, safety, and patient-cen- tered value of this novel approach. MATERIALS AND METHODS Study design and patients’ selection This was an observational, retrospective study based on prospectively collected data of patients undergoing diode laser enucleation of the prostate using the LEST between January 2018 and June 2020. Inclusion criteria for LEST were: men with symptomatic BPH refractory to medical therapy, prostate volume ≥ 40 mL, and suitability for endoscopic surgical management. Exclusion criteria included: prior prostate or urethral sur- gery, known prostate cancer, neurogenic bladder dysfunc- tion, or incomplete follow-up data at 6 months. All patients included were highly motivated to undergo a procedure with the potential advantage of preserving antegrade ejaculation. They were informed, however, that the technique could not guarantee complete (100%) preservation of ejaculation (19). Preoperatively, all patients underwent a PSA assessment. While in the past elevated PSA levels might have led to non-invasive testing such as PCA3 3 or even random biopsy, current practice involves routine multiparametric MRI. In cases where cancer was suspected, a targeted fusion biopsy was performed prior to surgery. Surgical technique and equipment All interventions were carried out by a single experienced surgeon (R.L.), with extensive expertise in laser prostate surgery. The procedures were performed using a high- power diode laser platform with dual wavelengths (980 and 1470 nm) in combination with dedicated “Twister” quartz contact fibers, specifically designed to allow pre- cise tissue vaporization and enucleation while minimizing collateral damage to ejaculatory structures. The standard LEST technique has been performed (19). Outcomes and follow-up Preoperative assessment included general data such as age, prostate-specific antigen (PSA), prostate volume (mea- sured by ultrasound), maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), International Prostate Symptom Score (IPSS), and erectile function assessed with the 5-item International Index of Erectile Function (IIEF-5). Ejaculatory function was assessed using the MSHQ-EjD short form. At 6-month follow-up, the same functional outcomes were reassessed, including IPSS, Qmax, PVR, IIEF-5, and ejaculatory status. Prostate volume reduction was also recorded (measured by ultra- sound). In addition, patient-reported satisfaction was evaluated using a dedicated 5-item decisional satisfaction questionnaire (see Supplementary File). Patient satisfaction questionnaire The questionnaire explored agreement or disagreement with five key statements regarding surgical decision-mak- ing and postoperative outcomes, using a 5-point Likert scale (from “strongly agree” to “strongly disagree”). Items included willingness to repeat the procedure, absence of regret, and perceived benefits versus harms. Statistical analysis Continuous variables were expressed as mean ± standard deviation or median (interquartile range) as appropriate. Comparisons between preoperative and postoperative outcomes were performed using paired t-tests or Wilcoxon signed-rank tests, depending on data distribu- tion. Categorical variables were summarized as frequen- cies and percentages, and differences were assessed with the χ² or Fisher’s exact test. A p-value < 0.05 was consid- ered statistically significant. Statistical analyses were per- formed using SPSS v.25 (IBM Corp., Armonk, NY, USA). RESULTS A total of 99 patients were included in the study. The mean age was 48.1 ± 3.5 years, reflecting a relatively young surgical population, and therefore a group in which preservation of sexual function may be particular- ly relevant. The median prostate volume was 67 ml [57.5- 78.5], with a mean of 68.2 ± 17.6 cc. Mean PSA was 2.2 ± 1.4 ng/mL. At baseline, patients presented with a high symptom burden, as reflected by a mean IPSS of 21.5 ± 5.1, low Qmax (9.1 ± 2.8 mL/s), and significant PVR (102.3 ± 46.1 mL). The baseline erectile function assessed with IIEF-5 averaged 14.4 ± 5.5 (Table 1). At a median follow-up of 6 months, all functional out- comes demonstrated marked improvement. IPSS decreased from 21.6 to 3.8 (p < 0.01), reflecting a sub- stantial reduction in LUTS. Qmax improved almost three- fold from 9.1 to 25.7 mL/s (p < 0.01). PVR decreased dra- Table 1 Descriptive characteristics of 99 patients who underwent LEST between January 2018 and June 2020. Parameter Cohort (n = 99) Age at surgery (yr), mean ± SD 48.1 ± 3.5 BMI (kg/cm2), median (IQR) 25.5 (24, 28) PSA level (ng/ml), mean ± SD 2.2 ± 1.4 Prostate volume (ml), median (IQR) 67 (57.5-78.5) Preoperative IPSS, mean ± SD 21.5 ± 5.1 Preoperative IIEF-5, mean ± SD 14.4 ± 5.5 Qmax (mL/s), mean ± SD 9.1 ± 2.8 PVR (ml), mean ± SD 102.3 ± 46.1 Archivio Italiano di Urologia e Andrologia 2025; 97(3):14296 3 Laser enucleation prostate with ejaculation sparing technique matically from 103 to 6.8 mL (p < 0.01), indicating effec- tive bladder emptying (Table 2, Figures 1-3). These improvements were not only statistically significant but also clinically meaningful, with the majority of patients reaching values within the normal or near-normal range. Regarding sexual function, the IIEF-5 scores increased modestly but significantly, from 14.4 to 16.2 (p < 0.01), suggesting stability or mild improvement in erectile func- tion. Importantly, antegrade ejaculation was preserved in 94.1% of the 85 patients with available data. Figure 1. Box plot showing the distribution of International Prostate Symptom Score (IPSS) values before and 6 months after surgery. Figure 2. Box plot of post- void residual urine volume (PVR) at baseline and 6 months after surgery. PVR decreased markedly following the procedure. Table 2. Functional results of 99 patients who underwent LEST between January 2018 and June 2020 at a median follow up of 6 months. Parameter Cohort (n = 99) P value* 6 months IPSS, mean ± SD 3.8 ± 3.1 < 0.01 6 months IIEF-5, mean ± SD 16.2 ± 4.5 < 0.01 Qmax (mL/s), mean ± SD 25.7 ± 3.1 < 0.01 PVR (ml), mean ± SD 6.8 ± 10.3 < 0.01 Archivio Italiano di Urologia e Andrologia 2025; 97(3):14296 R. Leonardi, G. Mantica, F. Ambrosini, et al. 4 Responses to the 5-item decisional satisfaction question- naire demonstrated consistently high satisfaction levels. Over 80% strongly agreed that they had made the right choice and would undergo the procedure again, while nearly all denied regret or harm from the decision. Specifically, for the statement “I would make the same choice”, 78.4% strongly agreed and 20.7% agreed. For negatively framed items such as “I regret my choice” and “The choice caused me damage”, approximately 80% of patients strongly disagreed. Collectively, these findings highlight that the combination of functional efficacy and ejaculatory preservation translated into exceptionally high patient-perceived value. Although detailed perioperative morbidity data were lim- ited, the overall safety profile was favorable. No transfu- sions or re-interventions were required, and minor com- plications were rare, consistent with the expected profile of diode laser enucleation. DISCUSSION The present study demonstrates that diode laser enucle- ation using the LEST provides excellent functional out- comes while achieving great preservation of antegrade ejaculation and very high patient satisfaction. The improvement in IPSS, Qmax, and PVR observed in this series is comparable to results historically reported for HoLEP, ThuLEP, GreenLEP in medium-large prostates (20-23). For example, large multicenter HoLEP series have reported IPSS reductions of about 17-20 points and Qmax increases of 12-16 mL/s at 6-12 months (24-25). Our improvements (IPSS -18, Qmax +16.5 mL/s, PVR -95 mL) fall squarely within these ranges, supporting the effi- cacy of the LEST approach. Crucially, this suggests that sparing key anatomical structures does not compromise the deobstructive effect of the surgery. Conventional endoscopic enucleation is associated with rates of retrograde ejaculation > 70%, largely due to dis- ruption of the ejaculatory hood, bladder neck fibers, and verumontanum. 16-18 This adverse effect, although not directly harmful, may significantly reduce patient satis- faction, particularly in young men. Many strategies to mitigate this problem have been described, including “ejaculation hood sparing” TURP and modified HoLEP techniques, with high reported ejaculatory preservation rates. Some of these approaches have consistently achieved rates > 80% (26-31). In our cohort, preservation reached 94.1% among respondents, a significant result that underscores the technical validity of LEST. This out- come is particularly relevant given the relatively young mean age of our patients, highlighting the role of LEST in a population with high expectations for preserved sexual function. The importance of patient satisfaction is of mandatory importance. Increasingly, surgical success is defined not only by objective functional metrics but also by alignment with patient priorities. In our series, deci- sional satisfaction was extremely high, with most patients affirming they made the right choice and would repeat the procedure. The congruence between objective func- tional efficacy and subjective patient satisfaction strength- ens the external validity of the findings. Our results sug- gest that LEST maintains the favorable safety profile of diode laser enucleation, with very low perioperative mor- bidity and no transfusion requirement. Although compli- cation details were limited, the absence of major adverse events further supports the feasibility of the technique. In order to optimize surgical outcomes, particularly the preservation of antegrade ejaculation, it is essential for surgeons to gain a thorough understanding of the prosta- tic anatomy and the genital sphincter complex. Adequate anatomical knowledge allows precise dissection while minimizing the risk of functional compromise. To achieve this level of proficiency, structured training on synthetic models and cadaveric dissection should be undertaken Figure 3. Box plot illustrating maximum urinary flow rate (Qmax) before and after surgery. Archivio Italiano di Urologia e Andrologia 2025; 97(3):14296 5 Laser enucleation prostate with ejaculation sparing technique before performing such procedures independently on patients, thereby ensuring both safety and functional preservation (32-35). This study is not without limitations. Its retrospective design, despite prospective data collection, introduces inherent biases. The absence of a control group undergo- ing standard procedures or other ejaculation-sparing technique precludes direct comparison of ejaculation rates and functional improvements. The follow-up period of 6 months, while adequate to assess early outcomes, is relatively short; durability of the antegrade ejaculation beyond 1-2 years remains to be demonstrated. In addi- tion, questionnaire response rates were incomplete for some items, and the MSHQ-EjD was underutilized, limit- ing detailed assessment of sexual function domains. The size is based on a single surgeon, highly expert for this procedure, therefore, his results may be reproducible by every surgeon after an adequate learning curve. All advanced surgery techniques (Robot Assisted Simple Prostatectomy, LEST, etc.) require a learning curve to get the best out of the technique used. Furthermore, in some settings, the culture traditionally tied to values of mas- culinity, virility, and modesty persists. This may translate into greater difficulty in admitting sexual problems such as erectile dysfunction, reduced libido, or ejaculatory dis- orders, compared to more urbanized or culturally liberal- ized contexts. This may be one of the reasons for obtain- ing such high rates of ejaculatory preservation. Finally, the study was conducted in a single center with experi- enced surgeons, potentially limiting generalizability. Despite these limitations, our findings have clear clinical implications. LEST represents a viable surgical option for men with symptomatic BPH, especially those with large prostates who also prioritize sexual function preservation. Its near-complete preservation of ejaculation may reduce patient reluctance to undergo surgery, thus improving treatment uptake and quality of life. Future studies should aim to validate these findings in randomized con- trolled designs, with longer follow-up and broader assess- ment of sexual and psychosocial outcomes. Multicenter collaboration will be essential to confirm generalizability and to establish LEST as a standard technique within guidelines. CONCLUSIONS Diode laser enucleation with LEST combines the efficacy of complete enucleation with the advantage of consistent ejaculatory preservation. For younger men and those concerned about sexual side effects, it offers a truly patient-centered surgical solution. If validated by larger prospective trials, LEST may represent a paradigm shift in the surgical management of BPH. REFERENCES 1. MacLennan S, Azevedo N, Duncan E, et al. Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries. Eur Urol. 2023; 83:393-401. 2. Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual func- tion after radical prostatectomy for clinically localized prostate can- cer: the Prostate Cancer Outcomes Study. 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It is a retrospective analysis involving standard clinical practices, including Diode Laser Enucleation of the Prostate (DILEP) with the Leonardi Ejaculation Sparing Technique (LEST), which are part of routine care according to current clinical guidelines for the management of benign prostatic hyperplasia (BPH). For this rea- son, and considering that in our institution patients routinely pro- vide written consent for the use of their anonymized clinical data for research purposes, specific ethical committee approval was not required. Consent for publication: All patients provided informed con- sent for the surgical procedure, data collection and publication. Availability of data and material: On demand to the main author R.L. Competing interests: The authors declare that they have no competing interests. Funding: None. 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Correspondence Rosario Leonardi rosario.leonardi@unikore.it Division of Urology, School of Medicine, Kore University of Enna, Enna, Italy Guglielmo Mantica (Corresponding Author) guglielmo.mantica@gmail.com Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genoa, Largo Rosanna Benzi 10, 16132, Genoa, Italy Francesca Ambrosini f.ambrosini1@gmail.com Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genoa, Largo Rosanna Benzi 10, 16132, Genoa, Italy Antonio Tufano antonio.tufano91@gmail.com Urology Unit, San Carlo di Nancy Hospital, Roma, Italy Gabriele Iacona gabriele.iacona@grupposamed.com Casa di Cura Musumeci GECAS, Gravina di Catania (CT) Alessandro Calarco alecalarco@gmail.com Urology Unit, San Carlo di Nancy Hospital, Roma, Italy