While less than a third of men in the general population have coexisting lower urinary tract symptoms (LUTS) and erectile dysfunction (ED), as many as 70% of men seeking treatment for LUTS have some degree of ED.¹ The strong relationship between LUTS and ED necessitates careful preoperative counseling regarding sexual side effects of benign prostatic hyperplasia (BPH) treatments, particularly in men with preexisting ED. More than 90% of men who are contemplating or have undergone BPH surgery consider maintaining their erectile and ejaculatory function to be important.²

Prior to 2013 surgical treatment options that preserved ejaculation were limited, forcing patients to choose the risk of sexual dysfunction vs improvement in LUTS. This discussion will be limited to surgical treatments supported by AUA Guidelines on the Surgical Management of BPH/LUTS, which endorse prostatic urethral lift (PUL) and water vapor thermal therapy as options that may be offered to patients who desire preservation of erectile and ejaculatory function.³ Aquablation, while not explicitly endorsed by AUA Guidelines as an option for preservation of ejaculation, also carries a lower risk of ejaculatory dysfunction compared to traditional transurethral resection of prostate (TURP).

Approved by the U.S. Food and Drug Administration in 2013, PUL (UroLift®) is a tissue-sparing approach that utilizes a transurethral implant placed under cystoscopic guidance to retract obstructing lobes of the prostate. AUA Guidelines endorse PUL for glands between 30 g and 80 g in men without a median lobe. Of the 206 patients randomized to PUL (140) vs sham (66) International Prostate Symptom Score (IPSS) improved from 22.32 to 14.37, while International Index of Erectile Function (IIEF-5) initially improved at 3, 6 and 24 months, this was no longer statistically significant at 36 to 60 months. Similarly, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) improved by 2.30 initially and trended toward 0 over time until it was no longer statistically significant at 60 months.⁴ Statistically significant improvements in MSHQ-EjD bother were maintained at all time points, for a final 6.3% improvement at 60 months. Though not endorsed by AUA Guidelines for median lobes, in 2019 Rukstalis et al published their 12-month results of a nonrandomized PUL trial in subjects with an obstructive median lobe, demonstrating similar results compared to patients who underwent PUL with no median lobe.⁵ No new onset cases of erectile or ejaculatory dysfunction were observed. Due to the nonrandomized nature of this study, it has not garnered a recommendation from the AUA Guidelines for use in median lobes.

Water vapor thermal therapy (Rezüm™ System) was approved in 2015 as a minimally invasive surgical therapy that uses convective radiofrequency thermal therapy to ablate prostatic tissue. It is endorsed by the AUA Guidelines for glands between 30 g and 80 g, including men with a median lobe (figs. 1 and 2). Recently published 5-year data from a randomized trial (135 patients) vs sham control trial (61 controls) demonstrated an improvement in IPSS from 21.5 to 11.1 at 5 years.⁶ At 12 months 4.4% of patients reported decrease in ejaculatory volume, while 2.9% reported anejaculation. No changes in MSHQ-EjD function were noted during the first 24 months, after which a statistically significant decline occurred at 36, 48 and 60 months. Of the 51 patients included in the analysis at 60 months, the MSHQ-EjD function domain declined 2.0±3.9 (17.5%) from baseline, which the authors asserted is consistent with the aging of the treated cohort. Statistically significant improvements in MSHQ-EjD bother initially noted at 12, 24 and 36 months were no longer significant at 48 and 60 months. No reports of de novo device or procedure-related ED were observed.

Figure 1. Obstructing median lobe on cystoscopy performed prior to water vapor thermal therapy.

Figure 2. View of bladder neck for same patient seen in figure 1 after water vapor thermal therapy.

The newest addition to the minimally invasive surgical treatments is aquablation (AquaBeam®). Aquablation utilizes ultrasound and robotics to ablate prostatic tissue with a heat-free, high-pressured saline jet. It is also endorsed by AUA Guidelines for glands between 30 g to 80 g. Data from a prospective double-blind randomized trial comparing TURP (67) and Aquablation (117) in glands less than 80 g demonstrated an improvement in IPSS from 22.9 to 8.5 in the Aquablation group vs 22.2 to 13.9 in the TURP group at 3 years (p=0.6848).⁷ No changes in MSHQ-EjD were noted in the aquablation group at all time points, while those in the TURP group averaged 2.8 points lower than baseline (p=0.0008). MSHQ-EjD bother score averaged 0.6 points higher in the TURP group (p=0.0411) at all time points, and no statistically significant changes in IIEF-15 were present in either group. Risk of anejaculation was 11% in the Aquablation group vs 29% in the TURP group (p=0.0039). A followup trial of 101 men with glands 80 g to 150 g demonstrated an improvement in IPSS from 23.2 to 5.8 at 2 years (p <0.0001). In this cohort of larger glands, the rate of ejaculatory dysfunction was 17% and risk of new onset erectile dysfunction was 1%.⁸

Unilateral transurethral incision of prostate (TUIP) has also historically been used to preserve ejaculation. AUA Guidelines advise TUIP is an option to treat glands less than 30 g, but do not specifically endorse TUIP as a method to preserve ejaculation. A meta-analysis of TUIP vs TURP demonstrates a lower risk of retrograde ejaculation, 18.2% for TUIP vs 65.4% for TURP, albeit far from neglibile.⁹ Prostate artery embolization may also pose a lower risk of ejaculatory dysfunction compared to TURP, but this treatment modality is not currently recommended outside of a clinical trial as high-quality randomized control trials are limited. Additional areas of interest with trials currently underway include intraprostatic injections, as well as intraprostatic stents and devices.¹⁰

Preservation of erectile and ejaculatory function is important to patients and should be at the forefront of any discussion regarding BPH surgery. Water vapor thermal therapy and PUL carry the lowest risk of ejaculatory dysfunction for patients with glands 30 g to 80 g (see table). For men with glands greater than 80 g, aquablation may be an alternative to reduce the risk of ejaculatory dysfunction compared to TURP, photovaporization of prostate, transurethral microwave therapy, laser enucleation and simple prostatectomy. The role of prostate artery embolization in this arsenal of tools remains to be determined.