The median lobe scenario. How to tackle this challenge best: systematic review and expert guidance

To explore the best endoscopic management for men with benign prostatic hyperplasia (BPH) and an enlarged median lobe.

A systematic search was conducted in accordance with the Joanna Briggs Institute (JBI) methodology and aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched MEDLINE, Embase, Web of Science, and CENTRAL from 2010 to February 2025. Eligible studies included patients with BPH and an enlarged median lobe treated endoscopically. Perioperative data and patients' outcomes were summarized descriptively.

From the 613 initially identified studies, 17 were included. Procedures evaluated included holmium laser enucleation of the prostate (HoLEP, n = 6), Rezūm (n = 4), GreenLight photovaporization (n = 2), Aquablation (n = 2), UroLift (n = 2) and transurethral resection of the prostate (TURP, n = 1). Studies either selectively treated the median lobe (ML-HoLEP and ML-TURP) or targeted the entire gland, including the median lobe (PVP, Aquablation, Rezūm, UroLift). Overall, all modalities provided significant improvements in urinary symptoms in patients with an enlarged median lobe. ML-HoLEP and ML-TURP demonstrated ejaculatory and continence outcomes comparable to minimally invasive approaches. Postoperative outcomes were reported inconsistently: only four studies provided a complete set of functional and sexual outcomes, and definitions of "median lobe" varied widely. Optilume or iTind procedures consistently excluded patients with significant median lobes. Heterogeneous definitions and incomplete reporting prevented quantitative analysis and definitive comparisons across modalities for this BPH sub-group.

The procedures reviewed demonstrated favorable functional outcomes for men with an enlarged median lobe and can therefore be considered, while Optilume and iTIND should not be offered. Patients must be counselled about procedure-specific adverse events and the likelihood of surgical or medical retreatment. To guide future research and clinical practice, we present an expert guidance recommending standardized median-lobe definitions and a minimum outcome set.