Minimally invasive treatments for benign prostatic hyperplasia: A narrative review

Benign prostatic hyperplasia-related lower urinary tract symptoms are highly prevalent in middle-aged and older men. Compared to traditional transurethral resection of the prostate (TURP), minimally invasive surgical therapies (MISTs) aim to provide meaningful symptom relief. This review evaluated the efficacy, safety, and procedural characteristics of 5 representative MISTs: water vapor thermal therapy (WVTT), prostatic urethral lift (PUL), prostatic artery embolization (PAE), temporary implantable nitinol device (iTIND), and Aquablation. A systematic literature search was conducted in PubMed (2018-2023), supplemented by backward citation tracking. Clinical studies reporting International prostate symptom score (IPSS), quality of life (QoL), and/or maximum flow rate (Qmax) were included, with higher-level evidence prioritized. Long-term data show that WVTT and PUL provide durable symptom improvement, achieving 48% IPSS reduction and 35% IPSS improvement, respectively, at 5 years. Aquablation has a lower rate of retrograde ejaculation than TURP. Importantly, no new sexual dysfunction has been reported after WVTT or PUL. The long-term retrograde ejaculation rate with iTIND is 4%. Most MISTs can be performed in an outpatient setting under local anesthesia. For prostates >80 cm3, PAE achieved >44% volume reduction. In summary, MISTs offer personalized treatment options for benign prostatic hyperplasia, though evidence strength varies. Aquablation has the strongest evidence for larger prostates, while WVTT and PUL are guideline-recommended for medium-sized glands. PAE is suitable for older/high-risk patients, and iTIND shows promise but requires more long-term data. Future research should focus on comparative trials to optimize patient selection.