Comprehensive efficacy of different prostate resection volumes for patients with benign prostatic hyperplasia: a systematic review and meta-analysis

Introduction

Benign prostatic hyperplasia (BPH) is a common disease worldwide and refers to the nonmalignant hyperplasia of prostate tissue. Studies have shown that patients with BPH account for nearly half of all men older than fifty years, and its prevalence could be as high as eighty percent in those older than seventy years of age (Ng, Leslie & Baradhi, 2024). Technically, the term BPH can be reserved only for histological diagnosis rather than for the description of clinical disease. Thus, other definitions, including bposit prostatic obstruction (BPO) or benign prostatic enlargement (BPE), are widely used in clinical work, especially for patients with lower urinary tract symptoms (LUTs) and bladder outlet obstruction (BOO) (Abrams et al., 2003; Gratzke et al., 2015). The urologist assesses the severity of BPH on the basis of the International Prostate Symptom Score (IPSS) and selects the appropriate treatment, such as medication and lifestyle behavior therapy (Barry et al., 2017). For patients who do not respond adequately to conservative treatment, surgery can be an effective option. Common surgical methods include traditional transurethral resection of the prostate (TURP), transurethral laser vaporization, plasma kinetic transurethral resection of the prostate (PK-TURP), or prostatic steam ablation. Among these procedures, TURP is considered the gold standard for prostate surgery and, to this day, continues to be ubiquitously employed. All these procedures can significantly alleviate LUTS in patients, especially during the voiding phase (Miernik & Gratzke, 2020; Martinelli et al., 2023). During the surgical procedure, the total prostate resection volume can be variable and is usually determined by the surgeon. The minimal TURP involves only localized tunneling resection, whereas the maximal TURP removes all glandular tissue down to the surgical capsule (Shin et al., 2023). Complications following urethral prostate surgery include bleeding, bladder neck contracture, urethral stricture, bladder perforation, and temporary difficulty urinating, which are possibly associated with the volume of prostate tissue removed during the operation (Ottaiano et al., 2022; Park et al., 2012). However, few studies have compared whether different prostate resection volumes can affect the incidence of postoperative complications in patients diagnosed with BPH. Therefore, we conducted this systematic review and meta-analysis to determine the impact of prostate resection volume on functional outcomes and complication rates in patients undergoing surgery for BPH.

Materials and Methods

Results

Literature search and study characteristics

The flowchart of the literature selection process is presented in Fig. 1. A total of 2,266 relevant primary studies in PubMed (n = 1,034), Embase (n = 157) and Web of Science (n = 1,075) were first identified through our systematic and artificial searches. A total of 166 unique studies were selected for the second screening after excluding 2,100 articles by reviewing their titles and abstracts. Finally, 16 eligible full-text randomized control trials involving 1,806 patients who underwent prostate surgery were included in this meta-analysis (Enikeev et al., 2020; Geavlete et al., 2015; Sun et al., 2019; Liu et al., 2006; Kuntz & Lehrich, 2002; Zhu et al., 2013; Xie et al., 2014; Helke et al., 2001; Zhao et al., 2010; Sun et al., 2014; Naspro et al., 2006; Ou et al., 2010; Mavuduru et al., 2009; Mattiasson et al., 2007; Jahnson et al., 1998; Dahlstrand et al., 1995). If studies involved more than two types of prostatic surgery, we conducted comparisons between every two types of surgery independently by repeating the inclusion of the same study. In addition, the mean prostate volume for each group was estimated based on baseline and postoperative prostate data, and subgroup analyses were also conducted according to the difference in average prostate volume between the two groups. In this study, the group with the larger resection volume was designated as the control group. Most of the involved studies were evaluated as medium or high-quality studies according to our assessment. The baseline characteristics of the included studies were shown in Table 1. In addition, the results of forest plot and funnel plot were also documented in Figs. S1 and S2.

Discussion

At present, although minimally invasive therapies are on the rise, TURP is still the most widely used surgery for treating BPH, and it is considered the gold standard for the treatment of LUTS (Sciacqua et al., 2023; Akpayak et al., 2017). Most TURP aims at debulking the prostate to produce an adequate channel for urine to flow by reducing the volume of the middle or lateral lobes of the prostate. However, owing to differences in the cognition and habits of surgeons, the proportion of actual resected prostate tissue produced by different surgeries or the same surgery could vary in clinical practice. Although various devices can be used for TURP, including electrocautery loops, lasers, and steam, it is believed that there are no uniform limits for the size and shape of these prostate resections (Leslie, Chargui & Stormont, 2024). Several minimally invasive procedures, including water vapor thermal infusion or microwave thermotherapy, induce localized destruction of prostate tissue and can ultimately reduce the prostate volume by approximately 30% (Mynderse et al., 2015; Franco et al., 2022).

Our study focused on the following three important indicators of prostatectomy: urinary, perioperative and complication outcomes. The urination-related outcomes are divided into several subgroups, including IPSS, QoL, Qmax and PVR. The IPSS is an effective and widely used tool for evaluating patients’ self-reported symptoms, as recommended by the American Urological Association. According to our research, in the subgroup analysis of different proportions of resected prostates, patients with more reserved tissue had a higher IPSS, which indicates a lower level of LUT alleviation. A study involving 667 participants reported a positive correlation between the IPSS and urethral resistance (Huang Foen Chung & Van Mastrigt, 2005). The larger the volume of prostate resection is, the greater the reduction in urethral resistance, leading to a decrease in the patient’s IPSS score. Furthermore, we found that among patients with a prostate resection volume difference greater than 50%, those with less preserved prostate tissue generally had a higher QoL; for patients with a difference of less than 50%, the impact of prostate resection on QoL remains a subject of debate. Specifically, although our study could not establish a significant correlation between resected prostate volume and QOL, the original studies to varying degrees indicate the definite advantage of prostate surgery over conservative treatment in improving patients’ quality of life (Geavlete et al., 2015; Sun et al., 2019; Liu et al., 2006; Zhu et al., 2013; Xie et al., 2014). A previous study demonstrated that other voiding parameters, including the Qmax and PVR, are also common tools used to evaluate postoperative voiding functions and have statistically significant relationships with IPSS (Kohler & Kausik, 2023). We found that when the difference in prostate volume resected exceeded 10%, patients with a larger resected volume had a greater Qmax than did those with a smaller volume, and the results were statistically significant. Conversely, when the difference in resected prostate volume ranged between 10% and 40%, the residual urine volume decreased as the resected volume increased. However, owing to the limited number of original studies, no significant difference in PVR was observed between patient groups with a resected prostate volume difference greater than 50% (Geavlete et al., 2015).

The catheterization time for patients who undergo transurethral resection or ablation is generally within 7 days, with the optimal time typically considered to be the third postoperative day. For patients who experience difficulty urinating after catheter removal and undergo recatheterization, the appropriate timing for subsequent removal of the catheter is four days later (Skolarus et al., 2019). Our results indicated that there was no significant correlation between catheterization time and the volume of prostate resection among the majority of patients. However, for the 30%–40% group, patients with more resected prostate tissue had longer catheterization times. The possible reason for this was that the original studies involving this group compared transvesical prostatectomy, which is associated with greater trauma and blood loss (Ou et al., 2010). Similarly, patients with a greater proportion of resected prostate tissue also had a longer irrigation time and hospital stay.

Our review also consolidated and analyzed the multiple types of complications reported in the included studies as much as possible. The most common complication of BPH surgery is bleeding, which mostly occurs during the operation procedure and the early postoperative period. Severe bleeding is more likely to occur in traumatic prostate surgeries, such as traditional open surgery and transurethral prostate resection. According to previous studies, the transfusion rate of monopolar TURP has historically reached approximately 0.4%–20% (Teo, Lee & Ho, 2017). However, with advancements in surgical techniques and equipment, the rate of blood transfusion has significantly decreased in contemporary practice, which is similar to our findings. For patients on anticoagulant medication, the risk of bleeding and blood transfusion are increased, and appropriate multidisciplinary consultations are necessary during the perioperative period (Heiman, Large & Krambeck, 2018; Romero-Otero et al., 2019). In addition, the other positive complication was retrograde ejaculation. Our research revealed that when the removed prostate volume was less than 30%, patients with more reserved prostate fluid had a higher incidence of etrograde ejaculation, with significant heterogeneity. It is generally believed that retrograde ejaculation is caused by damage to the bladder neck and sympathetic nerves during prostate surgery (Meng et al., 2007; Shoshany et al., 2017). Research has demonstrated that preserving the verumontanum and one centimeter of proximal tissue and mucosa during prostatectomy and preserving the bladder neck can significantly reduce the incidence of retrograde ejaculation (Alloussi et al., 2014; Abolazm et al., 2020; Yang et al., 2023). In general, our study revealed that there was no significant relationship between the overall incidence of complications and the volume of prostate resection. Complications of the procedure might be related to age, comorbidities, preoperative duration and multiple factors. Furthermore, the perioperative prostate volume and prolonged catheterization could also result in an increased rate of complications (Geremew, Gelaw & Beyene, 2022). Additionally, the duration of the operation is another important factor influencing postoperative complications. Studies have shown that a long duration promotes the rate of capsular perforation and transfusion and results in prolonged catheterization time (Tascıet al., 2011; Rassweiler et al., 2006; Mandal et al., 2013).

In addition, for a comprehensive evaluation of BPH surgical outcomes, retreatment rates for BPH procedures should not be overlooked. In general, it is reported that proportion of 1-year retreatment and 1-year complications by procedure (including TURP, photoselective vaporization of the prostate (PVP) and water vapor thermal therapy (WVTT)) is similar. However, traditional TURP has the lowest rate of 5-year treatment among cohorts of diverse surgical pethods. Otherwise, the same literature has revealed that patients accepted TURP and PVP had a higher risk of undergoing the same surgical retreatment within postoperative 30 days (Kaplan et al., 2024). Another research based on real-world data from medicare Australia reported a similar outcome for the high rate of revision surgery after TURP and PVP, but no significant difference was observed between these two groups (Jain et al., 2023).

Another aspect that warrants attention is the preservation of patients’ sexual function. Traditional prostate surgery often adversely affects sexual function, particularly ejaculatory performance of patients. Previous study has reported that the vast majority of men undergoing prostatectomy experience permanent retrograde ejaculation (Koren & Koren, 2020). Therefore, minimally invasive surgical therapies (MISTs) of prostate are continually being explored to minimize the incidence of retrograde ejaculation. The Leonardi Ejaculation Sparing Technique (LEST) is a prostate adenoma debulking technique that can be performed using either simple vaporization or enucleation for larger prostates, which can achieve postoperative antegrade ejaculation by preserving the course and openings of the ejaculatory ducts within the prostate and minimizing injury to the genital sphincter (Leonardi et al., 2025). Other MISTs, including Rezūm and i-Tind (Temporary implantable nitinol device), which aims to reshape the prostatic urethra and alleviate LUTS while preserving sexual function with favorable outcomes, have garnered significant attention in recent years (Busetto et al., 2025; Dimitri et al., 2025). Otherwise, several South Korean scholars compared the transurethral and transvesical robot-assisted simple prostatectomy, detected that the newly introduced urethral-sparing prostatectomy had clearly advantages on rapid symptom improvements and preserved antegrade ejaculation (Shin et al., 2025). However, while minimally invasive techniques continue to evolve, their widespread adoption is constrained by multifactorial barriers including socioeconomic disparities and surgical learning curves. Consequently, traditional prostatectomy remains a cornerstone approach in global practice, underscoring the imperative for rigorously designed prospective trials to evaluate integrated efficacy endpoints.

Our study is the first to explore the relationship between resected prostate volume and comprehensive postoperative efficacy, especially with respect to urinary and complication outcomes. In addition, subgroup analyses were also performed on the basis of the follow-up time and various resected prostate volumes, with the aim of exploring the long-term effects of prostate surgery. However, we must acknowledge that there are several limitations to our study. First, a part of the proportion of the resected volume was estimated roughly, which may have influenced the complication outcomes. Second, owing to the limited number of primary studies, several outcomes, including the incidence of bladder tamponade, capsular perforation or impotence, could not be analyzed. Furthermore, all RCTs explore the efficacy of two or more different surgery types. There are few clinical trials comparing the postoperative outcomes between the same surgery option and different resected prostate volumes, which may introduce bias into our results. Moreover, some outcomes in our analysis had significant noneliminated heterogeneity and publication bias, leading to inaccurate conclusions that can misguide clinical practice of BPH therapies. Thus, although our analysis revealed several meaningful outcomes, more primary studies, especially those involving the same type of surgery for BPH, are still needed in the future.

Conclusions

In summary, our study revealed that, compared with patients who had a smaller resected prostate volume, patients with more resected prostate tissue were more likely to have a lower IPSS, a lower PVR, a higher QoL and Qmax, and a decreased risk of bladder neck construction. However, patients with less resected prostate volume had advantages in terms of decreasing catheterization time, hospital stay, irrigation time, and the rates of blood transfusion and retrograde ejaculation. Moreover, the resected prostate volume was not correlated with the incidence of other complications. Given the limitations existing in our study, more primary studies are still needed in the future.

Supplemental Information