Ejaculation-sparing endoscopic surgery for benign prostatic hyperplasia: a systematic review and meta-analysis of randomized controlled trials

Background Ejaculatory dysfunction represents a major drawback of conventional endoscopic surgery for benign prostatic hyperplasia (BPH), substantially affecting postoperative quality of life. Ejaculation-sparing (ES) endoscopic techniques have been developed to preserve ejaculatory function while maintaining effective relief of lower urinary tract symptoms (LUTS). Methods A systematic review and meta-analysis of randomized controlled trials was conducted in accordance with the PRISMA 2020 guidelines. Adult men undergoing ES endoscopic prostate surgery were compared with those treated using standard endoscopic techniques. Primary outcomes included preservation of antegrade ejaculation, Male Sexual Health Questionnaire–Ejaculatory Dysfunction (MSHQ-EjD) scores, and semen volume. Secondary outcomes comprised erectile function, urinary flow parameters, symptom scores, operative time, and postoperative complications. Results Eight randomized trials, including 562 patients, were analyzed. ES techniques were associated with a substantially higher likelihood of preserving antegrade ejaculation compared with conventional surgery (OR 15.11, 95% CI 8.96–25.46, p < 0.0001). Ejaculatory-specific outcomes significantly favored ES surgery, with higher postoperative MSHQ-EjD scores and greater semen volume. Erectile function was preserved, with comparable International Index of Erectile Function–15 scores between groups and slightly higher IIEF-5 scores in the ES cohort. Conventional techniques demonstrated higher maximum urinary flow rates at 3 months. However, this advantage was not sustained at 6 months. Symptom scores were comparable early after surgery, but ES techniques favored them at mid-term follow-up. Operative time was shorter with ES approaches, while rates of minor and major postoperative complications were similar between groups. Conclusions Ejaculation-sparing endoscopic surgery for BPH offers a marked improvement in ejaculatory outcomes without compromising erectile function, mid-term urinary efficacy, or perioperative safety, supporting its use in appropriately selected patients prioritizing sexual function.