Optimizing ejaculatory function after prostate resection: A stratified meta-analysis of anatomical preservation strategies

OBJECTIVE: To evaluate the impact of ejaculation-preserving (EP) prostate resection techniques on postoperative ejaculatory and urinary outcomes in men with benign prostatic obstruction (BPO), and to determine whether additional bladder-neck preservation provides further functional benefit compared with peri-verumontanum-only preservation. METHODS: This meta-analysis was conducted in accordance with PRISMA 2020 guidelines. A systematic search of PubMed, Cochrane Library, and ScienceDirect up to June 2025 identified randomized controlled trials comparing EP and standard prostate resection. Studies were stratified by anatomical extent of preservation: peri-verumontanum only versus peri-verumontanum with bladder-neck preservation. Data were analyzed using a random-effects model in Review Manager v5.4, and study quality was assessed using the Cochrane Risk-of-Bias 2.0 tool. RESULTS: Eight randomized controlled trials including 580 patients were analyzed. EP prostate resection improved antegrade ejaculation preservation compared with standard resection while maintaining comparable urinary and erectile outcomes. Subgroup analysis revealed no additional functional advantage from extending preservation beyond the peri-verumontanum. CONCLUSION: EP techniques are associated with improved preservation of antegrade ejaculation while maintaining comparable short term urinary outcomes. Peri-verumontanum preservation appears to provide comparable functional outcomes to approaches extending preservation up to bladder neck. However, these findings remain exploratory and require validation in future larger, methodologically robust studies.