Modern Surgical Techniques for the Treatment of Benign Prostatic Hyperplasia: A Systematic Review

Aims: To systematically review randomized evidence on modern minimally invasive and endoscopic techniques for treating lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), focusing on clinical efficacy, safety, perioperative outcomes, preservation of sexual/ejaculatory function, and durability compared with TURP or sham. Methods: We conducted a systematic PubMed search (2020–2025) using predefined terms for BPH surgery and randomized controlled trials. Main findings from eligible articles were summarized. Results: The review identified 41 randomized controlled trials evaluating nine modern techniques (endoscopic enucleation, laser vaporization, Aquablation, Rezūm water vapor thermal therapy, prostatic urethral lift/PUL, transperineal laser ablation/TPLA, temporary nitinol device/iTind, drug-coated balloon/Optilume, and prostatic artery embolisation/PAE), comprising thousands of men with moderate-to-severe LUTS. Endoscopic enucleation and Aquablation showed durable, TURP-like or superior improvements in IPSS, QoL, Qmax, and PVR, particularly in large prostates (>80 mL), with better perioperative outcomes. Minimally invasive surgical therapies (MISTs) provided meaningful symptom relief and excellent preservation of sexual/ejaculatory function, while PAE had lower objective efficacy and higher reintervention rates. Serious complications were uncommon across all techniques. Conclusions: Current evidence supports these modern techniques as valuable alternatives to TURP, enabling individualized treatment based on prostate volume and patient priorities for sexual function, recovery, and durability. However, heterogeneity in follow-up duration, variable prostate-size criteria, and the limited number of large head-to-head trials restrict definitive conclusions. Further adequately powered, long-term randomized studies are needed to better define the optimal role of each modality in clinical practice.