“Z” Anatomical Needle Cut Leads Ejaculation (ZANCLE): Unilateral Incision for Primary Bladder Neck Obstruction with Ejaculation-Sparing Intent—An Extended Single-Surgeon Series with 24-Month Follow-Up

Objective: Long-term data on ejaculation-sparing transurethral surgery for primary bladder neck obstruction (PBNO) in young men remain limited. We report the extended outcomes of the ZANCLE technique—a monopolar or bipolar unilateral “Z”-shaped transurethral incision of the prostate and bladder neck (TUIP) designed to relieve obstruction while anatomically preserving the ejaculatory pathway—in the largest single-surgeon cohort published to date, with follow-up extended to 24 months. Materials and Methods: We retrospectively analyzed prospectively collected data from 186 consecutive patients who underwent the ZANCLE procedure at a single institution between December 2018 and September 2025. Eligibility required prostate volume < 30 mL and failure of alpha-blocker therapy. Voiding parameters—Qmax, post-void residual (PVR), IPSS, and IPSS-QoL—were recorded at baseline and at 1, 6, 12, and 24 months postoperatively. Ejaculatory function was evaluated at each follow-up visit. Results: Median patient age was 43 years (IQR 37–58); median prostate volume was 27 mL (IQR 20–29). Mean Qmax improved from 10.2 ± 2.5 mL/s preoperatively to 22.8 ± 3.9 mL/s at 1 month and remained at 19.8 ± 4.2 mL/s at 24 months (p < 0.001). IPSS fell from 16 ± 2.7 to 6.9 ± 1.5 at 1 month and 6.5 ± 1.6 at 24 months; IPSS-QoL from 4.3 ± 0.9 to 1.9 ± 1.6 and 1.6 ± 1.2, respectively (all p < 0.001). Mean PVR decreased from 125.5 ± 16.1 mL to 31.2 ± 8.9 mL at 24 months (p < 0.001). Anterograde ejaculation was maintained in all 186 patients (100%) at every postoperative timepoint. Minor complications (Clavien 1–2) occurred in 5 patients (2.7%); no major adverse events were recorded. Conclusions: The ZANCLE technique achieves sustained improvements in voiding function and quality of life over 24 months, with a 100% ejaculation preservation rate and an excellent safety profile. These findings support the ZANCLE technique as a clinically promising surgical option for selected young men with PBNO refractory to medical therapy, pending comparative evidence; functional outcomes were numerically consistent with those reported for laser-based approaches, without the associated cost burden, although direct comparison was not possible in this non-comparative design.