Preserving erectile and ejaculatory function in patients undergoing minimally invasive techniques: the first randomized clinical trial comparing convective water vapor ablation and transperineal laser ablation

Background: Benign prostatic hyperplasia (BPH) significantly impacts patients' quality of life, both from a urinary and sexual perspective. Surgical techniques for the treatment of BPH, such as transurethral resection of the prostate and laser enucleation techniques, are associated with postoperative sexual and ejaculatory dysfunctions. For these reasons, there has been growing interest in minimally invasive techniques (MISTs), which aim to improve urinary symptoms while preserving erectile and ejaculatory function. Aim: With this randomized trial (RCT), our aim is to analyze the impact of transperineal laser ablation (TPLA) and convective water vapor ablation (CWVA) on erectile and ejaculatory function of patients undergoing these MISTs and to compare the two techniques to assess any potential differences between them. Methods: This RCT included 80 patients 1:1 randomized to TPLA and CWVA between January and July 2024 based on their International Prostate Symptoms Score. Inclusion criteria included prostate volume > 30 ml, age > 50 years, IPSS>7, PSA < 4 ng/ml, and maximum flow rate < 15 ml/s with post-void residual>50 ml. Categorical variables were compared using the χ2 test with Yates' correction or Fisher's exact test. A General Linear Model for repeated measures was used to evaluate within- and between-group differences over time. Outcomes: The Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) and International Index of Erectile Function 5 (IIEF5) were collected 3- and 6-months after treatment. Results: Among 61 sexually active patients (31 CWVA, 30 TPLA), baseline characteristics were comparable, except for a larger prostate volume in the TPLA group (P < 0.001). IIEF-5 scores remained stable at 6 months, with no significant differences between groups [19 (9-24) TPLA vs. 16.5 (1.75-20) CWVA, P = 0.11]. A transient decline at 3 months in the TPLA group resolved by 6 months. At 6 months, MSHQ-EjD scores improved significantly in both groups (+51% TPLA, +33.3% CWVA, P < 0.0001). The MSHQ-EjD Bother domain also showed significant improvement (P < 0.0001). All patients, except one, were same day discharged and were free from prostate medications at the last evaluation. Clinical implications: The results indicate that both TPLA and CWVA effectively preserve patients' sexual function. Strengths and limitations: Although this is the first randomized study comparing these MISTs, the exclusion of sexually inactive patients from the analysis reduced the sample size. Furthermore, the findings are limited to short-term outcomes. Conclusions: Both techniques effectively preserve erectile function and improve MSHQ-EjD scores.