Transurethral resection of prostate (TURP) is still considered the gold standard therapy for mid volume prostate glands (30-80 ml), as recommended by worldwide guidelines.
In the last few years, other minimally invasive tretaments have been introduced with the aim to reduce the TURP related morbidity, such as: convective water vapor energy (Rezum) and water-jet ablation (Aquablation).
The aim of this prospective randomized study is to compare the perioperative and functional outcomes between gold standard TURP and the two new minimally invasive techniques (Rezum and Aquablation).

Patients with non-neurogenic Lower Urinary Tract Symptoms (LUTS) secondary to mid volume benign prostatic obstruction (30-80 ml), non-responders to medical therapy for at least 6 months, were prospectively randomized to the three surgical approaches between January 2021 and July 2023. 
All patients were preoperatively evaluated with digital rectal examination (DRE), PSA, prostate volume was evaluated by trans abdominal ultrasound. Preoperatively, 6-, and 9-months postop all subjects were investigated with: Uroflowmetry (Qmax and Qave) with postvoid residual (PVR), International Prostatic Symptoms Score (IPSS), Male Sexual Health Questionnaire (MSHQ) and International Index of Erectile Function (IIEF-5). In all patients urodynamics was performed.
Exclusion criteria were established as: prostate volume <30 and >80 ml, previous pelvic surgery, urethral strictures, urothelial or prostatic malignancies, neurogenic LUTS, and urinary stones.
Operating time, days of hospitalization, intraoperative and postoperative bleeding, catheterization time were evaluated for each procedure.

349 patients with mean age of 63.6 years old (56-74 years) were prospectively randomized to the following treatment groups: 112 subjects underwent Rezum (group A), 118 patients Aquablation (group B), and 119 patients bipolar TURP (group C). 
Postoperative IPSS resulted lower in patients underwent TURP and AQUABEAM (2 and 2, respectively) than Rezum (5; p<0.001). Both quality of life and sexual satisfaction evaluated through post-operative MSHQ reported a higher improvement after Rezum and Aquablation than after TURP.
Postoperative IIEF5 mean scores significantly increased in groups A and B (26 and 25, respectively) than in group C (17, p<0.001). The antegrade ejaculation was spared in all Rezum and Aquablation subjects, whereas all TURP patients reported retrograde ejaculation.

Operating time, length of hospital stay and bleeding drop were longer after TURP (respectively 56.9 min, 3 days) when compared to the other two groups (2.4 min, 0.6 days; 5.2 min, 1 day, in group A and B, respectively). The mean estimated blood loss (evaluated as postoperative drop in Hb) was significantly greater in group C (∆Hb 1.2 mg/dl) than in the other two groups (∆Hb 0.1 mg/dl observed in both groups, p <.005)
Postoperative bladder catheterization time was longer after Rezum (7 days) than after TURP (5 days) and Aquablation (1 day).

At post-operative urodynamics we observed a significant increase of flowmetry parameters (Qmax and Qave) as well as the Pdet values in all subjects. Particularly, the TURP group reported mean flowmetry parameters significantly better when compared to Aquabeam and Rezum groups (mean Qmax-Qave 19.4-10.6, 17.4-9.3, and 16.9-8.7 ml/sec, respectively p<.005). The PVR was significantly reduced in all groups with a mean value of 11.8 vs. 11.9. vs. 12.1, in group A, B and C, respectively (p>0.05).

This prospective randomized study is the first to compare new minimally invasive approaches to TURP, still considered the gold standard, in the treatment of non-neurogenic LUTS secondary to BPO for mid prostate volumes 30-80 ml. Postoperative outcomes were more effective in the Aquabeam and Rezum groups in terms of sexual function and overall satisfaction, especially when evaluating the antegrade ejaculation sparing.

Continence 12S (2024) 101401
DOI: 10.1016/j.cont.2024.101401