The surgical management of benign prostatic hyperplasia (BPH) has developed over time, and endoscopic enucleation of the prostate (EEP) has emerged as a potential competitor to the long-standing gold standard, transurethral resection of the prostate (TURP) [1]. First intended to replace open prostatectomy, EEP is performed using different energy sources and aims to remove the entire prostate adenoma [1, 2]. This meta-analysis by Vo et al. [3] provides a timely comparison of EEP and TURP by synthesizing data from 28 randomized controlled trials (RCTs) to evaluate efficacy, safety, and long-term outcomes. Their work aims to answer a relevant clinical question: whether EEP, independent of which energy source, offers durable advantages over TURP.

This meta-analysis was conducted following a solid study design. The authors have prospectively registered their protocol (PROSPERO: CRD42024514177), followed the PRISMA guidelines, and used the Cochrane Risk of Bias 2 (RoB 2) tool to assess the risk of every identified trial. There was no upper or lower limit placed on prostate size in the inclusion criteria, ensuring the findings of the study can draw size-independent conclusions. Moreover, the analysis was based on a wide set of outcomes (e.g., maximum urinary flow rate (Qmax), post-void residual (PVR) volumes, length of hospital stay, International Prostate Symptom Score (IPSS), the International Index of Erectile Function 5 (IIEF-5) and quality of life (QoL)).

The meta-analysis shows EEP is better than TURP in most outcome measures, although overall superiority is partially established. Regarding patient-reported outcomes, IPSS improvements were modest, and only reached statistical significance at the 12-month follow-up. Sexual function, as measured by IIEF-5 scores, was generally better with EEP, however, the differences were not statistically significant at any time point. QoL assessments initially favored TURP at 6 months, but at 36 months, EEP demonstrated statistically significant benefits.

Objective parameters illustrated EEP benefits. Qmax and PVR volumes were better with EEP, and the improvements were statistically significant at several postoperative times. Moreover, EEP reduced the hospital stay by 0.92 days, catheterization time by 1.12 days and rate of blood transfusion by 78%.

Rates of infection and bladder neck contracture were lower in the EEP group, while post-operative incontinence risk was slightly higher (RR = 1.18) compared to TURP, but these differences were not statistically significant. Moreover, stricture rates were lower with the EEP group in the medium-term follow-up (6–24 months) and the reoperation rate due to BPH regrowth was also lower (RR = 0.32), indicating that patients treated with EEP had 68% less risk of requiring reoperation for their BPH symptoms compared to TURP.

Nevertheless, some limitations deserve mention. For example, not all studies reported outcomes consistently; for instance, IIEF-5 scores, infection rates, bladder neck contracture, and reoperation rates were derived from 3, 7, 8, and 5 studies, respectively. Therefore, these results may not be a generalization of the effectiveness of all EEP procedures but rather the effectiveness of particular techniques used in those studies.

Moreover, most studies had either a high risk of bias or some concerns. In fact, 14 studies were classified as high-risk, 13 had some concerns, and only one was considered low-risk. The potential bias was likely compounded by the lack of blinding and high dropout rates. Finally, the lack of subgroup analysis according to prostate size, surgeon’s experience or enucleation technique (multi-lobar versus en bloc) limits the understanding of which patients or practices might benefit most from EEP.

The shift from TURP to EEP represents a major step forward in the surgical treatment of BPH. Perhaps one of the most important aspects is that EEP decreases the length of stay by almost one day, a benefit that has many advantages. For patients, it reduces their exposure to nosocomial infections, it limits interference with their lives, and it also minimizes the indirect costs such as wages lost [4]. Regarding healthcare systems, improved bed turnover is an essential advantage in settings with limited capacity [4].

A significant advantage of EEP is its durability. This durability is highlighted by the meta-analysis finding a 68% reduction in reoperation rates (RR = 0.32) compared to TURP, suggesting potential long-term decreased patient morbidity. However, as this outcome is based on data from only five studies, long-term follow-up (more than three years) in future studies would be valuable to confirm these trends.

Despite its advantages, the widespread adoption of EEP is limited by two main aspects: its learning curve and potential for post-operative incontinence. The meta-analysis indicates that EEP may be associated with a higher risk of incontinence than TURP (RR = 1.18). Although not statistically significant, it raises an interesting point for patients’ QoL. Postoperative incontinence is an important consideration following EEP, but is typically temporary, with most cases resolving within 1 to 6 months [5, 6]. This highlights the need for continued refinement in surgical techniques to mitigate early complications and emphasizes the importance of patients’ counseling and education regarding this matter.

Additionally, data shows that learning EEP requires three to five times as many cases as TURP, with proficiency generally achieved after 30 to 50 cases compared to around 10 cases for TURP [7, 8]. This highlights the importance of simulation and fellowship training programs to help the optimal acquisition of skills and minimize patient complications, especially during the initial stages of adopting EEP.

In conclusion, this meta-analysis by Vo et al. strengthens the evidence for EEP as a first-line surgical option for BPH. We congratulate the authors for their excellent work. Their rigorous synthesis of 28 RCTs is a significant step in understanding the possible advantages of EEP over TURP and lays a foundation for future research. Standardized reporting of outcomes in future RCTs, long-term data comparison and enhanced training programs will be essential to support the broader adoption of EEP.