Minimally invasive treatments for benign prostatic obstruction: a systematic review and network meta-analysis of randomized controlled trials at 12 months.

PURPOSE: This network meta-analysis evaluates efficacy outcomes of established and emerging techniques to inform evidence-based clinical decision-making. MATERIALS AND METHODS: PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials comparing minimally invasive treatments for benign prostatic hyperplasia. Primary outcomes encompassed urinary function, sexual function, safety, and durability. Network meta-analysis was conducted using MetaInsight. RESULTS: Among 36 randomized controlled trials and 4851 patients, no individual intervention significantly outperformed bTURP in either symptom control, peak urinary flow, hospital stay, complications, or medical retreatment at 12 months. PUL was the only technique significantly inferior to bTURP in bladder emptying (PVR: MD 67.47 mL; 95% CrI 11.02-125.79), yet demonstrated superior ejaculatory function preservation over mTURP/bTURP (MSHQ-EjD: MD 4.99; 95% CrI 1.32-8.64) without differences in ejaculatory bother. HoLEP showed significantly lower surgical retreatment rates versus bTURP and mTURP, and HoLEP and ThuLEP demonstrated shorter catheterization times versus bTURP (MD -36.26 h and -26.89 h, respectively). When grouped by category, stent/implant devices were significantly inferior to enucleation, ablation, and resection in urinary outcomes, yet demonstrated superior ejaculatory function preservation versus resection (MSHQ-EjD: MD 5.01; 95% CrI 1.33-8.65) without differences in ejaculatory bother. Enucleation was the only category with significantly reduced surgical retreatment versus sham. CONCLUSIONS: No intervention surpassed bTURP in urinary efficacy. HoLEP demonstrated superior durability, while stent/implant approaches and PUL showed inferior urinary outcomes. Preservation of ejaculatory function with stent/implant techniques did not translate into reduced patient-reported bother.