Introduction: In the last years minimally invasive endoscopic approaches have been proposed and introduced with the aim to reduce the morbidity related to TURP, such as: convective water vapor energy (Rezum) and heat free water-jet ablation (Aquablation).The aim of this prospective randomized study is to compare the perioperative and functional outcomes between gold standard surgery (TransUrethral Resection of Prostate, TURP) and these two new minimally invasive approaches (Rezum and Aquablation). Methods: Patients with benign prostatic obstruction were prospectively enrolled and randomized for the three surgical approaches between January 2021 and September 2022. All patients were preoperatively evaluated with digital rectal examination, PSA value and abdominal ultrasound for prostate volume measurement. Preoperatively and 6 months after surgery, patients were studied as follows: 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). All patients were also investigated by urodynamics. Operating time, days of hospital stay, intraoperative and postoperative bleeding, postoperative catheterization time were evaluated for each procedure. Results: 252 patients with mean age of 64.6 years old were included in the study. Patients were prospectively randomized to the following treatment groups: 61 subjects underwent Rezum (group A), 92 patients Aquablation (group B), and 99 patients bipolar TURP (group C). Postoperative IPSS resulted lower in patients underwent TURP and AQUABEAM than Rezum (p < 0.001). Postoperative IIEF5 mean scores significantly increased in groups A and B (25 and 24, respectively) than in group C (18, p<0.001). The antegrade ejaculation was spared in all Rezum and Aquablation subjects, whereas all TURP patients reported retrograde ejaculation. The TURP group reported mean flowmetry parameters significantly better when compared to Aquabeam and Rezum groups ( p<.005). Operating time and length of hospital stay were longer after TURP (respectively 75 min, 3 days) when compared to the other two groups (8 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 higher in group C (DHb 1.2 mg/dl) than in the other two groups (DHb 0.1 mg/dl observed in both groups, p <.005). Conclusions: This prospective randomized study is the first to compare new endoscopic approaches to gold standard surgery in the treatment of non-neurogenic LUTS secondary to BPH for prostate volumes 30-80 ml. Our results condrm that Rezum and Aquablation are safe and effective. Postoperative outcomes are better in new approaches in terms of sexual function and overall satisfaction, especially related to the preservation of the antegrade ejaculation. SOURCE OF Funding: None
