{"paper_id":"258c00ee-2f9a-448b-a0fd-2bc8d0fce22c","body_text":"Prostatic surgery with preservation of the supramonticular tissue versus standard surgery in benign prostatic hyperplasia: a systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prostatic surgery with preservation of the supramonticular tissue versus standard surgery in benign prostatic hyperplasia: a systematic review Giuston Mendoza Chuctaya, Kevin Rodrigo Ramos, Lucely Aycachi Centeno, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5728067/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To compare modified surgery with supramonticular tissue preservation versus standard prostate surgery. Methods: For this systematic review, we conducted searches in PubMed, Scopus, Web of Science, and Cochrane Library. Randomized controlled trials (RCTs) and quasi-experimental studies that compared modified surgery with standard surgery were included. Two reviewers independently selected the studies. Meta-analyses were performed using RevMan 5.4, and the GRADE approach was used to assess the certainty of the evidence. Results: We identified six studies (three RCTs and three quasi-experimental) with 336 participants. The meta-analyses showed that the modified technique may result in greater preservation of antegrade ejaculation (OR=3.12; 95% CI: 2.31 to 4.20) and may increase post-micturition residual volume (OR=4.54; 95% CI: -20.83 to 29.91). Additionally, it may have no effect on IPSS, maximum flow, and QoL. However, all these results had very low certainty of evidence. Conclusion: In patients undergoing endoscopic surgery for BPH, surgery performed with the modified technique (preserving supramonticular tissue 1 cm above the verum montanum) may result in increased preservation of antegrade ejaculation, may increase post-micturition residual volume, and may have no effect on IPSS, maximum flow, and QoL. However, the evidence for these effects is very uncertain. ejaculation preservation Endoscopy Urinary bladder neck obstruction retrograde ejaculation Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Benign prostatic hyperplasia (BPH) is a condition characterized by prostate enlargement accompanied by lower urinary tract symptoms, affecting more than 50% of individuals over 50 years of age [ 1 , 2 ]. Treatment varies depending on the severity of symptoms and can be conservative, pharmacological, or surgical. Surgical treatment has a high resolution capacity, with Transurethral Resection of the Prostate (TURP) being the gold standard, although in recent years various techniques such as Holmium Laser Enucleation of the Prostate (HOLEP), Thulium Laser Enucleation of the Prostate (TULEP), and Greenlight Laser Vaporization have been introduced [ 3 ]. There are three characteristics that define an ideal surgical technique: versatility to adapt to different scenarios, removal of prostate tissue, and preservation of the ejaculatory apparatus [ 4 ]. Although the various techniques have demonstrated versatility and high resolution, retrograde ejaculation has remained the most common complication [ 5 ]. Retrograde ejaculation is the partial or total absence of antegrade ejaculation, with semen refluxing into the bladder [ 6 ], and has been reported as a complication in 66.1% of patients undergoing TURP [ 5 ], 74% for HOLEP [ 7 ], 67.1% for Greenlight laser photovaporization [ 8 ], and 56% for TULEP [ 9 ]. This postoperative ejaculatory dysfunction is perceived as an unpleasant condition [ 10 , 11 ], leading to male infertility, changes in sexual satisfaction [ 12 ], anxiety, depression [ 13 ], and having a negative impact on the patient's quality of life [ 10 , 11 ]. Over time, efforts have been made to reduce the risk of retrograde ejaculation with a modified technique that involves preserving the paracollicular and supracollicular tissue (1 cm above the verum montanum), a structure defined as the \"ejaculatory cap\" [ 14 ]. The plausibility of this technique lies in the importance of the muscular tissue surrounding the verum montanum, as demonstrated by dynamic endorectal ultrasound [ 10 , 15 ]. However, to our knowledge, no published systematic review has evaluated this theory, conducted meta-analyses, or assessed the certainty of the evidence. For this reason, this study conducted a systematic review to compare the effects of supramonticular tissue preservation in patients undergoing benign prostatic surgery. Methodology A systematic review was conducted following the guidelines of the PRISMA 2020 statement [ 16 ] (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for reporting systematic reviews and meta-analyses. The protocol was registered in PROSPERO (CRD42023480706). Design and Eligibility Criteria For this systematic review, randomized controlled trials (RCTs) and quasi-experimental studies published in scientific journals were included. The population of interest were patients diagnosed with BPH who had undergone endoscopic prostate surgery (TURP, HOLEP, TULEP, or photovaporization). The intervention group consisted of those who underwent surgery using the modified technique, which involves preserving the supramonticular tissue (1 cm above the verum montanum). The comparator group consisted of patients who underwent standard surgery (without preservation of the supramonticular tissue). Information and Search Strategy A systematic search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library. The searches were performed on December 31, 2023. No language or publication date restrictions were applied. The search strategy is detailed in Supplementary Material 1. Study Selection and Data Collection Process For study selection, the Rayyan tool ( https://rayyan.qcri.org ) was used. After removing duplicate articles, three authors (GMC, RRC, and LPA) independently and in pairs reviewed all titles and abstracts to identify potentially eligible studies. The full text of these potential studies was then assessed for eligibility. All references from the included studies were reviewed to expand the search. Any disagreements were discussed by all authors and resolved by consensus. Collected Variables Two authors (GMC and LPA) independently collected information in a Microsoft Excel spreadsheet, recording data on: author, year of publication, sample size, and surgical characteristics. Additionally, the following perioperative outcomes were evaluated: International Prostate Symptom Score (IPSS, scored on a scale from 0 to 35, with higher scores indicating more frequent BPH symptoms), maximum urine flow rate (values below 10 ml/s indicate abnormal urine flow, values between 10 and 15 ml/s are questionable, and values above 15 ml/s indicate normal urine flow), postvoid residual volume (PVR), quality of life (QoL) score, and prostate volume (PV). Risk of Bias Assessment Risk of bias (RoB) assessment was performed using the Cochrane RoB 2.0 tool [ 17 ]. Two reviewers (GMC and LPA) independently assessed the RoB of each study, and any disagreements were resolved by consensus. Five bias domains were evaluated: randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. Each bias domain was rated as “low,” “high,” or “some concerns.” Each study was then rated as having low RoB if all domains were rated low, high RoB if at least one domain was rated high, or some concerns if at least one domain showed some concerns of RoB, with no domains rated as high. Statistical Analysis Meta-analyses were performed using RevMan 5.4 software. Odds ratios (OR) and mean differences (MD) were used to assess dichotomous and continuous data, respectively, and were calculated with a 95% confidence interval (CI). P-values < 0.05 were considered statistically significant. Meta-analyses were performed using the Mantel-Haenszel random-effects model and the inverse variance model, as appropriate. Heterogeneity was assessed using the I² statistic, with heterogeneity considered not important when I² < 40%. Publication bias was not assessed as the number of studies included in each meta-analysis was fewer than ten [ 17 ]. Certainty Assessment To evaluate the certainty of the evidence for each outcome, the GRADE methodology [ 18 ] was used, which assesses study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias. Results Study Selection A total of 1402 studies were found, duplicates were removed, and 731 titles and abstracts were examined. Of these, 720 were excluded, leaving 11 studies that were reviewed in full text. After evaluation, 6 studies were finally included [ 19 – 24 ]. Additionally, the references of these manuscripts were examined, and none met the inclusion criteria. The selection process is shown in Fig. 1 , and the table of studies excluded after full-text review is provided in Supplementary Material 2. Study Characteristics Six studies were included, consisting of three RCTs and three quasi-experimental studies, with a total of 336 participants. Each study was conducted in a single country and in a single hospital. The studies reported their results at various follow-up times, ranging from 3 to 48 months. The characteristics of the selected trials are shown in Table 1 . Table 1 Characteristics of the Studies Author (Year) Country Population (Intervention/Control) Funding Type of Technique Follow-up Duration Type of Energy Age (Intervention/Control) Prostate Volume (Intervention/Control) Randomized Controlled Trials (RCTs) Manasa (2022) India 90 (45/45) ND Resection > 1cm from the VM 6 months Monopolar TURP 66,21 ± 9,25 43.49 ± 4.77/ 43.67 ± 4.54 Abolazm (2020) Egypt 46 (24/22) ND Resection > 1cm from the VM 12 months GreenLight 180 w 58.9 ± 5 / 59.6 ± 5 55.3 ± 15.6/ 56.5 ± 13.3 Elshazly (2021) Egypt 60 (30/30) ND Resection 1cm from the VM and preserves the bladder neck 3 months Bipolar TURP 58 ± 7,3 / 61,1 ± 8 70.6 / 73.1 Quasi-Experimental Studies (QES) ND Kim (2014) Seul 52 (26/26) ND Resection > 1cm from the VM and > 2–3 mm laterally 9.7 months Holmium Laser 80 w 67.0 (55–79) 60.1 ± 21.7/ 64,9 ± 22.0 Ronzoni (1998) Italia 55 (45/10) ND Resection > 1cm from the VM 2 years TURP 53,2 (42–62) 32 ± 2 Abdel-Basir 2003) Egipto 40 (20/20) ND Resection > 1cm from the VM ND TURP 36,1 (29–45) ND RCT: randomized controlled tria. QES: quasi-experimental study. PV: prostate volumen. EG: experimental group. CG: control group. ND: No data. VM: verum montanum. TURP: transurethral resection of the prostate. Risk of Bias In general, 5 out of 6 studies were rated as having high or uncertain risk of bias. The three quasi-experimental studies were rated with high risk of bias due to the non-randomized sample. Among the three RCTs, two had an uncertain risk for the domain of selection of reported outcomes, as detailed in Fig. 2 . Outcome Results Regarding the preservation of antegrade ejaculation, the overall meta-analysis found that the modified technique was associated with the preservation of antegrade ejaculation (OR = 3.12; 95% CI = 2.31 to 4.20). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig. 3 A). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table 2 ). Table 2 Summary of Findings (SoF) Outcomes (follow-up in months) Number of patients (studies) Intervention: modified technique Control group: standard technique Relative effect (95% CI) Absolute difference (95% CI) Certainty Interpretation Preservation of Antegrade Ejaculation (3 to 24 months) 336 (3 RCTs y 3 QES) 146/186 (78.5%) 36/150 (24.0%) RR 3.12 (2.31 to 4.20) 51 more per 100 (+ 31 a + 77) ⨁◯◯◯ Very low a Compared to the standard technique, the modified technique could lead to a higher incidence of preservation of antegrade ejaculation, although the evidence is very uncertain. International Prostate Symptom Score (IPSS). Range: 0 to 35, higher score = worse (3 to 24 months) 336 (3 RCTs y 3 QES) Mean: 5.9 Mean: 6.0 MD + 0.03. (-1.51 to + 1.57) ⨁◯◯◯ Very low a b Compared to the standard technique, the modified technique might not alter the IPSS, although the evidence is very uncertain. Maximum Urine Flow (3 to 24 months) 336 (3 RCTs y 3 QES) Mean: 19.8 ml/second Mean: 20.0 ml/second MD -1.12 ml/second (-3.12 to + 0.88) ⨁◯◯◯ Very low a b Compared to the standard technique, the modified technique might not alter the maximum flow, although the evidence is very uncertain. Quality of Life (QoL) Range: 0 to 6, higher score means worse QoL (9.7 to 24 months) 186 (1 RCT y 3 QES) Mean: 1.8 Mean: 2.1 MD -0.27 points (-0.67 to + 0.12) ⨁◯◯◯ Very low a b Compared to the standard technique, the modified technique might not alter the QoL, although the evidence is very uncertain. Post-void Residual Volume (6 to 24 months) 197 (1 RCT y 2 QES) Mean: 20.41 ml Mean: 15.8 ml MD + 15.2 ml (+ 7.5 to + 22.9) ⨁◯◯◯ Very low a c Compared to the standard technique, the modified technique could lead to a higher post-void residual volume, although the evidence is very uncertain. International Index of Erectile Function (IIEF-5) higher score = better 60 (1 RCT) Mean: 15.76 Mean: 14.01 Outcome not evaluated Male Sexual Health Questionnaire for evaluating ejaculatory dysfunction (MSHQ EjD) higher score = better 46 (1 RCT) Mean: 28.5 Mean: 19 Outcome not evaluated RCT: randomized controlled tria. QES: quasi-experimental study, RR: risk ratio, CI: confidence interval, RD: risk difference, MD: mean difference. Explanations of certainty of evidence : When ECA and EQ had similar results, certainty started as high. When results differ, started as moderate. a. Se redujo dos niveles de certeza por riesgo de sesgo. b. Se redujo un nevel de certeza debido a la inconsistencia. c. Se redujo un nevel de certeza debido a la imprecision. Regarding the International Prostate Symptom Score (IPSS), the overall meta-analysis found no significant difference between the modified and standard techniques (MD = 0.03; 95% CI = [− 1.51, 1.57]; p = 0.97). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig. 3 B). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table 2 ). In the analysis of postvoid residual volume (PVR), the overall meta-analysis found no significant difference between the modified and standard techniques (MD = 4.54; 95% CI = [-20.83, 29.91]; p = 0.73). The direction of the result was opposite between the RCT subgroup and the quasi-experimental subgroup (Fig. 3 C). However, only one RCT was analyzed, and the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table 2 ). For maximum flow rate (Qmax), the overall meta-analysis found no significant difference between the modified and standard techniques (MD = − 1.12; 95% CI = [− 3.12, 0.88]; p = 0.27). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig. 4 A). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table 2 ). Regarding quality of life (QoL), the overall meta-analysis found no significant difference between the modified and standard techniques (MD = − 0.27; 95% CI = [− 0.67, 0.12]). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig. 4 B). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table 2 ). Discussion Globally, life expectancy is increasing, and with it, the number of patients with benign prostatic hyperplasia (BPH) [ 25 ]. Therefore, considering the preservation of antegrade ejaculation in older men who have good sexual function is important to avoid negatively affecting their quality of life. Our study reveals that the evidence is very uncertain to confirm that the modified technique (preservation of the supra-monticular tissue) could lead to an increase in the preservation of antegrade ejaculation, could increase post-void residual volume, and may have no effect on IPSS, maximum flow rate, and QoL. The benefits of various surgical techniques for the treatment of BPH are already well-established [ 26 ]. However, these are not exempt from ejaculatory dysfunction, which remains the most frequent complication. A systematic review comparing different surgical techniques showed no significant difference in ejaculatory dysfunction [ 27 ]. Therefore, the preservation of supra-monticular tissue emerged as an alternative to improve this complication, based on the anatomical preservation of the ejaculatory duct and the muscles that act on it [ 28 ]. The studies we reviewed that applied this technique showed a significant benefit in maintaining antegrade ejaculation. Furthermore, a systematic review without meta-analysis showed that ejaculatory preservation techniques (modified technique) are superior to standard techniques [ 29 ]. Our findings show no significant results in relation to IPSS, PVR, QoL, and Qmax, which demonstrates that the supra-monticular tissue preservation technique preserves antegrade ejaculation without compromising the efficacy in improving urinary symptoms compared to standard surgery. These results highlight the safety of performing this technique, as the primary objective of BPH surgery is to improve urinary symptoms. Over the years, TURP has remained the gold standard, although current laser therapies have attracted attention due to their simplicity, reduced complications, minimal bleeding, shorter hospital stays, and faster recovery, with no significant benefit compared to TURP [ 29 ]. Our study is the first to perform a meta-analysis of various techniques that preserve supra-monticular tissue (1 cm above the verum montanum) to maintain antegrade ejaculation. However, there are other less invasive techniques that have demonstrated preservation of antegrade ejaculation, such as transurethral incision of the prostate (TUIP), which involves one or two incisions at the bladder neck and prostate [ 30 ], and the technique that uses high-pressure water jet technology to cut and resect prostate tissue with precision. Another method is prostate urethral lift, which involves cystoscopically placing a transprostatic suture to widen the lumen [ 31 ]. These techniques are an effective option for the preservation of antegrade ejaculation in smaller prostates. However, over time, there is an increased risk of reintervention [ 32 ]. Limitations An important limitation was the scarcity of studies applying the preservation of supra-monticular tissue, as well as the statistical analysis involving randomized clinical trials and quasi-experimental studies. Furthermore, information on ejaculatory dysfunction is not well-defined in all studies and is generally self-reported, and as such, is subject to recall bias. In the subgroup analysis for PVR, differences were observed between one RCT and three quasi-experimental studies. However, this result pertains to just one RCT, and more studies are needed to compare the true impact of this outcome. In our analysis, no results from the meta-analysis were adjusted. Conclusion In patients undergoing endoscopic surgery for BPH, surgery performed with the modified technique (preservation of supra-monticular tissue 1 cm above the verum montanum) may lead to an increase in the preservation of antegrade ejaculation, may increase post-void residual volume, and may have no effect on IPSS, maximum flow rate, and QoL. However, the evidence for these effects is very uncertain. Declarations Funding Source This research has not received any specific funding from public sector agencies, commercial sector, or non-profit entities. Conflicts of Interest The authors declare that they have no conflicts of interest. Author Contributions GMC, KRR, LAC, and ATR contributed to the conception and design of the article, data collection, drafting, and approval of the final version. Additionally, GMC and ATR performed the data analysis and interpretation. 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Fertil Steril 116(3):611–617. https://doi.org/10.1016/j.fertnstert.2021.07.1199 Lourenco T, Shaw M, Fraser C, MacLennan G, N’Dow J, Pickard R (2010) The clinical effectiveness of transurethral incision of the prostate: a systematic review of randomised controlled trials. World J Urol 28(1):23–32. https://doi.org/10.1007/s00345-009-0496-8 Additional Declarations No competing interests reported. Supplementary Files supplementarymaterial1.docx supplementarymaterial2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5728067\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":396227612,\"identity\":\"41bec8fd-bc64-433f-96f5-f08f20629f74\",\"order_by\":0,\"name\":\"Giuston Mendoza Chuctaya\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDACZhhDgvkAiJQhTssBsBa2BBDJQ5xNEC08BiCKsBZ5dx7jzx8q7kTzz+75/OpGjQUPA/vhoxvwaTE8zGMmceDMs9wZd85us845BnQYT1raDbxamnnMGA62Hc7dIJG7zTiHDahFgseMkBbjDxAtOc+Mc/4RoUWemcdAAqqF+XFuGxFaDJjZyiTOnDmcO+NGmhlzbp8EDxshv8j3H978oaLicG7/jOTHn3O+1cnxsx8+ht+WAwg2mwSYxKccbEsDgs38gZDqUTAKRsEoGJkAAO1/SUpezX4qAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Universidad Nacional de San Antonio Abad del Cusco\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Giuston\",\"middleName\":\"Mendoza\",\"lastName\":\"Chuctaya\",\"suffix\":\"\"},{\"id\":396227613,\"identity\":\"d13d19b6-932c-40ad-b3cc-93b3607abdaa\",\"order_by\":1,\"name\":\"Kevin Rodrigo Ramos\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidad Nacional de San Antonio Abad del Cusco\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kevin\",\"middleName\":\"Rodrigo\",\"lastName\":\"Ramos\",\"suffix\":\"\"},{\"id\":396227614,\"identity\":\"dc485137-7108-4b37-acce-2de310aff0cd\",\"order_by\":2,\"name\":\"Lucely Aycachi Centeno\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Universidad Peruana Unión, Escuela Profesional de Medicina Humana\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Lucely\",\"middleName\":\"Aycachi\",\"lastName\":\"Centeno\",\"suffix\":\"\"},{\"id\":396227615,\"identity\":\"3d0a549c-c1e1-47d0-bd2a-01bfd33dfd40\",\"order_by\":3,\"name\":\"Alvaro Taype Rondan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Unidad de Investigación para la Generación y Síntesis de Evidencia en Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Alvaro\",\"middleName\":\"Taype\",\"lastName\":\"Rondan\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-12-29 02:08:05\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5728067/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5728067/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":72796326,\"identity\":\"caf440f6-a4f7-430c-b205-3c4b7485c2bc\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:02:27\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":45166,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow diagram of report items for systematic reviews and meta-analyses\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/9e36927cfda3e4029ddffca4.png\"},{\"id\":72796325,\"identity\":\"0a99bd6d-e695-4681-8086-26b23b54569c\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:02:27\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":76411,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eRisk of bias.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/4d432cc23717fa8f392be016.png\"},{\"id\":72798485,\"identity\":\"0b7467f3-c243-47d1-a89d-3eb16b58e1c9\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:10:28\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":902876,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest Plot. 3A: Retrograde ejaculation. 3B: International Prostate Symptom Score (IPSS). 3C: Post-void residual volume (PVR). The quasi-experimental studies did not present result adjustments.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/45b31a375e53f65cc01d4dca.png\"},{\"id\":72798480,\"identity\":\"158817ae-d080-48e9-906f-f13239a39355\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:10:27\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":687091,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest Plot. 4A: Maximum flow (Qmax). 4B: Quality of life (QoL). The quasi-experimental studies did not present result adjustments.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/413e29a137f84b048c02b28d.png\"},{\"id\":78236843,\"identity\":\"db6328e9-7f30-4a6b-9faf-6936a882e20c\",\"added_by\":\"auto\",\"created_at\":\"2025-03-11 08:32:36\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2972956,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/63f171b3-6145-422f-b2a4-6d14a523ddb6.pdf\"},{\"id\":72796330,\"identity\":\"7281842c-2c4f-4064-b0b6-d81d0edfa2c1\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:02:27\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20594,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"supplementarymaterial1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/a0eafeaf2a0bd12fc403d5b6.docx\"},{\"id\":72796320,\"identity\":\"fd8e4a12-039d-4508-8ab7-30a701e121f9\",\"added_by\":\"auto\",\"created_at\":\"2025-01-02 09:02:26\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":18583,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"supplementarymaterial2.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5728067/v1/b5e3779c94c0665ee046f886.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Prostatic surgery with preservation of the supramonticular tissue versus standard surgery in benign prostatic hyperplasia: a systematic review\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eBenign prostatic hyperplasia (BPH) is a condition characterized by prostate enlargement accompanied by lower urinary tract symptoms, affecting more than 50% of individuals over 50 years of age [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Treatment varies depending on the severity of symptoms and can be conservative, pharmacological, or surgical. Surgical treatment has a high resolution capacity, with Transurethral Resection of the Prostate (TURP) being the gold standard, although in recent years various techniques such as Holmium Laser Enucleation of the Prostate (HOLEP), Thulium Laser Enucleation of the Prostate (TULEP), and Greenlight Laser Vaporization have been introduced [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThere are three characteristics that define an ideal surgical technique: versatility to adapt to different scenarios, removal of prostate tissue, and preservation of the ejaculatory apparatus [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Although the various techniques have demonstrated versatility and high resolution, retrograde ejaculation has remained the most common complication [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Retrograde ejaculation is the partial or total absence of antegrade ejaculation, with semen refluxing into the bladder [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e], and has been reported as a complication in 66.1% of patients undergoing TURP [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e], 74% for HOLEP [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], 67.1% for Greenlight laser photovaporization [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e], and 56% for TULEP [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. This postoperative ejaculatory dysfunction is perceived as an unpleasant condition [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e], leading to male infertility, changes in sexual satisfaction [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e], anxiety, depression [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], and having a negative impact on the patient's quality of life [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOver time, efforts have been made to reduce the risk of retrograde ejaculation with a modified technique that involves preserving the paracollicular and supracollicular tissue (1 cm above the verum montanum), a structure defined as the \\\"ejaculatory cap\\\" [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. The plausibility of this technique lies in the importance of the muscular tissue surrounding the verum montanum, as demonstrated by dynamic endorectal ultrasound [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. However, to our knowledge, no published systematic review has evaluated this theory, conducted meta-analyses, or assessed the certainty of the evidence.\\u003c/p\\u003e \\u003cp\\u003eFor this reason, this study conducted a systematic review to compare the effects of supramonticular tissue preservation in patients undergoing benign prostatic surgery.\\u003c/p\\u003e\"},{\"header\":\"Methodology\",\"content\":\"\\u003cp\\u003eA systematic review was conducted following the guidelines of the PRISMA 2020 statement [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for reporting systematic reviews and meta-analyses. The protocol was registered in PROSPERO (CRD42023480706).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDesign and Eligibility Criteria\\u003c/h2\\u003e \\u003cp\\u003eFor this systematic review, randomized controlled trials (RCTs) and quasi-experimental studies published in scientific journals were included. The population of interest were patients diagnosed with BPH who had undergone endoscopic prostate surgery (TURP, HOLEP, TULEP, or photovaporization). The intervention group consisted of those who underwent surgery using the modified technique, which involves preserving the supramonticular tissue (1 cm above the verum montanum). The comparator group consisted of patients who underwent standard surgery (without preservation of the supramonticular tissue).\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eInformation and Search Strategy\\u003c/h3\\u003e\\n\\u003cp\\u003eA systematic search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library. The searches were performed on December 31, 2023. No language or publication date restrictions were applied. The search strategy is detailed in Supplementary Material 1.\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Selection and Data Collection Process\\u003c/h3\\u003e\\n\\u003cp\\u003eFor study selection, the Rayyan tool (\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://rayyan.qcri.org\\u003c/span\\u003e\\u003cspan address=\\\"https://rayyan.qcri.org\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e) was used. After removing duplicate articles, three authors (GMC, RRC, and LPA) independently and in pairs reviewed all titles and abstracts to identify potentially eligible studies. The full text of these potential studies was then assessed for eligibility. All references from the included studies were reviewed to expand the search. Any disagreements were discussed by all authors and resolved by consensus.\\u003c/p\\u003e\\n\\u003ch3\\u003eCollected Variables\\u003c/h3\\u003e\\n\\u003cp\\u003eTwo authors (GMC and LPA) independently collected information in a Microsoft Excel spreadsheet, recording data on: author, year of publication, sample size, and surgical characteristics. Additionally, the following perioperative outcomes were evaluated: International Prostate Symptom Score (IPSS, scored on a scale from 0 to 35, with higher scores indicating more frequent BPH symptoms), maximum urine flow rate (values below 10 ml/s indicate abnormal urine flow, values between 10 and 15 ml/s are questionable, and values above 15 ml/s indicate normal urine flow), postvoid residual volume (PVR), quality of life (QoL) score, and prostate volume (PV).\\u003c/p\\u003e\\n\\u003ch3\\u003eRisk of Bias Assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eRisk of bias (RoB) assessment was performed using the Cochrane RoB 2.0 tool [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Two reviewers (GMC and LPA) independently assessed the RoB of each study, and any disagreements were resolved by consensus. Five bias domains were evaluated: randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. Each bias domain was rated as \\u0026ldquo;low,\\u0026rdquo; \\u0026ldquo;high,\\u0026rdquo; or \\u0026ldquo;some concerns.\\u0026rdquo; Each study was then rated as having low RoB if all domains were rated low, high RoB if at least one domain was rated high, or some concerns if at least one domain showed some concerns of RoB, with no domains rated as high.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003eMeta-analyses were performed using RevMan 5.4 software. Odds ratios (OR) and mean differences (MD) were used to assess dichotomous and continuous data, respectively, and were calculated with a 95% confidence interval (CI). P-values\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 were considered statistically significant. Meta-analyses were performed using the Mantel-Haenszel random-effects model and the inverse variance model, as appropriate.\\u003c/p\\u003e \\u003cp\\u003eHeterogeneity was assessed using the I\\u0026sup2; statistic, with heterogeneity considered not important when I\\u0026sup2; \\u0026lt; 40%. Publication bias was not assessed as the number of studies included in each meta-analysis was fewer than ten [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eCertainty Assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eTo evaluate the certainty of the evidence for each outcome, the GRADE methodology [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] was used, which assesses study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eStudy Selection\\u003c/h2\\u003e\\n \\u003cp\\u003eA total of 1402 studies were found, duplicates were removed, and 731 titles and abstracts were examined. Of these, 720 were excluded, leaving 11 studies that were reviewed in full text. After evaluation, 6 studies were finally included [\\u003cspan class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. Additionally, the references of these manuscripts were examined, and none met the inclusion criteria. The selection process is shown in Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, and the table of studies excluded after full-text review is provided in Supplementary Material 2.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eStudy Characteristics\\u003c/h2\\u003e\\n \\u003cp\\u003eSix studies were included, consisting of three RCTs and three quasi-experimental studies, with a total of 336 participants. Each study was conducted in a single country and in a single hospital. The studies reported their results at various follow-up times, ranging from 3 to 48 months. The characteristics of the selected trials are shown in Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\n \\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003ctable id=\\\"Tab1\\\" style=\\\"width: 1003.63px;\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eCharacteristics of the Studies\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAuthor (Year)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCountry\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePopulation (Intervention/Control)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFunding\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eType of Technique\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFollow-up Duration\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eType of Energy\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAge (Intervention/Control)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eProstate Volume (Intervention/Control)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003cth style=\\\"width: 275px;\\\" colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRandomized Controlled Trials (RCTs)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eManasa (2022)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIndia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e90 (45/45)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection\\u0026thinsp;\\u0026gt;\\u0026thinsp;1cm from the VM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMonopolar TURP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e66,21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9,25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e43.49\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.77/ 43.67\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAbolazm (2020)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEgypt\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e46 (24/22)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection\\u0026thinsp;\\u0026gt;\\u0026thinsp;1cm from the VM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e12 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGreenLight 180 w\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e58.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5 / 59.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e55.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.6/ 56.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;13.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eElshazly (2021)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEgypt\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60 (30/30)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection 1cm from the VM and preserves the bladder neck\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBipolar TURP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e58\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7,3 / 61,1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e70.6 / 73.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 275px;\\\" colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eQuasi-Experimental Studies (QES)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eKim (2014)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSeul\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e52 (26/26)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection\\u0026thinsp;\\u0026gt;\\u0026thinsp;1cm from the VM and \\u0026gt;\\u0026thinsp;2\\u0026ndash;3 mm laterally\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9.7 months\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHolmium Laser 80 w\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e67.0 (55\\u0026ndash;79)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.7/ 64,9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;22.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRonzoni (1998)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eItalia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e55 (45/10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection\\u0026thinsp;\\u0026gt;\\u0026thinsp;1cm from the VM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2 years\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTURP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e53,2 (42\\u0026ndash;62)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 63px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAbdel-Basir 2003)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 48px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEgipto\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 164px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e40 (20/20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 49px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 144px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eResection\\u0026thinsp;\\u0026gt;\\u0026thinsp;1cm from the VM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 73px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTURP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 151px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e36,1 (29\\u0026ndash;45)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 174px;\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eND\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 945.632px;\\\" colspan=\\\"9\\\" align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRCT: randomized controlled tria. QES: quasi-experimental study. PV: prostate volumen. EG: experimental group. CG: control group. ND: No data. VM: verum montanum. TURP: transurethral resection of the prostate.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eRisk of Bias\\u003c/h2\\u003e\\n \\u003cp\\u003eIn general, 5 out of 6 studies were rated as having high or uncertain risk of bias. The three quasi-experimental studies were rated with high risk of bias due to the non-randomized sample. Among the three RCTs, two had an uncertain risk for the domain of selection of reported outcomes, as detailed in Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eOutcome Results\\u003c/h2\\u003e\\n \\u003cp\\u003eRegarding the preservation of antegrade ejaculation, the overall meta-analysis found that the modified technique was associated with the preservation of antegrade ejaculation (OR\\u0026thinsp;=\\u0026thinsp;3.12; 95% CI\\u0026thinsp;=\\u0026thinsp;2.31 to 4.20). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n \\u003cdiv class=\\\"gridtable\\\"\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003cdiv class=\\\"colspec\\\" align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/div\\u003e\\n \\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eSummary of Findings (SoF)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutcomes\\u003c/p\\u003e\\n \\u003cp\\u003e(follow-up in months)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNumber of patients (studies)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIntervention: modified technique\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eControl group: standard technique\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRelative effect\\u003c/p\\u003e\\n \\u003cp\\u003e(95% CI)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAbsolute difference\\u003c/p\\u003e\\n \\u003cp\\u003e(95% CI)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCertainty\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInterpretation\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePreservation of Antegrade Ejaculation\\u003c/p\\u003e\\n \\u003cp\\u003e(3 to 24 months)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e336\\u003c/p\\u003e\\n \\u003cp\\u003e(3 RCTs y 3 QES)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e146/186 (78.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e36/150 (24.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRR 3.12\\u003c/p\\u003e\\n \\u003cp\\u003e(2.31 to 4.20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e51 more per 100\\u003c/p\\u003e\\n \\u003cp\\u003e(+\\u0026thinsp;31 a\\u0026thinsp;+\\u0026thinsp;77)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e⨁◯◯◯\\u003c/p\\u003e\\n \\u003cp\\u003eVery low \\u003csup\\u003ea\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompared to the standard technique, the modified technique could lead to a higher incidence of preservation of antegrade ejaculation, although the evidence is very uncertain.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInternational Prostate Symptom Score (IPSS). Range: 0 to 35, higher score\\u0026thinsp;=\\u0026thinsp;worse\\u003c/p\\u003e\\n \\u003cp\\u003e(3 to 24 months)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e336\\u003c/p\\u003e\\n \\u003cp\\u003e(3 RCTs y 3 QES)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 5.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 6.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMD\\u0026thinsp;+\\u0026thinsp;0.03.\\u003c/p\\u003e\\n \\u003cp\\u003e(-1.51 to +\\u0026thinsp;1.57)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e⨁◯◯◯\\u003c/p\\u003e\\n \\u003cp\\u003eVery low \\u003csup\\u003ea b\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompared to the standard technique, the modified technique might not alter the IPSS, although the evidence is very uncertain.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMaximum Urine Flow\\u003c/p\\u003e\\n \\u003cp\\u003e(3 to 24 months)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e336\\u003c/p\\u003e\\n \\u003cp\\u003e(3 RCTs y 3 QES)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 19.8 ml/second\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 20.0 ml/second\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMD -1.12 ml/second\\u003c/p\\u003e\\n \\u003cp\\u003e(-3.12 to +\\u0026thinsp;0.88)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e⨁◯◯◯\\u003c/p\\u003e\\n \\u003cp\\u003eVery low \\u003csup\\u003ea b\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompared to the standard technique, the modified technique might not alter the maximum flow, although the evidence is very uncertain.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eQuality of Life (QoL)\\u003c/p\\u003e\\n \\u003cp\\u003eRange: 0 to 6, higher score means worse QoL\\u003c/p\\u003e\\n \\u003cp\\u003e(9.7 to 24 months)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e186\\u003c/p\\u003e\\n \\u003cp\\u003e(1 RCT y 3 QES)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 1.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 2.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMD -0.27 points\\u003c/p\\u003e\\n \\u003cp\\u003e(-0.67 to +\\u0026thinsp;0.12)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e⨁◯◯◯\\u003c/p\\u003e\\n \\u003cp\\u003eVery low \\u003csup\\u003ea b\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompared to the standard technique, the modified technique might not alter the QoL, although the evidence is very uncertain.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePost-void Residual Volume\\u003c/p\\u003e\\n \\u003cp\\u003e(6 to 24 months)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e197\\u003c/p\\u003e\\n \\u003cp\\u003e(1 RCT y 2 QES)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 20.41 ml\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 15.8 ml\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMD\\u0026thinsp;+\\u0026thinsp;15.2 ml\\u003c/p\\u003e\\n \\u003cp\\u003e(+\\u0026thinsp;7.5 to +\\u0026thinsp;22.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e⨁◯◯◯\\u003c/p\\u003e\\n \\u003cp\\u003eVery low \\u003csup\\u003ea c\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompared to the standard technique, the modified technique could lead to a higher post-void residual volume, although the evidence is very uncertain.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInternational Index of Erectile Function (IIEF-5) higher score\\u0026thinsp;=\\u0026thinsp;better\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60\\u003c/p\\u003e\\n \\u003cp\\u003e(1 RCT)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 15.76\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 14.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutcome not evaluated\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMale Sexual Health Questionnaire for evaluating ejaculatory dysfunction (MSHQ EjD) higher score\\u0026thinsp;=\\u0026thinsp;better\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e46\\u003c/p\\u003e\\n \\u003cp\\u003e(1 RCT)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 28.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMean: 19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutcome not evaluated\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003eRCT: randomized controlled tria. QES: quasi-experimental study, RR: risk ratio, CI: confidence interval, RD: risk difference, MD: mean difference.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003e\\u003cstrong\\u003eExplanations of certainty of evidence\\u003c/strong\\u003e:\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003eWhen ECA and EQ had similar results, certainty started as high. When results differ, started as moderate.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003ea. Se redujo dos niveles de certeza por riesgo de sesgo.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003eb. Se redujo un nevel de certeza debido a la inconsistencia.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\"\\u003ec. Se redujo un nevel de certeza debido a la imprecision.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n \\u003c/table\\u003e\\n \\u003c/div\\u003e\\n \\u003cp\\u003eRegarding the International Prostate Symptom Score (IPSS), the overall meta-analysis found no significant difference between the modified and standard techniques (MD\\u0026thinsp;=\\u0026thinsp;0.03; 95% CI = [\\u0026minus;\\u0026thinsp;1.51, 1.57]; p\\u0026thinsp;=\\u0026thinsp;0.97). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eB). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n \\u003cp\\u003eIn the analysis of postvoid residual volume (PVR), the overall meta-analysis found no significant difference between the modified and standard techniques (MD\\u0026thinsp;=\\u0026thinsp;4.54; 95% CI = [-20.83, 29.91]; p\\u0026thinsp;=\\u0026thinsp;0.73). The direction of the result was opposite between the RCT subgroup and the quasi-experimental subgroup (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eC). However, only one RCT was analyzed, and the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n \\u003cp\\u003eFor maximum flow rate (Qmax), the overall meta-analysis found no significant difference between the modified and standard techniques (MD\\u0026thinsp;=\\u0026thinsp;\\u0026minus;\\u0026thinsp;1.12; 95% CI = [\\u0026minus;\\u0026thinsp;3.12, 0.88]; p\\u0026thinsp;=\\u0026thinsp;0.27). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003eA). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n \\u003cp\\u003eRegarding quality of life (QoL), the overall meta-analysis found no significant difference between the modified and standard techniques (MD\\u0026thinsp;=\\u0026thinsp;\\u0026minus;\\u0026thinsp;0.27; 95% CI = [\\u0026minus;\\u0026thinsp;0.67, 0.12]). The direction of the result was similar between the RCT subgroup and the quasi-experimental subgroup (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003eB). However, the very low certainty of the evidence indicates that the evidence is very uncertain about the effect on this outcome (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eGlobally, life expectancy is increasing, and with it, the number of patients with benign prostatic hyperplasia (BPH) [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. Therefore, considering the preservation of antegrade ejaculation in older men who have good sexual function is important to avoid negatively affecting their quality of life. Our study reveals that the evidence is very uncertain to confirm that the modified technique (preservation of the supra-monticular tissue) could lead to an increase in the preservation of antegrade ejaculation, could increase post-void residual volume, and may have no effect on IPSS, maximum flow rate, and QoL.\\u003c/p\\u003e \\u003cp\\u003eThe benefits of various surgical techniques for the treatment of BPH are already well-established [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. However, these are not exempt from ejaculatory dysfunction, which remains the most frequent complication. A systematic review comparing different surgical techniques showed no significant difference in ejaculatory dysfunction [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. Therefore, the preservation of supra-monticular tissue emerged as an alternative to improve this complication, based on the anatomical preservation of the ejaculatory duct and the muscles that act on it [\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. The studies we reviewed that applied this technique showed a significant benefit in maintaining antegrade ejaculation. Furthermore, a systematic review without meta-analysis showed that ejaculatory preservation techniques (modified technique) are superior to standard techniques [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur findings show no significant results in relation to IPSS, PVR, QoL, and Qmax, which demonstrates that the supra-monticular tissue preservation technique preserves antegrade ejaculation without compromising the efficacy in improving urinary symptoms compared to standard surgery. These results highlight the safety of performing this technique, as the primary objective of BPH surgery is to improve urinary symptoms. Over the years, TURP has remained the gold standard, although current laser therapies have attracted attention due to their simplicity, reduced complications, minimal bleeding, shorter hospital stays, and faster recovery, with no significant benefit compared to TURP [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur study is the first to perform a meta-analysis of various techniques that preserve supra-monticular tissue (1 cm above the verum montanum) to maintain antegrade ejaculation. However, there are other less invasive techniques that have demonstrated preservation of antegrade ejaculation, such as transurethral incision of the prostate (TUIP), which involves one or two incisions at the bladder neck and prostate [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e], and the technique that uses high-pressure water jet technology to cut and resect prostate tissue with precision. Another method is prostate urethral lift, which involves cystoscopically placing a transprostatic suture to widen the lumen [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. These techniques are an effective option for the preservation of antegrade ejaculation in smaller prostates. However, over time, there is an increased risk of reintervention [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e].\\u003c/p\\u003e \"},{\"header\":\"Limitations\",\"content\":\"\\u003cp\\u003eAn important limitation was the scarcity of studies applying the preservation of supra-monticular tissue, as well as the statistical analysis involving randomized clinical trials and quasi-experimental studies. Furthermore, information on ejaculatory dysfunction is not well-defined in all studies and is generally self-reported, and as such, is subject to recall bias. In the subgroup analysis for PVR, differences were observed between one RCT and three quasi-experimental studies. However, this result pertains to just one RCT, and more studies are needed to compare the true impact of this outcome. In our analysis, no results from the meta-analysis were adjusted.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn patients undergoing endoscopic surgery for BPH, surgery performed with the modified technique (preservation of supra-monticular tissue 1 cm above the verum montanum) may lead to an increase in the preservation of antegrade ejaculation, may increase post-void residual volume, and may have no effect on IPSS, maximum flow rate, and QoL. However, the evidence for these effects is very uncertain.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding Source\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research has not received any specific funding from public sector agencies, commercial sector, or non-profit entities.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eGMC, KRR, LAC, and ATR contributed to the conception and design of the article, data collection, drafting, and approval of the final version. Additionally, GMC and ATR performed the data analysis and interpretation.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eAgarwal A, Eryuzlu LN, Cartwright R, Thorlund K, Tammela TLJ, Guyatt GH et al (2014) What Is the Most Bothersome Lower Urinary Tract Symptom? Individual- and Population-level Perspectives for Both Men and Women. Eur Urol 65(6):1211\\u0026ndash;1217. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.eururo.2014.01.019\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.eururo.2014.01.019\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCornu JN et al EAU Guidelines on Non-neurogenic Male LUTS, 2023. In: EAU Guidelines published at the 38th EAU Annual Congress, Milan. EAU Guidelines Office, Arnhem, The Netherlands\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKaravitakis M, Kyriazis I, Omar MI, Gravas S, Cornu JN, Drake MJ et al (2019) Management of Urinary Retention in Patients with Benign Prostatic Obstruction: A Systematic Review and Meta-analysis. Eur Urol 75(5):788\\u0026ndash;798. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.eururo.2019.01.046\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.eururo.2019.01.046\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDestefanis P, Sibona M, Soria F, Vercelli E, Vitiello F, Bosio A et al (2021) Ejaculation-sparing versus non-ejaculation-sparing anatomic GreenLight laser enucleo-vaporization of the prostate: first comparative study. World J Urol 39(9):3455\\u0026ndash;3463. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00345-021-03615-7\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00345-021-03615-7\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMarra G, Sturch P, Oderda M, Tabatabaei S, Muir G, Gontero P (2016) Systematic review of lower urinary tract symptoms/benign prostatic hyperplasia surgical treatments on men\\u0026rsquo;s ejaculatory function: time for a bespoke approach? Int J Urol Off J Jpn Urol Assoc 23:22\\u0026ndash;35. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/iju.12866\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/iju.12866\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLa Vignera S, Aversa A, Cannarella R, Condorelli RA, Duca Y, Russo GI et al (2021) Pharmacological treatment of lower urinary tract symptoms in benign prostatic hyperplasia: consequences on sexual function and possible endocrine effects. Expert Opin Pharmacother 22(2):179\\u0026ndash;189. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1080/14656566.2020.1817382\\u003c/span\\u003e\\u003cspan address=\\\"10.1080/14656566.2020.1817382\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAhyai SA, Lehrich K, Kuntz RM (2007) Holmium Laser Enucleation versus Transurethral Resection of the Prostate: 3-Year Follow-Up Results of a Randomized Clinical Trial. Eur Urol 52(5):1456\\u0026ndash;1464. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.eururo.2007.04.053\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.eururo.2007.04.053\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eThomas JA, Tubaro A, Barber N, d\\u0026rsquo;Ancona F, Muir G, Witzsch U et al (2016) A Multicenter Randomized Noninferiority Trial Comparing GreenLight-XPS Laser Vaporization of the Prostate and Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: Two-yr Outcomes of the GOLIATH Study. 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Br J Urol 81(6):830\\u0026ndash;833. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1046/j.1464-410x.1998.00658.x\\u003c/span\\u003e\\u003cspan address=\\\"10.1046/j.1464-410x.1998.00658.x\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eManasa T, Reddy N, Puvvada S, Mylarappa P (2022) Evaluating outcomes of combined bladder neck and supramontanal sparing ejaculatory preserving transurethral resection of the prostate: Results from a prospective, randomised study. Cent Eur J Urol 75(3):292. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.5173/ceju.2022.0004\\u003c/span\\u003e\\u003cspan address=\\\"10.5173/ceju.2022.0004\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim M, Song SH, Ku JH, Kim HJ, Paick JS (2015) Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate. 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World J Urol 39(11):4215\\u0026ndash;4219. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00345-021-03752-z\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00345-021-03752-z\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAbolazm AE, El-Hefnawy AS, Laymon M, Shehab-El-Din AB, Elshal AM (2020) Ejaculatory Hood Sparing versus Standard Laser Photoselective Vaporization of the Prostate: Sexual and Urodynamic Assessment through a Double Blinded, Randomized Trial. J Urol 203(4):792\\u0026ndash;801. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1097/JU.0000000000000685\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/JU.0000000000000685\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAbdel-Basir Sayed M (2003) Bladder Neck Resection with Preservation of Antegrade Ejaculation: Basir Technique. J Endourol 17(2):109\\u0026ndash;111. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1089/08927790360587441\\u003c/span\\u003e\\u003cspan address=\\\"10.1089/08927790360587441\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEgan KB (2016) The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms. Urol Clin North Am 43(3):289\\u0026ndash;297. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.ucl.2016.04.001\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ucl.2016.04.001\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePang KH, Ortner G, Yuan Y, Biyani CS, Tokas T (2022) Complications and functional outcomes of endoscopic enucleation of the prostate: a systematic review and meta-analysis of randomised-controlled studies. Cent Eur J Urol 75(4):357. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.5173/ceju.2022.174\\u003c/span\\u003e\\u003cspan address=\\\"10.5173/ceju.2022.174\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCacciamani GE, Cuhna F, Tafuri A, Shakir A, Cocci A, Gill K et al (2019) Anterograde ejaculation preservation after endoscopic treatments in patients with bladder outlet obstruction: systematic review and pooled-analysis of randomized clinical trials. Minerva Urol Nefrol 71(5). \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.23736/s0393-2249.19.03588-4\\u003c/span\\u003e\\u003cspan address=\\\"10.23736/s0393-2249.19.03588-4\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSturch P, Woo HH, McNicholas T, Muir G (2015) Ejaculatory dysfunction after treatment for lower urinary tract symptoms: retrograde ejaculation or retrograde thinking? BJU Int 115(2):186\\u0026ndash;187. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/bju.12868\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/bju.12868\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGuldibi F, Altunhan A, Aydın A, Sonmez MG, \\u0026Ccedil;akır \\u0026Ouml;O, Balasar M et al (2023) What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions? A systematic review. 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Fertil Steril 116(3):611\\u0026ndash;617. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.fertnstert.2021.07.1199\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.fertnstert.2021.07.1199\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLourenco T, Shaw M, Fraser C, MacLennan G, N\\u0026rsquo;Dow J, Pickard R (2010) The clinical effectiveness of transurethral incision of the prostate: a systematic review of randomised controlled trials. World J Urol 28(1):23\\u0026ndash;32. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00345-009-0496-8\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00345-009-0496-8\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"ejaculation preservation, Endoscopy, Urinary bladder neck obstruction, retrograde ejaculation\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5728067/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5728067/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e To compare modified surgery with supramonticular tissue preservation versus standard prostate surgery.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e For this systematic review, we conducted searches in PubMed, Scopus, Web of Science, and Cochrane Library. Randomized controlled trials (RCTs) and quasi-experimental studies that compared modified surgery with standard surgery were included. Two reviewers independently selected the studies. Meta-analyses were performed using RevMan 5.4, and the GRADE approach was used to assess the certainty of the evidence.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e We identified six studies (three RCTs and three quasi-experimental) with 336 participants. The meta-analyses showed that the modified technique may result in greater preservation of antegrade ejaculation (OR=3.12; 95% CI: 2.31 to 4.20) and may increase post-micturition residual volume (OR=4.54; 95% CI: -20.83 to 29.91). Additionally, it may have no effect on IPSS, maximum flow, and QoL. However, all these results had very low certainty of evidence.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e In patients undergoing endoscopic surgery for BPH, surgery performed with the modified technique (preserving supramonticular tissue 1 cm above the verum montanum) may result in increased preservation of antegrade ejaculation, may increase post-micturition residual volume, and may have no effect on IPSS, maximum flow, and QoL. However, the evidence for these effects is very uncertain.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Prostatic surgery with preservation of the supramonticular tissue versus standard surgery in benign prostatic hyperplasia: a systematic review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-01-02 09:02:21\",\"doi\":\"10.21203/rs.3.rs-5728067/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"32642400-178e-4562-a231-1551eae5aada\",\"owner\":[],\"postedDate\":\"January 2nd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-03-11T08:24:18+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-01-02 09:02:21\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5728067\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5728067\",\"identity\":\"rs-5728067\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}