Comparative Analysis of Standard ThuFLEP versus Median lobe-only ThuFLEP: Impact on Antegrade Ejaculation Preservation

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Methods We retrospectively analyzed the patients who underwent ThuFLEP between May 2024 and December 2025 for benign prostatic obstruction (BPO). 84 patients comprised the median lobe–only enucleation group (ml-ThuFLEP), while 68 constituted the standard ThuFLEP group performed using the standart three lobe technique (sThuFLEP). Perioperative and postoperative functional outcomes, as well as postoperative ejaculation statuses of the patients, were evaluated and compared. Results In both groups, regarding Qmax [26 (6) vs. 25 (5), p: 0.156], IPSS [7 (4) vs. 6 (4), p > 0.05], and PVR [4.5 (3.75) vs. 5 (3) ml, p > 0.05], no significant difference was found between the two groups at the 6-month postoperative follow-up. The rate of retrograde ejaculation (RE) was significantly lower when medial lobe-only enucleation was performed, in comparison to standart enucleation (for RE; 2.4% vs. 95.6%, respectively; p < 0.001). Conclusion The median lobe-only ThuFLEP is an effective approach for improving postoperative urinary function while preserving AE in suitable patients. This technique may be proposed for patients who wish to preserve ejaculation after LEP procedure. antegrade ejaculation benign prostatic obstruction laser enucleation retrograde ejaculation ThuFLEP Figures Figure 1 Introduction Lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are a health problem that affects 50–75% of men aged 50 and over are known to have a significant impact upon men's quality of life [ 1 , 2 ]. Over the past ten years, minimally invasive approaches to surgical treatment of BPO have become increasingly popular. First described in 1998, Holmium laser enucleation of the prostate (HoLEP) is currently the most widely used minimally invasive BPO method worldwide [ 3 ]. Advancements in laser technology, which have become ubiquitous in the field of endourology, have paved the way for the introduction of various laser types in the arena of BPO surgery and studies have demonstrated the efficacy of these lasers in enhancing postoperative functional outcomes in prostatic enucleation [ 4 – 6 ]. One of these, the Thulium fiber laser (TFL) was introduced as a novel energy source for laser enucleation of the prostate (LEP) in 2005 and commenced utilisation [ 7 ]. Studies show that Thulium fiber laser enucleation of the prostate (ThuFLEP) procedur is as effective and reliable as HoLEP in the surgical treatment of BPO, even in large prostates [ 8 , 9 ]. Although LUTS shows significant improvement postoperatively, retrograde ejaculation (RE), which is a common adverse effect following LEP [ 10 – 12 ], can be bothersome for sexually active patients [ 13 ]. To manage RE, various ejaculation-preserving techniques for different lasers are employed during LEP procedure [ 14 , 15 ]. However, there is lack on the ejaculation-preserving approach in LEP surgery performed using TFL. In the present study, we aimed to demonstrate the effect of median lobe-only enucleation on antegrade ejaculation (AE) in patients undergoing ThuFLEP due to BPO. Material and Methods After obtaining approval from the institutional review board (IRB: 2025/3-2557), we performed a retrospective review of patients who underwent ThuFLEP between May 2024 and December 2025. Patient selection A total of 152 patients were included in the study. Patients were eligible for inclusion if they had a maximum urinary flow rate (Qmax) of ≤ 15 mL/s, an International Prostate Symptom Score (IPSS) of ≥ 12, a post-void residual volume (PVR) of > 100 mL, inadequate response to at least 6 months of medical therapy (alpha-blockers and/or 5-alpha reductase inhibitors), recurrent or refractory urinary retention, or bladder stones. Patients with a history of urethral stricture, neurogenic bladder dysfunction, prostate cancer, prior prostatic or pelvic surgery, previous pelvic radiotherapy or postoperative use of alpha-adrenergic antagonists were excluded from the analysis. Among the patients who underwent ThuFLEP, 84 comprised the median lobe–only enucleation group (ml-ThuFLEP), while 68 constituted the standard ThuFLEP group performed using the standart three lobe technique (sThuFLEP). Between two groups, perioperative and postoperative functional outcomes, as well as postoperative ejaculation statuses of the patients, were evaluated and compared. ml-ThuFLEP was performed in carefully selected patients following comprehensive preoperative counseling. Selection was based on preoperative imaging and cystoscopic findings demonstrating predominant median lobe obstruction, including intravesical prostatic protrusion, high bladder neck, or an increased prostatic urethral angle. Patients with obstructing, coapting lateral lobes were not considered suitable for median lobe–only enucleation. In selected cases, ml-ThuFLEP was preferred at the surgeon’s discretion, with consideration of patient preference for preserving AE, particularly among younger and sexually active patients. Equipment and surgical procedure All procedures were performed by a single experienced surgeon with substantial expertise in endoscopic prostate enucleation. A TFL (Quanta System,Italy) was used in all cases. Laser settings were standardized at 60 W for cutting and 30 W for coagulation. A 22-French Tontarra resectoscope (Tontarra Medizintechnik GmbH, Tuttlingen, Germany) was utilized in all procedures. In the sThuFLEP group, complete anatomical enucleation of the median and both lateral lobes was performed using a standard three-lobe technique, followed by intravesical morcellation. In the ml-ThuFLEP group, enucleation was limited to the obstructing median lobe. Specifically, the initial incision was initiated approximately 1 to 1.5 cm proximal to the verumontanum and extended cranially while preserving a small apical tissue mound on both sides of the verumontanum to maintain antegrade ejaculation. The lateral lobes were intentionally preserved in this group. Hemostasis was achieved using laser coagulation, and a three-way Foley catheter was placed at the end of each procedure. Perioperative and postoperative data Preoperative variables included demographic characteristics, prostate-specific antigen (PSA), prostate volume, maximum flow rate (Qmax), postvoid residual volume (PVR), and International Prostate Symptom Score (IPSS). Prostate volume and PVR were measured by transabdominal ultrasonography. Perioperative data included operative time, tissue removed (g), operative efficiency (g/min), length of hospital stay, and catheterization duration. The follow-up was scheduled at 1,3 and 6 months postoperatively. Functional outcomes were evaluated by comparing changes in Qmax, PVR, IPSS, and PSA levels relative to baseline values. Postoperative complications, including capsule perforation, bleeding requiring intervention, urethral stricture, and urinary incontinence, were documented. Urinary incontinence was defined as any involuntary urine leakage reported by the patient at follow-up. Continence was defined as complete dryness. Stress urinary incontinence (SUI) was defined as involuntary leakage occurring during physical exertion, coughing, or sneezing. Urge urinary incontinence (UUI) was defined as involuntary leakage accompanied by or immediately preceded by urgency. Ejaculation statuses of the patients were assessed by recording the presence or absence of retrograde ejaculation at follow-up visits. Statistical analysis Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 26.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as median and interquartile range (IQR), while categorical variables were presented as frequencies and percentages. Between-group comparisons of continuous variables were performed using the Mann–Whitney U test. Within-group comparisons between baseline and postoperative follow-up values were assessed using the Wilcoxon signed-rank test. Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. P value < 0.05 was considered statistically significant. Results Baseline characteristics A total of 152 patients were included in the analysis, of whom 68 underwent sThuFLEP and 84 underwent ml-ThuFLEP. Patients in the sThuFLEP group were significantly older than those in the ml-ThuFLEP group [62 (8.58) vs. 57.5 (9.75) years, respectively; p < 0.001]. Prostate volume was also significantly larger in the sThuFLEP cohort [55 (13) cc vs. 47.5 (16.75) cc, respectively; p < 0.001]. Baseline functional parameters demonstrated statistically significant differences between groups (Table 1 ). Baseline Qmax was lower in the sThuFLEP group than ml-ThuFLEP group [9 (3) vs. 11 (3) ml/sec, respectively; p < 0.001]. Similarly, baseline IPSS and PVR were higher in the sThuFLEP group [IPSS: 20 (5) vs. 19 (5), respectively; p: 0.005 and PVR: 55 (55.25) vs. 39 (41) ml, respectively; p < 0.001]. Perioperative outcomes Perioperative outcomes are summarized in Table 1 . Operative time was significantly longer in the sThuFLEP group compared to ml-ThuFLEP [30 (13.5) vs. 10 (5) min, respectively; p < 0.001]. The amount of tissue removed was significantly greater in sThuFLEP [34 (13.75) g vs. 13 (6) g, respectively; p < 0.001]. However, operative efficiency (g/min) was slightly higher in the ml-ThuFLEP group [1.2 (0.14) vs. 1.1 (0.14), respectively; p:0.006]. Length of hospital stay and catheterization time were both significantly shorter in the ml-ThuFLEP group (1 vs. 2 days respectively for both parameters, p < 0.001). Capsule perforation occurred more frequently in the sThuFLEP group (5.9% vs. 0%, respectively; p:0.024). There were no statistically significant differences in bleeding requiring intervention (0% vs. 1.4%, respectively; p > 0.05) or urethral stricture rates (6.5% vs. 1.4%, respectively; p > 0.05). Functional outcomes Functional outcomes at baseline and 6 months are presented in Table 2 and Fig. 1 . Both sThuFLEP and ml-ThuFLEP groups demonstrated significant improvements in all functional parameters at 6 months compared to baseline (all p < 0.001). When comparing postoperative outcomes between groups, Qmax was slightly higher in the sThuFLEP group at 1 month [29 (5) vs. 27 (6) ml/sec, p: 0.036]; however, this difference was no longer observed at 3 months (p > 0.05) or 6 months (p > 0.05). At 6 months, IPSS [7 (4) vs. 6 (4), p > 0.05] and PVR [4.5 (3.75) vs. 5 (3) ml, p > 0.05] were not statistically significantly different between the two techniques (Table 1 ). RE was markedly more common following sThuFLEP (95.6% vs. 2.4%, respectively; p 0.05). In contrast, no cases of SUI were observed in either group. Table 1 Comparison of clinical, perioperative, and functional outcomes between sThuFLEP and ml-ThuFLEP sThuFLEP ml-ThuFLEP p median (IQR) median (IQR) Age, yr 62 (8,5) 57,5 (9,75) < 0.001 Prostate volume, cc 55 (13) 47,5 (16,75) < 0.001 Baseline Qmax ml/sec 9 (3) 11 (3) < 0.001 Baseline Qmean ml/sec 5 (2) 6 (2) 0.001 Baseline IPSS 20 (5) 19 (5) 0.005 Baseline PVR, ml 55 (55,25) 39 (41) < 0.001 Baseline PSA, ng/ml 2 (0,88) 1,2 (0,80) < 0.001 1-month Qmax ml/sec 29 (5) 27 (6) 0.036 3-month Qmax ml/sec 27 (5) 26 (4,75) 0.076 6-month Qmax ml/sec 26 (6) 25 (5) 0.156 6-month IPSS 7 (4) 6 (4) 0.76 6-month PVR, ml 4,5 (3,75) 5 (3) 0.92 6-month PSA, ng/ml 0,6 (0,53) 0,9 (0,40) < 0.001 Operative time, min 30 (13,5) 10 (5) < 0.001 Tissue removed, g 34 (13,75) 13 (6) < 0.001 Operation efficiency, g/min 1,1 (0,14) 1,2 (0,14) 0.006 Lenght of stay, days 2 (0 ) 1 (0) < 0.001 Catheterization time, days 2 (0) 1 (0) < 0.001 Retrograde ejeculation, n(%) 65 (95,6) 2 (2,4) < 0.001 Bleeding requiring intervention, n(%) 0 (0) 1 (1,4) 0.36 Urethral stricture, n(%) 4 (6,5) 1 (1,4) 0.12 Capsule perforation, n(%) 4 (5,9) 0 (0) 0.024 6-month UUI, n(%) 3 (4,8) 11 (14,9) 0.06 6-month SUI, n(%) 0 (0) 0 (0) N/A IPSS: International Prostate Symptom Score; PVR: Postvoid residual volume, PSA: Prostate-specific antigen; Qmax: maximal urinary flow rate; N/A: not applicable; sThuFLEP: standart Thulium fiber laser enucleation of the prostate; ml-ThuFLEP: median lobe–only Thulium fiber laser enucleation of the prostate; UUI: urge urinary incontinence; SUI: stress urinary incontinence Table 2 Changes in urinary and biochemical parameters from baseline to 6 months after sThuFLEP and ml-ThuFLEP PSA (ng/ml) Baseline 6th month p sThuFLEP 2 (0,88) 0,6 (0,53) < 0.001 ml-ThuFLEP 1,2 (0,80) 0,9 (0,40) < 0.001 IPSS sThuFLEP 20 (5) 7 (4) < 0.001 ml-ThuFLEP 19 (5) 6 (4) < 0.001 PVR (ml) sThuFLEP 55 (55,25) 4.5 (3,75) < 0.001 ml-ThuFLEP 39 (41) 5 (3) < 0.001 Qmax (ml/sec) sThuFLEP 9 (3) 26 (6) < 0.001 ml-ThuFLEP 11 (3) 25 (5) < 0.001 IPSS: International Prostate Symptom Score; PVR: Postvoid residual volume, PSA: Prostate-specific antigen; Qmax: maximal urinary flow rate; sThuFLEP: standart Thulium fiber laser enucleation of the prostate; ml-ThuFLEP: median lobe–only Thulium fiber laser enucleation of the prostate Discussion Although the LEP procedure has become more widespread and offers encouraging results in terms of urinary function, RE remains a significant problem for sexually active patients [ 16 ]. Consequently, ejaculatory preservation techniques are of paramount importance for patients. In this study, we could demonstrate that in patients who underwent ThuFLEP due to BPO, postoperative urinary function at 6 month has improved and the rate of RE was significantly lower when medial lobe-only enucleation was performed, in comparison to total lobe enucleation (for RE; 2.4% vs. 95.6%, respectively; p < 0.001). Despite the long-standing consensus that the primary anatomical structure implicated in RE is the bladder neck, and that inadequate bladder neck closure during ejaculation leads to RE, a study by Vernet et al. concluded that the bladder neck is not a significant contributing factor [ 17 ]. Vernet et al. utilised endorectal ultrasound videos to visualise the prostate, bulbar urethra, and bladder neck at the time of ejaculation during real-time masturbation. The images obtained revealed that the muscle tissue surrounding the verumontanum and its proximal portion plays a significant role in directing the ejaculate distally during ejaculation. The findings of studies that have demonstrated that postoperative RE is not solely due to insufficiency at the bladder neck provide important insights into the anatomical structures that require attention during enucleation and the strategies that should be followed [ 18 ]. Given that HoLEP has become the most popular BPO procedure in recent years, it is not surprising that the vast majority of studies in the literature are based on HoLEP’s ejaculation-preserving modification. In a very recent systematic review, data from a total of 1,657 patients who underwent HoLEP in 10 studies were analyzed. The study demonstrated that modified HoLEP techniques performed to preserve ejaculation provide significantly more AE compared to conventional HoLEP [ 19 ]. Additionally, it was reported that selective median lobe enucleation provides the highest AE protection in anatomically suitable patients. In another systematic review comprising 1877 men in 15 studies (12 HoLEP procedures, 3 ThuLEP procedures), the incidence rates of RE were compared between ejaculation-preserving LEP and standard LEP, and notwithstanding the technique applied, the rate of RE in LEP was determined to be 71.3% ± 16.1% with standard techniques and 27.2% ± 18.1% with modified techniques that preserve ejaculation (p < 0.001) [ 20 ]. In light of the recent surge in interest surrounding LEP, various approaches aimed at preventing ejaculation have gained prominence [ 19 ]. One of these procedures, median lobe enucleation is based on the isolated resection of the middle lobe, which is known to cause obstruction, while preserving the lateral lobes and ensuring that the structures surrounding the verumontanum remain intact. In a retrospective study by Press et al. aimed at preserving ejaculation, the authors performed "selective laser enucleation of the median lobe" [ 14 ]. In cases undergoing HoLEP, the mucosa above the verumontanum is incised, and the two lateral incisions are connected to each other. The median lobe is then removed retrograde along the capsular plane and directed towards the bladder. The remaining mucosal attachments at the bladder neck are cut, thereby freeing the median lobe. The study demonstrated that ejaculation was preserved in approximately 90% of the men. The authors posit that the preservation of the lateral lobes is instrumental in ensuring the preservation of paracolicular and supracolicular tissue, thereby preventing disruption of the ejaculatory anatomy. In another study, Depaquit et al. performed median lobe enucleation in 55 patients who underwent HoLEP and reported a de novo RE rate of 12.5% [ 21 ]. The present study is consistent with these findings; an AE rate of over 90% was demonstrated following ThuFLEP with median lobe enucleation. However, it is important to note that the energy source used in our study differs from those used in these studies. There is a lack of studies investigating ejaculation outcomes following ThuLEP and ThuFLEP. In a study, a comparison has been conducted on the outcomes of ejaculation-sparing ES-ThuLEP and ES-ThuFLEP procedures [ 22 ]. Accordingly, in both the 3-month and 6-month follow-ups, the rate of AE after ES-ThuLEP was 81.0% while it was 81.5% after ThuFLEP, and no significant difference was observed between the two groups. In the ejaculation-preserving technique utilised in this study, the initial incision was shifted approximately 1.5 cm cranially from the verumontanum. The incision was then extended towards the lateral lobes, leaving a small cluster of prostate tissue at the apex on either side of the verumontanum. Trama et al. performed ejaculatory-preserving surgery on patients who had undergone ThuLEP [ 15 ]. A 1-cm Omega-shaped incision was made at the cranial end of the verumontanum, after which the incision was extended towards the two lateral lobes. A small amount of tissue from the lateral lobes was preserved at the level of the prostatic apex near the verumontanum, in order to ensure the integrity of the ejaculatory muscles and to keep the verumontanum beneath the sphincter. It was anticipated that this would facilitate the passage of semen into the bulbar urethra. The study observed that ejaculation was preserved in 94% of patients at the 12-month postoperative follow-up. In another study, ES-ThuLEP was shown to effectively preserve ejaculation in more than two-thirds of 283 patients while improving urinary function [ 23 ]. It should be noted that the results of this study demonstrate that the efficacy of median lobe enucleation in this study was comparable to that of standard enucleation. While improvements were observed in outcomes such as Qmax [26 (6) vs. 25 (5), p > 0.05], IPSS [7 (4) vs. 6 (4), p > 0.05] and PVR [4.5 (3.75) vs. 5 (3) ml, p > 0.05] at 6 months postoperatively with both techniques, no significant difference was found between the two groups. Furthermore, SUI, a significant concern following LEP, was not observed in any patient at the 6-month follow-up. Therefore, it is important to emphasise that performing ml-ThuFLEP in suitable patients to preserve AE does not imply compromising on functional outcomes. To the best of our knowledge, our study is one of the few to investigate post-ThuFLEP RE; however, it is important to note the limitations of our study. First of all, the present study is retrospective in nature and is a single-surgeon study. Furthermore, the number of patients in the study is small, and the follow-up period is relatively short. It should also be noted that data on some functional outcomes such as IPSS or PVR at the 1- and 3-month postoperative periods are missing. Nevertheless, we believe that our functional outcomes at the 6-month postoperative period and our rates of antegrade ejaculation can be considered adequate in light of the focus of our study. Conclusions The median lobe-only ThuFLEP is an effective approach for improving postoperative urinary function while preserving AE in suitable patients. This technique may be proposed for patients who wish to preserve ejaculation after LEP procedure. Multicenter, large-scale prospective studies involving a broader patient population and a longer follow-up period are necessary to more clearly establish the generalizability of these results. Declarations Funding: No funding was received. Conflicts of interest: The authors have no conflicts of interest to declare. Availability of data and material: The raw data is with the corresponding author and can be provided on request. Code availability: Not applicable for this section. Authors' contributions: Y.O.A. took part in the study design and supervision, while K.Y.Y. and E.G. collected the data and wrote the first manuscript draft. M.E.A. shaped the article to its final form, proof-reading and rearranging for better flow. Ethics approval: Approval was obtained from Istinye University Faculty of Medicine Institutional Review Board (Approval Number ID: 25-57 ). The procedures used in this study adhere to the tenets of the Declaration of Helsinki . Consent to participate (include appropriate statements): Not applicable for this section . Consent for publication: Not applicable for this section. 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Fr J Urol 34:102581. 10.1016/j.fjurol.2024.102581 Perri D, Besana U, Mazzoleni F, Pacchetti A, Calcagnile T, Romero-Otero J, Roche JB, Govorov A, Pushkar D, Pastore AL, Sighinolfi MC, Rocco B, Bozzini G (2025) Ejaculation-sparing enucleation of the prostate with Thulium: Yag laser (ES-ThuLEP) versus Thulium Fiber laser (ES-ThuFLEP): outcomes on sexual function. World J Urol 43:92. 10.1007/s00345-025-05483-x Bozzini G, Berti L, Maltagliati M, Besana U, Calori A, Müller A, Sighinolfi MC, Micali S, Pastore AL, Ledezma R, Broggini P, Rocco B, Buizza C (2021) Ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP): outcomes on a large cohort. World J Urol 39:2029–2035. 10.1007/s00345-020-03442–2 Additional Declarations No competing interests reported. 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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-9500849","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635022556,"identity":"bfd11c7e-e075-4848-b227-b587ad142424","order_by":0,"name":"Kenan Yiğit Yıldız","email":"data:image/png;base64,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","orcid":"","institution":"Istinye University","correspondingAuthor":true,"prefix":"","firstName":"Kenan","middleName":"Yiğit","lastName":"Yıldız","suffix":""},{"id":635022557,"identity":"5f413f53-98ff-4132-b998-f87462a90e64","order_by":1,"name":"Eymen Gazel","email":"","orcid":"","institution":"Liv Hospital Vadiistanbul Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eymen","middleName":"","lastName":"Gazel","suffix":""},{"id":635022558,"identity":"e95a941e-9c01-4e8c-93e6-4c539efcbb90","order_by":2,"name":"Mehmet Eren Akan","email":"","orcid":"","institution":"Sisli Hamidiye Etfal Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Eren","lastName":"Akan","suffix":""},{"id":635022559,"identity":"e208a868-df4c-40b9-8837-a5b2f9b6d526","order_by":3,"name":"Yusuf Oğuz Acar","email":"","orcid":"","institution":"Liv Hospital Vadiistanbul Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yusuf","middleName":"Oğuz","lastName":"Acar","suffix":""}],"badges":[],"createdAt":"2026-04-23 00:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9500849/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9500849/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108972226,"identity":"861639e8-e2db-46de-b7d6-b795b9705079","added_by":"auto","created_at":"2026-05-11 10:35:10","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":159211,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChanges in Qmax, IPSS, and PVR in the sThuFLEP and ml-ThuFLEP groups over time.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9500849/v1/24100db24e07241c69c9cd06.jpeg"},{"id":108982209,"identity":"37425e10-907e-4f94-bf3b-1415ff13edf0","added_by":"auto","created_at":"2026-05-11 12:24:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":431759,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9500849/v1/52a40838-f5eb-433f-8234-bd6ec0bbd7b7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Analysis of Standard ThuFLEP versus Median lobe-only ThuFLEP: Impact on Antegrade Ejaculation Preservation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are a health problem that affects 50\u0026ndash;75% of men aged 50 and over are known to have a significant impact upon men's quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over the past ten years, minimally invasive approaches to surgical treatment of BPO have become increasingly popular. First described in 1998, Holmium laser enucleation of the prostate (HoLEP) is currently the most widely used minimally invasive BPO method worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdvancements in laser technology, which have become ubiquitous in the field of endourology, have paved the way for the introduction of various laser types in the arena of BPO surgery and studies have demonstrated the efficacy of these lasers in enhancing postoperative functional outcomes in prostatic enucleation [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. One of these, the Thulium fiber laser (TFL) was introduced as a novel energy source for laser enucleation of the prostate (LEP) in 2005 and commenced utilisation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Studies show that Thulium fiber laser enucleation of the prostate (ThuFLEP) procedur is as effective and reliable as HoLEP in the surgical treatment of BPO, even in large prostates [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough LUTS shows significant improvement postoperatively, retrograde ejaculation (RE), which is a common adverse effect following LEP [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], can be bothersome for sexually active patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. To manage RE, various ejaculation-preserving techniques for different lasers are employed during LEP procedure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, there is lack on the ejaculation-preserving approach in LEP surgery performed using TFL. In the present study, we aimed to demonstrate the effect of median lobe-only enucleation on antegrade ejaculation (AE) in patients undergoing ThuFLEP due to BPO.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eAfter obtaining approval from the institutional review board (IRB: 2025/3-2557), we performed a retrospective review of patients who underwent ThuFLEP between May 2024 and December 2025.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eA total of 152 patients were included in the study. Patients were eligible for inclusion if they had a maximum urinary flow rate (Qmax) of \u0026le;\u0026thinsp;15 mL/s, an International Prostate Symptom Score (IPSS) of \u0026ge;\u0026thinsp;12, a post-void residual volume (PVR) of \u0026gt;\u0026thinsp;100 mL, inadequate response to at least 6 months of medical therapy (alpha-blockers and/or 5-alpha reductase inhibitors), recurrent or refractory urinary retention, or bladder stones. Patients with a history of urethral stricture, neurogenic bladder dysfunction, prostate cancer, prior prostatic or pelvic surgery, previous pelvic radiotherapy or postoperative use of alpha-adrenergic antagonists were excluded from the analysis. Among the patients who underwent ThuFLEP, 84 comprised the median lobe\u0026ndash;only enucleation group (ml-ThuFLEP), while 68 constituted the standard ThuFLEP group performed using the standart three lobe technique (sThuFLEP). Between two groups, perioperative and postoperative functional outcomes, as well as postoperative ejaculation statuses of the patients, were evaluated and compared. ml-ThuFLEP was performed in carefully selected patients following comprehensive preoperative counseling. Selection was based on preoperative imaging and cystoscopic findings demonstrating predominant median lobe obstruction, including intravesical prostatic protrusion, high bladder neck, or an increased prostatic urethral angle. Patients with obstructing, coapting lateral lobes were not considered suitable for median lobe\u0026ndash;only enucleation. In selected cases, ml-ThuFLEP was preferred at the surgeon\u0026rsquo;s discretion, with consideration of patient preference for preserving AE, particularly among younger and sexually active patients.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEquipment and surgical procedure\u003c/h3\u003e\n\u003cp\u003eAll procedures were performed by a single experienced surgeon with substantial expertise in endoscopic prostate enucleation. A TFL (Quanta System,Italy) was used in all cases. Laser settings were standardized at 60 W for cutting and 30 W for coagulation. A 22-French Tontarra resectoscope (Tontarra Medizintechnik GmbH, Tuttlingen, Germany) was utilized in all procedures.\u003c/p\u003e \u003cp\u003eIn the sThuFLEP group, complete anatomical enucleation of the median and both lateral lobes was performed using a standard three-lobe technique, followed by intravesical morcellation.\u003c/p\u003e \u003cp\u003eIn the ml-ThuFLEP group, enucleation was limited to the obstructing median lobe. Specifically, the initial incision was initiated approximately 1 to 1.5 cm proximal to the verumontanum and extended cranially while preserving a small apical tissue mound on both sides of the verumontanum to maintain antegrade ejaculation. The lateral lobes were intentionally preserved in this group. Hemostasis was achieved using laser coagulation, and a three-way Foley catheter was placed at the end of each procedure.\u003c/p\u003e\n\u003ch3\u003ePerioperative and postoperative data\u003c/h3\u003e\n\u003cp\u003ePreoperative variables included demographic characteristics, prostate-specific antigen (PSA), prostate volume, maximum flow rate (Qmax), postvoid residual volume (PVR), and International Prostate Symptom Score (IPSS). Prostate volume and PVR were measured by transabdominal ultrasonography. Perioperative data included operative time, tissue removed (g), operative efficiency (g/min), length of hospital stay, and catheterization duration.\u003c/p\u003e \u003cp\u003eThe follow-up was scheduled at 1,3 and 6 months postoperatively. Functional outcomes were evaluated by comparing changes in Qmax, PVR, IPSS, and PSA levels relative to baseline values.\u003c/p\u003e \u003cp\u003ePostoperative complications, including capsule perforation, bleeding requiring intervention, urethral stricture, and urinary incontinence, were documented. Urinary incontinence was defined as any involuntary urine leakage reported by the patient at follow-up. Continence was defined as complete dryness. Stress urinary incontinence (SUI) was defined as involuntary leakage occurring during physical exertion, coughing, or sneezing. Urge urinary incontinence (UUI) was defined as involuntary leakage accompanied by or immediately preceded by urgency.\u003c/p\u003e \u003cp\u003eEjaculation statuses of the patients were assessed by recording the presence or absence of retrograde ejaculation at follow-up visits.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 26.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as median and interquartile range (IQR), while categorical variables were presented as frequencies and percentages. Between-group comparisons of continuous variables were performed using the Mann\u0026ndash;Whitney U test. Within-group comparisons between baseline and postoperative follow-up values were assessed using the Wilcoxon signed-rank test. Categorical variables were compared using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eA total of 152 patients were included in the analysis, of whom 68 underwent sThuFLEP and 84 underwent ml-ThuFLEP. Patients in the sThuFLEP group were significantly older than those in the ml-ThuFLEP group [62 (8.58) vs. 57.5 (9.75) years, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Prostate volume was also significantly larger in the sThuFLEP cohort [55 (13) cc vs. 47.5 (16.75) cc, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001].\u003c/p\u003e \u003cp\u003eBaseline functional parameters demonstrated statistically significant differences between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Baseline Qmax was lower in the sThuFLEP group than ml-ThuFLEP group [9 (3) vs. 11 (3) ml/sec, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Similarly, baseline IPSS and PVR were higher in the sThuFLEP group [IPSS: 20 (5) vs. 19 (5), respectively; p: 0.005 and PVR: 55 (55.25) vs. 39 (41) ml, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerioperative outcomes\u003c/h3\u003e\n\u003cp\u003ePerioperative outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Operative time was significantly longer in the sThuFLEP group compared to ml-ThuFLEP [30 (13.5) vs. 10 (5) min, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. The amount of tissue removed was significantly greater in sThuFLEP [34 (13.75) g vs. 13 (6) g, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. However, operative efficiency (g/min) was slightly higher in the ml-ThuFLEP group [1.2 (0.14) vs. 1.1 (0.14), respectively; p:0.006].\u003c/p\u003e \u003cp\u003eLength of hospital stay and catheterization time were both significantly shorter in the ml-ThuFLEP group (1 vs. 2 days respectively for both parameters, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eCapsule perforation occurred more frequently in the sThuFLEP group (5.9% vs. 0%, respectively; p:0.024). There were no statistically significant differences in bleeding requiring intervention (0% vs. 1.4%, respectively; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) or urethral stricture rates (6.5% vs. 1.4%, respectively; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003ch3\u003eFunctional outcomes\u003c/h3\u003e\n\u003cp\u003eFunctional outcomes at baseline and 6 months are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Both sThuFLEP and ml-ThuFLEP groups demonstrated significant improvements in all functional parameters at 6 months compared to baseline (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eWhen comparing postoperative outcomes between groups, Qmax was slightly higher in the sThuFLEP group at 1 month [29 (5) vs. 27 (6) ml/sec, p: 0.036]; however, this difference was no longer observed at 3 months (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) or 6 months (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). At 6 months, IPSS [7 (4) vs. 6 (4), p\u0026thinsp;\u0026gt;\u0026thinsp;0.05] and PVR [4.5 (3.75) vs. 5 (3) ml, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05] were not statistically significantly different between the two techniques (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRE was markedly more common following sThuFLEP (95.6% vs. 2.4%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At 6 months, the rate of UUI was higher in the ml-ThuFLEP group compared to the sThuFLEP group (14.9% vs. 4.8%); however, no statistically significant difference was observed (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In contrast, no cases of SUI were observed in either group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical, perioperative, and functional outcomes between sThuFLEP and ml-ThuFLEP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003esThuFLEP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eml-ThuFLEP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (8,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57,5 (9,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate volume, cc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47,5 (16,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline Qmax ml/sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline Qmean ml/sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline IPSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline PVR, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (55,25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline PSA, ng/ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0,88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,2 (0,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-month Qmax ml/sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3-month Qmax ml/sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (4,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month Qmax ml/sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month IPSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month PVR, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,5 (3,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month PSA, ng/ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,6 (0,53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,9 (0,40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (13,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTissue removed, g\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (13,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation efficiency, g/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,1 (0,14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,2 (0,14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLenght of stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheterization time, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetrograde ejeculation, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (95,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding requiring intervention, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrethral stricture, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapsule perforation, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month UUI, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-month SUI, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIPSS:\u0026nbsp;International Prostate Symptom Score; PVR: Postvoid residual volume, PSA: Prostate-specific antigen; Qmax: maximal urinary flow rate; N/A: not applicable; sThuFLEP: standart Thulium fiber laser enucleation of the prostate; ml-ThuFLEP: median lobe\u0026ndash;only Thulium fiber laser enucleation of the prostate; UUI: urge urinary incontinence; SUI: stress urinary incontinence\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in urinary and biochemical parameters from baseline to 6 months after sThuFLEP and ml-ThuFLEP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePSA (ng/ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6th month\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0,88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,6 (0,53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eml-ThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,2 (0,80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,9 (0,40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eml-ThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVR (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (55,25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5 (3,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eml-ThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQmax (ml/sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eml-ThuFLEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIPSS:\u0026nbsp;International Prostate Symptom Score; PVR: Postvoid residual volume, PSA: Prostate-specific antigen;\u0026nbsp;Qmax: maximal urinary flow rate; sThuFLEP: standart Thulium fiber laser enucleation of the prostate; ml-ThuFLEP: median lobe\u0026ndash;only Thulium fiber laser enucleation of the prostate\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eAlthough the LEP procedure has become more widespread and offers encouraging results in terms of urinary function, RE remains a significant problem for sexually active patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Consequently, ejaculatory preservation techniques are of paramount importance for patients. In this study, we could demonstrate that in patients who underwent ThuFLEP due to BPO, postoperative urinary function at 6 month has improved and the rate of RE was significantly lower when medial lobe-only enucleation was performed, in comparison to total lobe enucleation (for RE; 2.4% vs. 95.6%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eDespite the long-standing consensus that the primary anatomical structure implicated in RE is the bladder neck, and that inadequate bladder neck closure during ejaculation leads to RE, a study by Vernet et al. concluded that the bladder neck is not a significant contributing factor [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Vernet et al. utilised endorectal ultrasound videos to visualise the prostate, bulbar urethra, and bladder neck at the time of ejaculation during real-time masturbation. The images obtained revealed that the muscle tissue surrounding the verumontanum and its proximal portion plays a significant role in directing the ejaculate distally during ejaculation. The findings of studies that have demonstrated that postoperative RE is not solely due to insufficiency at the bladder neck provide important insights into the anatomical structures that require attention during enucleation and the strategies that should be followed [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven that HoLEP has become the most popular BPO procedure in recent years, it is not surprising that the vast majority of studies in the literature are based on HoLEP\u0026rsquo;s ejaculation-preserving modification. In a very recent systematic review, data from a total of 1,657 patients who underwent HoLEP in 10 studies were analyzed. The study demonstrated that modified HoLEP techniques performed to preserve ejaculation provide significantly more AE compared to conventional HoLEP [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, it was reported that selective median lobe enucleation provides the highest AE protection in anatomically suitable patients. In another systematic review comprising 1877 men in 15 studies (12 HoLEP procedures, 3 ThuLEP procedures), the incidence rates of RE were compared between ejaculation-preserving LEP and standard LEP, and notwithstanding the technique applied, the rate of RE in LEP was determined to be 71.3% \u0026plusmn; 16.1% with standard techniques and 27.2% \u0026plusmn; 18.1% with modified techniques that preserve ejaculation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn light of the recent surge in interest surrounding LEP, various approaches aimed at preventing ejaculation have gained prominence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. One of these procedures, median lobe enucleation is based on the isolated resection of the middle lobe, which is known to cause obstruction, while preserving the lateral lobes and ensuring that the structures surrounding the verumontanum remain intact. In a retrospective study by Press et al. aimed at preserving ejaculation, the authors performed \"selective laser enucleation of the median lobe\" [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In cases undergoing HoLEP, the mucosa above the verumontanum is incised, and the two lateral incisions are connected to each other. The median lobe is then removed retrograde along the capsular plane and directed towards the bladder. The remaining mucosal attachments at the bladder neck are cut, thereby freeing the median lobe. The study demonstrated that ejaculation was preserved in approximately 90% of the men. The authors posit that the preservation of the lateral lobes is instrumental in ensuring the preservation of paracolicular and supracolicular tissue, thereby preventing disruption of the ejaculatory anatomy. In another study, Depaquit et al. performed median lobe enucleation in 55 patients who underwent HoLEP and reported a de novo RE rate of 12.5% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The present study is consistent with these findings; an AE rate of over 90% was demonstrated following ThuFLEP with median lobe enucleation. However, it is important to note that the energy source used in our study differs from those used in these studies.\u003c/p\u003e \u003cp\u003eThere is a lack of studies investigating ejaculation outcomes following ThuLEP and ThuFLEP. In a study, a comparison has been conducted on the outcomes of ejaculation-sparing ES-ThuLEP and ES-ThuFLEP procedures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Accordingly, in both the 3-month and 6-month follow-ups, the rate of AE after ES-ThuLEP was 81.0% while it was 81.5% after ThuFLEP, and no significant difference was observed between the two groups. In the ejaculation-preserving technique utilised in this study, the initial incision was shifted approximately 1.5 cm cranially from the verumontanum. The incision was then extended towards the lateral lobes, leaving a small cluster of prostate tissue at the apex on either side of the verumontanum. Trama et al. performed ejaculatory-preserving surgery on patients who had undergone ThuLEP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A 1-cm Omega-shaped incision was made at the cranial end of the verumontanum, after which the incision was extended towards the two lateral lobes. A small amount of tissue from the lateral lobes was preserved at the level of the prostatic apex near the verumontanum, in order to ensure the integrity of the ejaculatory muscles and to keep the verumontanum beneath the sphincter. It was anticipated that this would facilitate the passage of semen into the bulbar urethra. The study observed that ejaculation was preserved in 94% of patients at the 12-month postoperative follow-up. In another study, ES-ThuLEP was shown to effectively preserve ejaculation in more than two-thirds of 283 patients while improving urinary function [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt should be noted that the results of this study demonstrate that the efficacy of median lobe enucleation in this study was comparable to that of standard enucleation. While improvements were observed in outcomes such as Qmax [26 (6) vs. 25 (5), p\u0026thinsp;\u0026gt;\u0026thinsp;0.05], IPSS [7 (4) vs. 6 (4), p\u0026thinsp;\u0026gt;\u0026thinsp;0.05] and PVR [4.5 (3.75) vs. 5 (3) ml, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05] at 6 months postoperatively with both techniques, no significant difference was found between the two groups. Furthermore, SUI, a significant concern following LEP, was not observed in any patient at the 6-month follow-up. Therefore, it is important to emphasise that performing ml-ThuFLEP in suitable patients to preserve AE does not imply compromising on functional outcomes.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, our study is one of the few to investigate post-ThuFLEP RE; however, it is important to note the limitations of our study. First of all, the present study is retrospective in nature and is a single-surgeon study. Furthermore, the number of patients in the study is small, and the follow-up period is relatively short. It should also be noted that data on some functional outcomes such as IPSS or PVR at the 1- and 3-month postoperative periods are missing. Nevertheless, we believe that our functional outcomes at the 6-month postoperative period and our rates of antegrade ejaculation can be considered adequate in light of the focus of our study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe median lobe-only ThuFLEP is an effective approach for improving postoperative urinary function while preserving AE in suitable patients. This technique may be proposed for patients who wish to preserve ejaculation after LEP procedure. Multicenter, large-scale prospective studies involving a broader patient population and a longer follow-up period are necessary to more clearly establish the generalizability of these results.\u003c/span\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u0026nbsp;\u003c/strong\u003eThe authors\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ehave no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eThe raw data is with the corresponding author and can be provided on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability:\u0026nbsp;\u003c/strong\u003eNot applicable for this section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e Y.O.A. took part in the study design and supervision, while K.Y.Y. and E.G. collected the data and wrote the first manuscript draft. M.E.A. shaped the article to its final form, proof-reading and rearranging for better flow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eApproval was obtained from Istinye University Faculty of Medicine Institutional Review Board (Approval Number ID: 25-57 ). The procedures used in this study adhere to the tenets of the Declaration of Helsinki\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate (include appropriate statements):\u0026nbsp;\u003c/strong\u003eNot applicable for this section\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable for this section.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEgan KB (2016) The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. 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World J Urol 39:2029\u0026ndash;2035. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-020-03442\u0026ndash;2\u003c/span\u003e\u003cspan address=\"10.1007/s00345-020-03442\u0026ndash;2\" 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":"[email protected]","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":"antegrade ejaculation, benign prostatic obstruction, laser enucleation, retrograde ejaculation, ThuFLEP","lastPublishedDoi":"10.21203/rs.3.rs-9500849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9500849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eWe aimed to demonstrate the effect of median lobe-only enucleation on antegrade ejaculation (AE) in patients undergoing Thulium fiber laser enucleation of the prostate (ThuFLEP) due to BPO.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed the patients who underwent ThuFLEP between May 2024 and December 2025 for benign prostatic obstruction (BPO). 84 patients comprised the median lobe\u0026ndash;only enucleation group (ml-ThuFLEP), while 68 constituted the standard ThuFLEP group performed using the standart three lobe technique (sThuFLEP). Perioperative and postoperative functional outcomes, as well as postoperative ejaculation statuses of the patients, were evaluated and compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn both groups, regarding Qmax [26 (6) vs. 25 (5), p: 0.156], IPSS [7 (4) vs. 6 (4), p\u0026thinsp;\u0026gt;\u0026thinsp;0.05], and PVR [4.5 (3.75) vs. 5 (3) ml, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05], no significant difference was found between the two groups at the 6-month postoperative follow-up. The rate of retrograde ejaculation (RE) was significantly lower when medial lobe-only enucleation was performed, in comparison to standart enucleation (for RE; 2.4% vs. 95.6%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe median lobe-only ThuFLEP is an effective approach for improving postoperative urinary function while preserving AE in suitable patients. This technique may be proposed for patients who wish to preserve ejaculation after LEP procedure.\u003c/p\u003e","manuscriptTitle":"Comparative Analysis of Standard ThuFLEP versus Median lobe-only ThuFLEP: Impact on Antegrade Ejaculation Preservation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 10:34:53","doi":"10.21203/rs.3.rs-9500849/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"4ff77476-f05b-4d92-877e-5f1d1083e6eb","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-11T08:52:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T23:49:42+00:00","index":35,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T04:28:09+00:00","index":34,"fulltext":""},{"type":"reviewerAgreed","content":"179878248633301917079600713500247226513","date":"2026-05-05T19:38:41+00:00","index":33,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T22:12:31+00:00","index":32,"fulltext":""},{"type":"reviewerAgreed","content":"312635111289448379083585537362189892611","date":"2026-05-03T20:11:34+00:00","index":31,"fulltext":""},{"type":"reviewerAgreed","content":"215930183351614235928750337717445634974","date":"2026-05-03T18:53:53+00:00","index":30,"fulltext":""},{"type":"reviewerAgreed","content":"100071882111331204025296004414300837638","date":"2026-05-03T16:27:13+00:00","index":29,"fulltext":""},{"type":"reviewerAgreed","content":"260011946942373877566766543634890423543","date":"2026-05-02T19:55:13+00:00","index":28,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T23:26:51+00:00","index":25,"fulltext":""},{"type":"reviewerAgreed","content":"137668215688891313129530757623309830854","date":"2026-04-30T21:45:49+00:00","index":24,"fulltext":""},{"type":"reviewerAgreed","content":"110048742301461077224891545099172795288","date":"2026-04-30T17:16:19+00:00","index":23,"fulltext":""},{"type":"reviewerAgreed","content":"145475690543344131513648008818562626281","date":"2026-04-30T16:04:02+00:00","index":22,"fulltext":""},{"type":"reviewersInvited","content":"16","date":"2026-04-30T15:54:47+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T11:36:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 10:34:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9500849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9500849","identity":"rs-9500849","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}