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Clinical

Complication rate across the minimally invasive surgical treatments (MISTs): where do we stand? A systematic review of the literature

Prostate Cancer and Prostatic Diseases volume 28, pages 639–651 (2025)Cite this article

Subjects

Abstract

Background

Over the past decade, the range of surgical options to benign prostatic obstruction (BPO) has expanded significantly with the advent of minimally invasive surgical therapies (MISTs). Nevertheless, the available evidence in the field is heterogeneous. Efficacy and safety thresholds are yet to be determined.

Objective

To evaluate perioperative and long-term complications after MISTs - including Aquablation, steam injection (Rezūm), Transperineal laser ablation of the prostate (TPLA), implantation of a prostatic urethral lift (PUL) and temporary implantable nitinol device (iTIND) - in patients with lower urinary tract symptoms due to BPO.

Evidence acquisition

A systematic literature search was conducted in January 2024 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria (Patients, Interventions, Comparisons, Outcomes) [1], focusing specifically on patients with BPH-associated LUTS who underwent MIST or other comparative treatments, aiming to assess both perioperative and long-term safety outcomes. Article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest.

Evidence synthesis

The initial electronic search identified 3660 records, of which 24 ultimately met the inclusion criteria and were included in the analysis. Overall, Aquablation was associated with a higher major complications rate of 14% (IQR 6–22), particularly in the case of patients with prostates <70 ml. PUL showed a higher early postoperative acute urinary retention rate (10.9%, IQR 9.2–12.3%), while 1.4% of patients treated with iTIND experienced major perioperative complications. Urinary tract infections were mostly reported in series assessing TPLA and Rezūm.

Conclusions

The adoption of MISTs for LUTS due to BPH is associated with a varied spectrum of perioperative and long-term complications. Our findings showed an acceptable safety profile with specific complications dependent on the type of MIST performed, highlighting the importance of individualized patient selection and procedure-specific considerations.

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Fig. 1: Major complications rate across included series according to prostate volume.
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Authors and Affiliations

  1. Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50121, Florence, Italy

    Luca Lambertini, Alessandro Sandulli, Simone Coco, Daniele Paganelli, Anna Cadenar, Fabrizio Di Maida, Antonio Andrea Grosso, Gianni Vittori, Andrea Minervini & Andrea Mari

  2. Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Paolo Dell’Oglio

  3. Department of Urology, University of Modena and Reggio Emilia, Modena, Italy

    Stefano Puliatti

  4. University of Turin San Luigi Gonzaga Hospital, Division of Urology, Turin, Italy

    Daniele Amparore

  5. Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy

    Riccardo Bertolo & Alessandro Antonelli

  6. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy

    Riccardo Campi

  7. Department of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy

    Riccardo Lombardo & Cosimo De Nunzio

  8. Unit of Urology, Department of Health Science, University of Milan, ASST Santi Paolo and Carlo, Milan, Italy

    Matteo Ferro & Bernardo Rocco

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  1. Luca Lambertini
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Contributions

LL: Conceptualization, data analysis, original draft preparation. AS, SC, DP: Data collection, Data Analysis; AC: Data collection and curation; PDO, SP, FDM, AAG, DA, RB, RC, RL, MF, BR, GV, AA, CDN: Manuscript revision and editing; AM, AM: Supervision, original draft preparation, conceptualization.

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Correspondence to Andrea Mari.

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CDN, Editor in Chief of prostate Cancer and Prostatic Disease.

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Lambertini, L., Sandulli, A., Coco, S. et al. Complication rate across the minimally invasive surgical treatments (MISTs): where do we stand? A systematic review of the literature. Prostate Cancer Prostatic Dis 28, 639–651 (2025). https://doi.org/10.1038/s41391-024-00900-5

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