Endoscopic enucleation of the prostate versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review and meta-analysis

Background: Endoscopic enucleation of the prostate (EEP) has emerged as a leading surgical treatment for benign prostatic hyperplasia (BPH), traditionally managed by transurethral resection of the prostate (TURP). EEP involves complete adenoma removal along the surgical capsule and can be performed using different energy sources, such as holmium, thulium, GreenLight and diode lasers, or bipolar electrocautery. This meta-analysis compares the efficacy and safety of EEP versus TURP. Methods: A comprehensive search of MEDLINE, EMBASE, CENTRAL, Web of Science, and Scopus (2003-present) identified randomised controlled trials (RCTs) comparing EEP with TURP in adult males (≥18 years) with BPH. Primary outcomes comprised functional measures (Qmax, PVR, IPSS, QoL, IIEF-5), while secondary outcomes included adverse events (incontinence, bleeding, infection, re-treatment rates, hospital stay duration). Two reviewers independently performed data extraction and assessed risk of bias using the Cochrane RoB2 tool. Results: Twenty-eight RCTs (n = 3085) met inclusion criteria: 1538 patients underwent EEP and 1547 underwent TURP. EEP was associated with significantly improved IPSS (at 12 months), Qmax (1, 6, 12, 24 months), and PVR (6, 12, 36 months) compared with TURP. Perioperative outcomes favoured EEP, including shorter catheterisation time (MD = −1.12 days), reduced hospital stay (MD = −0.92 days), and lower transfusion rates (RR = 0.22). No significant differences were observed in long-term incontinence or bladder neck contracture, though EEP yielded lower stricture rates (RR = 0.55) and reoperation rates for recurrent BPH (RR = 0.32). Heterogeneity was high in several outcomes, reflecting variability in patient characteristics, enucleation techniques, and surgeon experience. Conclusions: EEP compares favourably with TURP for BPH, providing notable benefits in bleeding control, faster recovery and durable obstruction relief. Anatomical enucleation yields functional outcomes at least equal and often superior to TURP. Energy source choice may reflect resources and surgeon preferences. Future research should distinguish enucleation completeness from energy source.