Redefining clinical success in minimally invasive surgery for BPH: A composite endpoint integrating ejaculatory function, urinary improvement, and safety metrics

Objectives: Achieving both relief of urinary obstruction and preservation of ejaculatory function is a key goal of modern surgical management for benign prostatic hyperplasia (BPH). However, standardized definitions of success that integrate multiple clinical domains remain limited. This study introduces a composite definition of clinical success and explores its predictors using a multicenter dataset of minimally invasive, ejaculation-preserving procedures. Methods: Multi-institutional data were combined, including patients who underwent urethral-sparing robot-assisted simple prostatectomy (usRASP; n = 94), Aquablation ( n = 95), or Rezum ( n = 308). Complete clinical success (CSS) was defined as: (1) ⩾30% International Prostatic Symptoms Score (IPSS) reduction at 12-months; (2) preserved ejaculation, based on a positive response to the Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EjD Q3); and (3) absence of ⩾Grade III Clavien–Dindo complications. Partial clinical success (PCS) was defined as the achievement of any two of the three criteria. A multivariable logistic regression analysis identified independent predictors of CCS. Results: The final cohort included 497 patients. CCS rates were 66.0% (usRASP), 73.6% (Aquablation), and 68.8% (Rezum); PCS rates were 28.7%, 14.7%, and 20.1%, respectively. No significant differences were observed among groups for IPSS ( p = 0.455), ejaculation rates ( p = 0.07), or complication rates ( p = 0.445). On multivariable analysis, prostate volume < 110 mL (OR 0.52; p = 0.034), higher MSHQ-EjD Q3 (OR 1.07; p < 0.001), and shorter catheterization time (OR 0.91; p = 0.02) independently predicted CCS at 1 year. Conclusions: This composite endpoint offers a pragmatic and clinically relevant framework for evaluating success in minimally invasive BPH surgery. Its adoption may enhance cross-technique comparisons and inform individualized treatment strategies.