Comparative Effectiveness of MRI-Guided Transurethral Ultrasound Ablation, TURP, and HoLEP for Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

Abstract

Introduction: Benign prostatic hyperplasia (BPH) causes lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BPO). MRI-guided transurethral ultrasound ablation (TULSA) offers real-time thermal feedback for precise prostate ablation. This systematic review and meta-analysis evaluates the efficacy, safety, and functional outcomes of TULSA for BPH/LUTS.

Methods: A systematic review was conducted following PRISMA guidelines. Major databases were screened for adult men (≥18 years) with BPH/BPO/LUTS undergoing TULSA. Outcomes included IPSS, Qmax, PVR, QoL, prostate volume reduction, complications, and retreatment rates.

Results: From 50 identified sources, 5 provided direct BPH-specific data (n=158). The BPH-dedicated study (Anttinen et al., n=20) showed significant improvement: median IPSS decreased from 16 to 6, Qmax increased from 11 to 23 mL/s, and prostate volume reduced from 51 to 38 mL (p<0.01). All 17 patients discontinued LUTS medications post-procedure. In a PCa subgroup with severe LUTS (Elterman et al., n=9), IPSS improved 58% to 6.3 (p=0.003), with 70% prostate volume reduction. Continence preservation was 96-100%, and IIEF scores remained stable or improved. Major complications (Clavien-Dindo grade IIIa) occurred in 5-7% (epididymitis). No grade IV/V events or bowel injuries were reported.

Conclusion: TULSA is a safe, feasible MIST for BPH/LUTS, providing significant symptom relief, improved flow rates, excellent continence, and preserved sexual function. However, evidence is limited to single-arm, small cohorts with short follow-up. High-level RCT evidence with long-term follow-up is urgently needed