Innovations in the surgical management of BPH safeguard sexual health

When considering surgical treatment for benign prostatic hyperplasia (BPH), patients and providers must weigh the potential improvement in urinary symptoms against multiple factors, including the risk for postprocedural sexual dysfunction. The new standard of care should include counseling men with BPH who are sexually active on available treatment options as well as the potential risks to sexual health, said Kevin Zorn, MD.

Zorn, the Director of Robotics/MIS Mont-Royal Surgery Center at the University of Montreal Hospital, in Montreal, Canada, delivered Sunday’s State-of-the-Art Lecture: Preservation of Ejaculatory Function with BPH Treatments, at the 2025 Annual Meeting of the American Urological Association (AUA 2025) in Las Vegas, Nevada.

In an era when men live longer and continue to be sexually active, the preservation of erectile and ejaculatory functions has become an important preoperative consideration for individuals undergoing surgery for BPH. In a study designed to evaluate the perspectives of 300 men who had undergone or were contemplating surgery for BPH, Zorn and colleagues showed that most patients and candidates were concerned about the permanent impact of the procedures on sexual function, regardless of their age, and more than 90% of the participants wanted to discuss ejaculatory function preoperatively [Bouhadana D et al. J Sex Med. 2020;17(10):2108-2112]. A different study conducted at the Houston Methodist Hospital, presented at AUA 2025, also showed that the loss of ejaculatory function was the number one concern before BPH surgery in a cohort of more than 1,000 U.S.-based patients

The rates of ejaculatory dysfunction after surgery for BPH have decreased significantly over the past decade, due to the introduction of multiple minimally invasive surgical techniques (MIST), which give select patients the option to improve urinary symptoms with a minimal impact on ejaculation. In patients with large prostate volumes (>80 cc), Aquablation has been shown to preserve sexual function in more than 85% of cases, with much more favorable outcomes than those of conventional treatments such as transurethral resection of the prostate (TURP) or laser enucleation (LEP). 
Aquablation is a minimally invasive surgical procedure that employs a robotic-guided, heat-free, high-pressure water jet to precisely remove excess prostate tissue, enabling surgeons to personalize BPH treatment. The real-time, ultrasound-guided imaging of the prostate allows for the visualization of the patient’s anatomy, specifically the apical tissue surrounding the verumontanum. “During Aquablation, there is a deliberate and purposeful preservation of apical tissue to improve functional safety for both continence and sexual function,” Zorn explained. “The deeper butterfly [apical] cut can damage the ejaculatory duct beyond the verumontanum.”  In limited-resource settings, where Aquablation is not an option, conventional procedures such as TURP, laser vaporization (PVP), or endoscopic enucleation surgery can be adapted to preserve apical structures, thus safeguarding ejaculatory function.

Understanding the anatomy is critical, Zorn said, pointing out the importance of preserving the longitudinal muscular column that lies beneath the ejaculatory duct, which is implicated in the mechanism of ejaculation. “We now have more than ever – and a few more coming along – minimally invasive procedures that are going to give patients [symptom] relief and maintain their sexual function,” Zorn said. “We have come a long way in understanding the key anatomic structures and there are ways we can further personalize the ejaculatory duct system.”

Visualization modalities can provide that window into each patient’s anatomy, enabling the surgeon to observe refined details of the ejaculatory duct system and personalize the surgical plan. “There is large variability in the angle, depth, and course of the ejaculatory duct,” Zorn noted. “All those [are] variants that we may be ablating during the butterfly cut.” Unlike other MIST, Aquablation provides visualization of the surgical field in real time. Nevertheless, other cutting-edge imaging modalities, including micro ultrasound and retrograde verugram ultrasound, can be used during minimally invasive techniques to make adjustments and tailor surgical planning to each patient’s unique needs.

“Ejaculation is an important aspect of male health,” Zorn added. “We have underestimated it. It is time to have that discussion with our patients. Once you lose it, it is unlikely to come back. I think it is our new standard of care that we engage in that discussion and make that part of our counseling of patients.”