Erectile Function Following Surgery for Benign Prostatic Obstruction: A Systematic Review and Network Meta-analysis of Randomised Controlled Trials

Alexander Light, Dost Jabarkhyl, Peter Gilling, Gincy George, Mieke Van Hemelrijck, Ben Challacombe, Sachin Malde, Rick Popert, Prokar Dasgupta*, Oussama Elhage

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

5 Citations (Scopus)


Context: Benign prostatic obstruction (BPO) is associated with sexual dysfunction. Furthermore, numerous BPO interventions may themselves impact sexual function. Objective: To perform a systematic review with network meta-analysis to evaluate how BPO interventions affect erectile function. Evidence acquisition: Three databases were searched for randomised controlled trials (RCTs) comparing surgical interventions for BPO. The primary outcome was postoperative International Index of Erectile Function-5 (IIEF-5) score at ten time points up to 72 mo. A random-effects Bayesian network meta-analysis with meta-regression was performed. In comparison to monopolar transurethral resection (mTURP), the mean difference (MD) with 95% credible interval (CrI) and rank probability (rank p) were calculated for interventions. The mean baseline score was studied in meta-regression. τ2 values were used to quantify heterogeneity. Evidence synthesis: A total of 48 papers (33 RCTs, 5159 patients, 16 interventions) were included. Prostatic urethral lift (PUL) ranked highest at 1 mo (MD 3.88, 95% CrI −0.47 to 8.25; rank p = 0.742), 6 mo (MD 2.43, 95% CrI −0.72 to 5.62; rank p = 0.581), 12 mo (MD 2.94, 95% CrI −0.26 to 6.12, rank p = 0.782), and 24 mo (MD 3.63, 95% CrI 0.14 to 7.11; rank p = 0.948), at which point statistical significance was reached. At time points up to 60 mo, there were no statistically significant comparisons for other interventions. Analyses were not possible at 18, 48, or 72 mo. β did not reach statistical significance in meta-regression. τ2 was highest at 1 mo (0.56) and 60 mo (0.55). Conclusions: PUL ranked highly and resulted in erectile function improvement at 24 mo compared to mTURP, but direct evidence is lacking. We did not observe significant differences in erectile function following other interventions up to 60 mo. Owing to heterogeneity, our conclusions are weakest at 1 and 60 mo. Further RCTs comparing sexual function outcomes are recommended, such as PUL versus holmium laser or bipolar enucleation. Patient summary: Different surgical treatments can be used to treat benign enlargement of the prostate causing urinary problems. We compared the effects of various treatments on erectile function at time points up to 5 years after surgery. Compared to surgical removal of some of the prostate gland (transurethral resection of the prostate, TURP), a technique called prostatic urethral lift resulted in better erectile function scores at 24 months. However, other treatments did not differ in their effect on erectile function.

Original languageEnglish
Pages (from-to)174-187
Number of pages14
JournalEuropean Urology
Issue number2
Publication statusPublished - Aug 2021


  • Benign prostatic hyperplasia
  • Benign prostatic obstruction
  • Ejaculation
  • Ejaculatory dysfunction
  • Erectile dysfunction
  • Erectile function
  • International Index of Erectile Function-5
  • Network meta-analysis
  • Prostatic urethral lift
  • Sexual function


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