Retrograde Ejaculation or Ejaculation Preservation after TURP, GreenLight PVP, HoLEP, or Urolift?

Will we get Retrograde Ejaculation or Ejaculation Preservation after TURP, GreenLight PVP, HoLEP, or Urolift?

First the good news: The Ejaculation Preservation technique involves not removing some tissues that otherwise would have been removed during a BPH procedure. Studies have proved that the functional outcomes of an EP procedure are "comparable" with a standard procedure and the complication and re-treatment rates are more or less the same.  The EP is a simple technique as it is really easy to mark off the tissues not to be cut. Thus it does not need new training or add complexity to the surgical procedure. Your urologist probably knew all about it as the technique was developed in 2003. If not, it will take only a few minutes for him to understand. Thus, any experienced urologist could do it if he chooses to. Second, the not so good news: it may be difficult to convince your urologist to use EP in your surgery as most of the urologists' web pages do not advertise this technique. Thus, it is difficult if not impossible to find out which urologist in a given area who does EP procedure. Why most urologists are not using the EP techniques in their procedures is unclear and puzzling.

As patients, we would like to know what EP is, how does it work, how well it works, whether there is any complications and finally, would like to collect as much information as possible to make a decision if it is good for us to ask for it. So in the following, I will list videos showing real life EP operations, explain the EP technique, list EP failure rate for standard procedures as well as success rate of EP procedures reported by various studies including how well does it work compared with standard procedures.

Brief Background And Purpose

Some patients were told or thought losing ejaculation comes with BPH surgical treatments. It is the price we have to pay for getting better. It is the purpose of this post to find out the chance that will happen and if there is anyway to decrease that chance.

I have BPH. Recently, visited 3 urologists. Drugs did not work on me. My main urologist told me that he performed only TURP and Green Laser and asked me to google what they were. He also told me that after the procedure, I would get "retrograde ejaculation" which, he explained, meant semen flowed backward into the bladder, but I would still have orgasm. Since my prostate was small, he suggested Urolift and referred me to another urologist. I did some research on Urolift and I felt OK to go forward with it. The office then submitted a pre-authorization request to BCBS, but was rejected. It seemed that BSBC wanted me to do TURP instead. I will have a better chance to successfully appeal the decision if I understand the various BPH surgeries currently being offered to patients.

I am not a MD. I just started to read about TURP and GreenLight PVP and realized that TURP is the gold standard, but also came across HoLEP, which some urologists said was the new gold standard. I did not pay any attention to retrograde ejaculation(RE), as I believed my urologist who implied that was the price I had to pay for relieving my BPH symptoms. Casual reading of scientific papers on TURP seemed to confirm that as most of them said, a majority of patients ended up with RE.  I then noticed that RE for TURP is not always 100% as my urologist had implied and also came across the term Ejaculation Preservation (EP), something none of my urologists told me. It piqued my interest. I did research on that subject and would like to share what I had found out.

Main Source Of Information

I was lucky and was able to find the most recent review paper on ejaculation preservation. This saved me a lot of time to google to find out all kinds of papers in order to understand what had been done. The paper is : "A systematic review about ejaculation preservation technics for benign prostatic obstruction surgical treatment" by Souhil Lebdai and 12 coauthors from 13 institutions in France. Some of their as well as others' results are given below.  

I am only concerned about TURP, GreenLight Laser PVP(GL-PVP) and HoLEP as other technologies are not easily accessible to me. If you are interested in them, please read the paper.

What New Knowledge Is Needed to Understand The EP Technique?

We only need to learn one new anatomy to understand the EP technique. It is a piece of tissue called verumontanum or seminal colliculus. (I will call it  veru for short). As the resectoscope enters the prostatic urine channel, located at 6 o'clock is a small piece of tissue sticking out like a little mountain, that is verumontanum. The ejaculation ducts are situated on that mountain. It is the most important land mark for navigation that urologists used when they perform the removal of adenoma from the prostate capsule. When the patient is lying down, the horizontal tissue in front of the veru toward the bladder neck is the median lobe (if it gets too big, sometimes it blocks the bladder neck), and the two vertical tissues on the left and right of the veru towards the bladder neck are the left and right lateral lobes.

From wiki: "Verumontanum is translated from Latin. It means "mountain ridge". See picture on www.earthslab.com/anatomy/verumontanumseminal-colliculus/ or google seminal colliculus.

The Ejaculation Preservation Technique: 

"The resection of the median lobe had to stop at 1 cm above (note for a patient lying down means in front of) the verumontanum. As, for the lateral lobes, they were resected to the verumontanum level (note: means do not remove  any lateral lobe tissue lower than the height of veru) , but without damaging the paracollicular tissue. The bladder neck was resected in a standard manner. Using these anatomical landmarks to preserve the apical area". (paracollicular tissue: my understanding is the tissue that lie in the valley between veru and  a lateral lobe. There are two valleys , one on each side of the veru.)

Real Life Videos That Perform The Ejaculation Preservation Technique

We are very lucky. There are two recent YouTube videos that show how EP is done, one for GL-PVP and one for TURP. 

(1) EP GreenLight PVP

Enrique Rijo: Ejaculation Preserving  photos elective vaporization of prostate (EP-PVP) with GreenLight 180W Laser, published in Nov, 2017. His written comment: "EP-PVP was successful in preserving ejaculation function in up to 87.5% patients. The outcomes of EP-PVP technique are comparable with the standard PVP."  

Note the important word "COMPARABLE".

In Rijo's video, before he removed any tissue, the first thing he did was to make 3 marks, one in front of the veru and then one each on the lateral lobes. These 3 marks formed a U. The height of the U is the same as the height of the veru. The U is placed about 1 cm in front of the veru. The tissues behind this U are the tissues that should not be vaporized -- the forbidden zone. He started vaporizing from the bladder neck and worked backward toward the veru. Every now and then, he would stopped and checked his landmarks to make sure he didn't enter the forbidden zone. When he was nearly done, there were two big chunk of tissues left, one on each of the lateral lobes next to the veru. He only cut away tissues above his marks which were at the same height as the veru. The presence of these two uncut remaining tissues formed a narrower opening. If you watch another standard PVP procedure video by Rijo, these left over tissues would have been cut resulting in a much bigger opening.  However, the urine flow rate (Qmax) of the prostatic channel is limited by its narrowest opening. Perhaps, the opening formed by these uncut tissues might not formed the narrowest opening and thus would not impede urine flow.

Rijo's EP technique is the same one developed for TURP. See "The Ejaculation Preservation Technique" given later.

(2) EP TURP

Dr. Wassim Chaabane: [TURP] Prostate Enucleation (Antegrade Ejaculation preserved) 

In Chaabane's video, he first made a groove on each side of the median lobe, then enuclearted the median lobe from in front of veru towards the bladder neck. However, the video did not show how he removed the lateral lobes. I had watch several YouTube TURP videos on which the surgeons cut rather indiscriminately and they cut away tissues up to the veru. And some even considered removing the veru; just read this tile, "Is verumontanum resection needed in transurethral resection of the prostate?" by Mazaris (2013).

How the Ejaculation Preservation Technique was Developed?

Hedlund observed in 1985 that patients, who had bladder neck incision (in which a cut was made from the bladder neck towards the veru at 6 o'clock.) had their ejaculation preserved.  The modern EP technique was developed in 1998 by recognizing "preserving the area proximal to veru would preserve ejaculation". It was thought that muscle fibers near the bladder neck was also involved (it was thought wrongly that during ejaculation, the bladder neck had to be closed). And finally an definitive experiment was done to settle the issue. "Vernet et al. showed that contraction of the bladder neck was not important for antero- grade ejaculation [35]. Using endorectal ultrasound videos performed during masturbation in 30 men, it was possible to visualize the bladder neck, the prostate, and the bulbar urethra during ejaculation. They observed that during ejaculation, the verumontanum underwent a slight caudal shift, momentarily making contact with the opposite urethral wall and sperm emitted from the ejaculatory ducts was directed distally by contractions of the external sphincter coordinated with contractions of the bulbar urethra, thus demonstrating the importance of the muscular tissue around the verumontanum and particularly its proximal part. They described this area as a “high-pressure ejaculatory area”. The closure of the bladder neck did not seem to play a role in this mechanism. As a result, one can conclude that as long as the tissues around the verumontanum are not injured, ejaculation should still occur even with a well-open bladder neck [36]." (Square bracket with a number is the reference cited in the original article.)

Knowing the bladder neck was not involved and what other tissues were involved during ejaculation developed the modern Preservation of Ejaculation BPH technique. Note that some called the “high-pressure ejaculatory area” a "hood" and thus EP is sometime also called "hood sparing" technique. The hood includes paracollicular tissues.

The Ejaculation Preservation Technique 

The technique was first developed by using TURP. 

"The conventional technique of transurethral resection is traditionally performed with ‘careful removal of apical tissue around the verumontanum’[2,14]. To preserve the antegrade ejaculation, the paracollicular and the situated tissue, which is located 1cm proximal to the verumontanum should not be resected. This is mainly related to the importance of the mus- culus ejaculatorius and verumontanum for ejaculation[11–13,15]. 

.........

The epTURP procedure was undertaken in the following steps:

(1) setting a mark cut 1 cm proximal of the verumontanum as orientation;

(2) complete resection of the middle lobe to the above- mentioned mark;

(3) resection of lateral lobes to the capsule and the ventral side to the level of the verumontanum with avoidance of paracollicular digging;

(4) circular resection of the internal bladder neck;

(5) apical resection utilizing the colliculus seminalis as a distal resection border and maintaining a 1 cm safety area for preservation of ejaculation;

(6) total removal of prostate cuts and final check to con-

firm that there are no obstructive components (Fig. 1B).

The paracollicular tissue and the area 1 cm proximal of the verumontanum were preserved and were not affected by cutting or coagulation. Deep resection behind the verumontanum was avoided because of the increased risk of damaging the ejaculatory ducts or the musculus ejaculatorius."

"Middle or side lobe enlargement as long as it does not include the apex has no effect on the re- section technique. "

"In particular, strong delineation of the boundary of the verumontanum without advanced para- collicular digging resection may account for the avoidance of stress urinary incontinence."

(Alloussi's et all. 2014.)

How Long Will the Preserved Ejaculation from TURP Last?

"With relevance to functional outcome, the beneficial results in this study persisted throughout long-term follow-up, with no significant decrease in flow, symptoms (IPSS, LQI) and PVR."

(Alloussi's et all. 2014.)

Note: the Alloussi study followed the patients for 5 years. Thus, it should last at least 5 years. 

What Are The Chance of  Getting Retrograde Ejaculation From Regular Standard Procedures?

(A) TURP(the most studied EP procedure):

"The conventional technique of transurethral resection is traditionally performed with ‘careful removal of apical tissue around the verumontanum' [2,14]" (Alloussi et al. 2014.)

(Note: Being careful around the veru could have resulted in EP.)

(1) "A recent review of 30 RCTs (randomized controlled trials) reported a 66.1% rate of EjD (ejaculation dysfunction) [1]." 

(2) "Chen et al. published a series of 100 patients randomized between monopolar and bipolar-TURP. The retrograde ejaculation rates were 50 versus 36% for monopolar and bipolar-TURP, respectively." (Note: not sure why EP-bipolar is better than EP-monopolar.  EP is the result of  what tissues are not removed. It should be independent of what instrument is used for the surgery.)

(B) Greenlight XPS Laser PVP vs TURP (XPS means the laser output is 180W)

"The GOLIATH study compared TURP and PVP [20]. PVP was non-inferior to TURP for IPSS improvement, Qmax, and complications. The study reported similar EjD rates for both technics with now significant difference: 67.1 versus 65.1% for PVP and TURP, respectively."

(C) HoLEP 

(1) "Ahyai et al. reported a randomized study of 200 patients comparing HoLEP versus TURP with a 3-year follow-up. They showed that HoLEP micturition outcomes compared favorably with TURP [17]. However, the rates of EjD were similar between both techniques with no significant difference: 74 versus 70% for HoLEP and TURP, respectively [17, 18]."

(2) "Placer et al. focused on sexual outcomes in a retrospective analysis of 419 patients treated by HoLEP [19]. After a 12-month follow-up, 70.3% of patients reported no ejaculation versus 10.7% at baseline(about 59.6% net?). The rate of patients reporting an ejaculation with normal quantity of semen decreased from 29.4% at baselines to 8.7% at 12 months. Pain or discomfort during ejaculation raised from 73.7% at baseline to 91.3% at 12 months. Similarly, Kim et al. reported a 73.7% rate of anejaculation after a 9-month mean follow-up [8].

In summary, HoLEP achieved equivalent outcomes compared to TURP, but also deteriorated antegrade ejaculation in the same extend." (Only 8.7 out of 29,4% has normal quality of semen.)

From the above, with standard procedures, the range of TURP's RE rate is  from 36% to 70%. I will use the one with 30 RCTs which is 66%, whereas GL-PVP and HoLEP are slightly worse. 70% RE will be a good number to remember for TURP, GL-PVP and HoLEP. The remaining lucky 30%, not all have "normal quantity of semen".

It is not surprising that RE rate for TURP, GL-PVP and HoL is not 100% even without using the EP technique. The reason could be for some patients, the tissues removed might be nearly the same as those removed by the EP technique if EP technique were used. They are the lucky ones.

What Is The Success Rate of Ejaculation Preservation Technique?

(D) EP-TURP (mono),  EP-TURP (bipolar), EP-TURP (bipolar and enucleation)

(1) "Alloussi et al. showed in a prospective study on 89 patients ... [6]. They performed the standard monopolar resection except that they ensured the preservation of the verumontanum and the surrounding tissues. The resection of the median lobe had to stop at 1 cm above the verumontanum. As, for the lateral lobes, they were resected to the verumontanum level, but without damaging the paracollicular tissue. The bladder neck was resected in a standard man- ner. Using these anatomical landmarks to preserve the apical area, 91% of the patients had preserved ejaculatory functions. Functional results were satisfactory with significant improvements in maximum flow rate (+ 14.3 ml/s), PVR (- 59 ml), and IPSS (- 18.3) at 3 months (p < 0.002). These improvements were maintained at 60 months. No serious adverse events were reported, but 13% patients received a second TURP due to the development of bladder neck scar tissue during long-term follow-up."

"The epTURP procedure was repeated in eight patients (12.7%) following the development of bladder neck scar tissue and diagnosis of BOO during long-term follow-up. Re- treatment did not influence the ability to preserve antegrade ejaculation in these patients."

Note: I did compare Alloussi's IPSS, Qmax and PVR for EP-TURP against other published standard TURP results. Indeed, his results are comparable to them.

(2) "Ronzoni et al. reported similar results in a prospective controlled study [5]. After 2 years of follow-up, 80% of the patients who had partial resection presented conserved ejaculatory function. Therefore, it appears that modified-TURP allowed the preservation of antegrade ejaculation with equivalent functional outcomes to the conventional TURP."

Note the important words "equivalent functional outcomes to the conventional TURP".

(3) "Rhouma et al. reported a prospective, randomized, single-blind, comparative study between modified-TURP (preservation of 1 cm tissue around the supramontanal prostate) versus conventional TURP (n = 70 patients) [37]. Average prostate volume was 60 and 58 cc, respectively. ... No serious adverse events were reported with the two techniques. Significant improvements in urinary function were similar, assessed by decreased IPSS scores and PVR (IPSS: from 21.4 to 7.06 and from 21.06 to 7.54, respectively, p = 0.7. PVR: from 211 to 26 cc and from 204 to 49 cc, respectively; p = 0.2). The ejaculation was preserved in 65.7% with the modified-TURP versus 28.6% with the conventional TURP (p < 0.05). Unfortunately, the follow-up was only 3 months." 

Note:  for EP-TURP, the success rate is from 65.7% to 91%. The difference could be due to the the surgeon used slightly different techniques or the small sample size or both of them. The average of these two numbers is 78%.

Sometimes ejaculation preservation was only partially successful as illustrated by the small sample study form Moscow given below.

(4) "Ejaculatory-protective transurethral resection of the prostate" by Martov et al., published in 2014.

From May to December 2010, 42 patients with infravesicular obstruction caused by benign prostatic hyperplasia (study group) underwent adopted original method of ejaculatory-protective TURP (EP TURP). The control group consisted of 40 patients who underwent standard TURP. Exclusion criteria included: history of surgery on the pelvic organs, the presence of urethral stricture, diabetes mellitus, neurological disease, and erectile dysfunction. Patients in both groups were matched by age, prostate volume, I-PSS and QoL indices, peak flow rate and residual urine volume. The performance of intraoperative and immediate postoperative period, as well as long-term results 12, 24 and 36 months after surgery were evaluated.

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In both groups, the positive results achieved by surgery have remained stable for 3 years. Serious intra- and postoperative complications in any of the groups were not recorded. Ejaculatory-protective surgery has allowed to fully preserve the natural ejaculation in 48.7% of patients, and partially – in 25.6% versus 14.3 and 8.6% of patients who underwent the standard method of surgery."

Note: In this study, about 50% of patients preserved their ejaculation fully while the other 25% was partially preserved. The total success rate is 75%.

(5)  Abotaleb et al. reported (2016) EP technique was used in BIPOLAR TURP using Enucleation (50 patients) and compared with BIPOLAR EP-TURP (50 patients). 

"Sexual function evaluation: At 1 months , preservation of antegrade ejaculation was reported by 88 of 100 patients (88%) "44 patient in each group" ....this percentage remained unchanged at 3 and 6 months follow up."

The functional outcomes of these two BIPOLAR EP-TURP  techniques are similar to standard TURP.

"Ejaculation preserving transurethral bipolar enucleation of prostate:

(1) At first incision was made at bladder neck at 5 o’clock deep down to the capsule to a point few millimeters proximal to the veru.

(2) Another incision was made at bladder neck at 7 o’clock deep down to the capsule to the above-mentioned point then the two incisions were connected.  

(3) Mechanical enucleation of the median lobe was done using the peak of the sheath, energy was used only to control bleeding and dissect any adhesive tissue

(4) Similar incisions were made at 11 and 1 o’clock to the level of the point few millimeters proximal to the veru.

(5) Mechanical enucleation of both lateral lobes was done until they became connected to the bladder neck only by a stalk

(6) Enucleated lobes were cut into chips by bipolar plasma kinetic resection loop and then evacuated by elliks evacuator (no morcellator used)"

Note: EP-enucleation also worked and both techniques cut "few millimeters proximal to the veru" as opposed to the recommended 1 cm. For EP-TURP, mono, bipolar, regular and enucleation all can be used to preserve ejaculation.

(E) EP-PVP 

(1) "Leonardi et al. reported a modified vaporization technique in which they spared the triangle of urethral mucosa, which had the bladder neck at its base and ended with the seminal colliculus. The muscle fibers at the level of the bladder neck were preserved. At 6 months, antegrade ejaculation was maintained in 50/52 [96%] patients; two patients reported anejaculation and two reported a reduced volume of ejaculate [38]. The issue with this study was its very short follow-up that does not provide any mid- or long-term data."

(2) Talab et al. reported a multicentric retrospective series of 160 patients treated with EP-PVP with a 28-month average follow-up [7]. The technique involved: the preservation of bladder neck muscle fibers, the preservation of the precollicular tissue and the preservation of paracollicular prostate tissue. Mean prostate volume was 64 cc (17–230 cc). ...The success rate was 86.6% without compromising functional voiding results. IPSS scores pre- and post-procedure were 20.3 and 5.3, respectively. The mean pre-operative Qmax was 8.4 ml/ min, which signifcantly improved to 20.6 ml/min. Post-op ejaculatory function evaluation showed that 88 (56%) patients had normal antegrade ejaculation and 48 (30.6%) patients had diminished ejaculation after surgery, while 21 (13.4%) patients reported no ejaculations. [Note:,56% to 30.6% is about  a 2:1 ratio and 56+30.6=87%]

Note: IPSS and Qmax numbers are comparable to but just slightly not as good as conventional TURP.

(3) Miyauchi et al. reported similar results with a 92% success rate on a prospective series of 24 patients [39]. Ten (45%) patients had a decreased quantity of sperm. The technique was slightly different; all the tissues located at the apex at 10 mm from the verumontanum level were pre- served. Mean prostates’ volume was 44.7 ± 13.9 cc. ... IPSS, QOL score, and Qmax were significantly improved at 6 months. The reduction rate of PSA and prostate volume were 57 and 47%. The follow-up was too short to assess the re-treatment rate. In summery, it appears that modified-PVP also allowed EP with equivalent functional outcomes to the conventional

PVP."

Note the important words: "equivalent functional outcomes to the conventional

PVP."

(4) Tabatabaei et al.

"GreenLight PVP ... preserve ejaculation.The technique involves three steps: 1) Preservation of bladder neck muscle ?bers; 2) Preservation of precollicular tissue; 3) preservation of paracollicular prostate tissue (Ejaculatory hood).

2004 to 2010 .. had normal sexual function prior to surgery. EP-PVP was performed in 120 patients. Postoperative ejaculation were scored as none (0), low-volume ejaculation (1), and normal ejaculation(2). Followup is between 4 months to 6 years with average follow up of 18 months.

Prostate volume was between16 to 231 cc, with average volume of 65 cc....

66 (58.9%) patients had normal antegrade ejaculation after surgery, 32(28.6%) had diminished ejaculation and 14 (12.5%) had no ejaculation. IPSS score pre and post procedure were 22 and 6 respectively. Quality of life score was dropped on average from 5 to 2.

EP-PVP technique is successful in preserving ejaculation function in 87.5% of patients, post PVP. In patients who have decreased ejaculation secondary to alpha blockers or 5-alphareductase inhibitors an improvement may be seen. This technique does not compromise LUTS outcomes, as is re?ected in the amount of energy used and post procedure IPSS scores."

The success rates of the above four EP-PVPs using green light laser are very impressive. It approaches up to 90%. However,  do note that the success rate is the total rate as it includes both ejaculation fully preserved (56%) and partially preserved (30.6%) as given in (2) above. Note in particular that the "functional voiding outcomes were not compromised". Also note that (1), (2) and (4) used a different EP techniques, which is "spared the triangle of urethral mucosa, which had the bladder neck at its base and ended with the seminal colliculus. The muscle fibers at the level of the bladder neck were preserved" whereas (3) used the EP-TURP technique which is preserved 1 cm of tissues proximal to and ahead of the veru.

(F) EP-HoLEP 

"Only Kim et al. evaluated EP-HoLEP in a prospective controlled study [8]. They tried to preserve the ejaculatory hood defined as the paracollicular and supracollicular tissue up to 1 cm proximal to the verumontanum. Patients were alternatively allocated to the standard HolEP group and the EP-HoLEP group. Twenty-six patients received the ejaculatory hood sparing technique and twenty- six patients underwent the conventional HoLEP. The success rate of ejaculation preservation was 46% in the preservation-group versus 27% in the conventional-HoLEP group (p=0.2). The difference was not significant, likely because the technique only focused on the preservation of the ejaculatory hood without sparing the apical tissues located less than 1 cm from the verumontanum, thus making the preservation inefficient. Therefore, another modified HoLEP technique preserving apical tissue should be assessed."

Note the important words: "because the technique only focused on the preservation of the ejaculatory hood without sparing the apical tissues located less than 1 cm from the verumontanum, thus making the preservation inefficient." 

This study did not use the same EP technique developed for TURP. The surgeon only spared the veru but did not spare the apical tissues within 1 cm of the veru. The authors believed this is the reason for the low success rate of this EP-HoLEP study. Unfortunately, there is no more study done after this one.

In theory, if we use a modified EP-HoLEP that spares the same tissues as in EP-TURP and EP-GL PVP,  we would expect to get the same results from EP-TURP and EP-GL PVP.

This study by not sparing tissues within one cm of veru is really unfortunate as some think  HoLEP, will replace TURP as the gold standard for BPH.  At this point, all we can say is that EP-HoLEP has not yet been fully developed. However, the EP success rate is still 46%, as oppose to 27% using standard method. Among the 46% of patients, it is not clear how many are fully and partially preserved.

(G) Urolift or Prostatic Urolift(PUL)

Urolift uses on average 4 implants (suture with small two metal tabs on both ends) to compress the prostrate to open up the constricted prostatic urine channel. However, the opened channel is not as wide as in TURP, GL-PVP or HoLEP. The narrow channel is reflected in lower Qmax (peak urine flow), higher PVR (post void residual urine volume) and moderate symptoms relief as compared to T, G and H. One advantage is that the tabs inside the urine channel can be removed at a later date and the remaining tabs and sutures stayed in the body and do not prevent other subsequent BPH procedures. However, the greatest advantage is that the implants do not disturb the veru and the surrounding tissues and as a result, the procedure fully preserves ejaculation function as seen below.

"Roehrborn published, in 2017, the results of a multi-centric study including 140 PUL implantations versus 69 control patients. Patients were followed-up for 5 years. .... no EjD (ejaculation dysfunction) was reported [9, 40].

Gratzke et al. compared PUL versus TURP in 80 patients with a 2-year follow-up [10]. Re-treatment rate was significantly higher for the PUL-group than the TURP-group (13.6 versus 5.7%, respectively). ....Erectile function was preserved in both arms. 

The main dfference was about ejaculatory function with 100% of preserved ejaculation in the PUL-group versus 34% in the TURP-group at 2 years (p < 0.001).

.....PUL preserved ejaculatory and erectile functions, but maximum IPSS improvement was around ten points."

There is no surprise why Urolift's re-treatment rate is 2.4 times higher than TURP. It could be due to the opened prostatic channel is narrower than TURP, thus when the prostate continue to grow, it will constrict the prostatic channel again and sooner than TURP.

Summary 

1) Ejaculation Preservation technique does not guarantee 100% success rate. It is only 80-90%. Semens of some of  those success patients were reduced.

2) For TURP and GL-PVP, the BPH symptoms relief from EP and from standard procedure is "COMPARABLE"; 

3) For HoLEP,  EP-HoLEP has not yet been fully developed to the level as good as EP- TURP and EP-GLPVP. This is so because the surgeons had removed tissues that were not removed in EP-TURP and EP-GL PVP. However, the EP success rate is still 46%, as oppose to 27% using standard technique;

4)  Also beware that in all the above studies, ejaculation pain, blood in ejaculation, intensity of orgasm, desire or frequency, etc. were not reported.

5)  If the BPH symptoms relief from EP and from standard procedure is "COMPARABLE", then the patients are getting the ejaculation preservation without paying any penalties. All is needed is for the surgeons be more careful while performing the surgeries.

I have spent time to compile and organize the above material and I hope it is useful to u. Using this info, you could have a more informed discussion on ejaculation preservation with your urologist. But please don't believe it completely, but rather use it as a starting point to do your own research and form your own understanding.

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