Minimally invasive surgical techniques (MISTs) for benign prostatic hyperplasia: results from a Delphi consensus project to shed light on controversial topics.

Jun 09, 2025

Experts: Federica Passarelli,Daniele Castellani,Silvia Secco,Mauro Gacci,Mattia Sibona,Ioannis Kartalas Goumas,Celeste Manfredi,Giovanni Ferrari,Enrico Finazzi Agrò,Andrea Cocci,Carlos Miacola,Carlo Marenghi,Daniele D'Agostino,Davide Arcaniolo,Emanuele Baldassarre,Federico Deho,Fabrizio Palumbo,Franco Gadda,Gianluca Sampogna,Lorenzo Ruggera,Luca Ferrando,Mirko Preto,Nicolò Schifano,Paolo Capogrosso,Elisa De Lorenzis,Yasser Hussein Mohamed Ismail,Ludovico Maria Basadonna,Giorgio Graps,Fabrizio Longo,Andrea Salonia,Emanuele Montanari,Luca Boeri

To conduct a Delphi consensus in order to address key uncertainties and provide expert insights to bridge the gap between guidelines and real-world practice concerning minimally invasive surgical techniques (MISTs) for benign prostatic hyperplasia (BPH).
The Advisory Board developed 343 statements on 35 debated topics in the surgical management of BPH, each including multiple items rated on a 9-point Likert scale. The questionnaire was emailed to a Panel of 28 Italian urologists with 5-year experience in MISTs for the first round of voting. Statements that did not reach consensus were identified as “hot topics” and underwent a second round of voting during a Consensus conference, attended by all first-round participants, where the results were reviewed, debated, and re-voted upon anonymously.
The Panel agreed in defining TPLA, Rezum, iTIND, PAE and Urolift as MISTs, but no consensus was reached regarding Aquablation. Essential characteristics for being defined as MISTs were considered the feasibility in outpatient and one-night stay settings, minimal bleeding risk, early postoperative recovery of daily activities and a reduced impact on urinary continence and ejaculatory function. The Panel agreed that, compared to TURP, PAE, TPLA, Rezum, iTIND and Urolift were associated with lower postoperative bleeding rates, lower operative and hospitalization time, lower risk of postoperative incontinence; non consensus on these topics was achieved for Aquablation. The Panel agreed that flow rates after PAE, TPLA, iTIND and Urolift were worse than TURP, however, no consensus was achieved for Rezum and Aquablation. A high risk of retreatment was recognized for TPLA, iTIND and Urolift, but this was not the case for Rezum and Aquablation. iTIND and Urolift were deemed as the best options for prostate volume 30 ml, TPLA, Rezum and Aquablation for prostate volume 30-80 ml while no consensus was obtained for the best approach in larger volumes. No consensus was achieved for various aspects of postoperative management of MISTs.
Results from this Delphi project confirmed the lack of agreement on certain topics related to MISTs for BPH including the ideal treatment for large prostate volumes, functional outcomes and postoperative management.

© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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ABOUT THE EXPERTS

Federica Passarelli,Daniele Castellani,Silvia Secco,Mauro Gacci,Mattia Sibona,Ioannis Kartalas Goumas,Celeste Manfredi,Giovanni Ferrari,Enrico Finazzi Agrò,Andrea Cocci,Carlos Miacola,Carlo Marenghi,Daniele D'Agostino,Davide Arcaniolo,Emanuele Baldassarre,Federico Deho,Fabrizio Palumbo,Franco Gadda,Gianluca Sampogna,Lorenzo Ruggera,Luca Ferrando,Mirko Preto,Nicolò Schifano,Paolo Capogrosso,Elisa De Lorenzis,Yasser Hussein Mohamed Ismail,Ludovico Maria Basadonna,Giorgio Graps,Fabrizio Longo,Andrea Salonia,Emanuele Montanari,Luca Boeri

Federica Passarelli

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Daniele Castellani

Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti Di Ancona, Università Politecnica Delle Marche, Ancona, Italy.

Silvia Secco

Urology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

Mauro Gacci

Unit of Urological Robotic Surgery and Renal Transplantation, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy.

Mattia Sibona

Urology Clinic, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza – Molinette Hospital, University of Turin, Turin, Italy.

Ioannis Kartalas Goumas

Department of Urology, Istituto Clinico Beato Matteo, Vigevano, Italy.

Celeste Manfredi

Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy.

Giovanni Ferrari

Department of Urology, C.Ur.E, Centro Urologico Europeo, Hesperia Hospital, Modena, Italy.

Enrico Finazzi Agrò

Department of Experimental Medicine and Surgery, Unit for Functional Urology, Tor Vergata University Hospital, Rome, Italy.

Andrea Cocci

Unit of Urological Robotic Surgery and Renal Transplantation, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy.

Carlos Miacola

Department of Emergency and Organ Transplantation, Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy.

Carlo Marenghi

ASST Rhodense Garbagnate Milanese, Milan, Italy.

Daniele D’Agostino

Ospedale Villa Salus, Venice, Italy.

Davide Arcaniolo

Urology Unit, Luigi Vanvitelli University, Naples, Italy.

Emanuele Baldassarre

Division of Urology, Ospedale Parini, Aosta, Italy.

Federico Deho

Department of Medicine and Technological Innovations (DIMIT)/Unit of Urology, Circolo & Fondazione Macchi Hospital, University of Insubria, Varese, Italy.

Fabrizio Palumbo

Department of Urology, Di Venere Hospital, Bari, Italy.

Franco Gadda

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Gianluca Sampogna

Urology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

Unit of Neuro-Urology – Unipolar Spinal Unit, Niguarda Hospital, Milan, Italy.

Lorenzo Ruggera

Department of Surgery, Oncology, and Gastroenterology-Urology Clinic, University of Padua, Padua, Italy.

Luca Ferrando

Azienda Ospedaliera Universitaria San Luigi Gonzaga, Orbassano, Italy.

Mirko Preto

Urology Clinic, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza – Molinette Hospital, University of Turin, Turin, Italy.

Nicolò Schifano

Department of Medicine and Technological Innovations (DIMIT)/Unit of Urology, Circolo & Fondazione Macchi Hospital, University of Insubria, Varese, Italy.

Paolo Capogrosso

Department of Medicine and Technological Innovations (DIMIT)/Unit of Urology, Circolo & Fondazione Macchi Hospital, University of Insubria, Varese, Italy.

Elisa De Lorenzis

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy.

Yasser Hussein Mohamed Ismail

Urology Unit, Surgical Department, ASST Bergamo Ovest, Treviglio, Italy.

Ludovico Maria Basadonna

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Giorgio Graps

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Fabrizio Longo

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Andrea Salonia

Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.

Vita-Salute San Raffaele University, Milan, Italy.

Emanuele Montanari

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy.

Dipartimento di Scienze Cliniche e di Comunità, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy.

Luca Boeri

Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milan, Italy. dr.lucaboeri@gmail.com.