Prof. Bove discusses minimally invasive techniques for benign prostatic hyperplasia: precision, personalization, and clinical common sense
A common condition, and an answer that must be tailored.
Benign prostatic hyperplasia (BPH) is one of the most common conditions in men after the age of fifty. It involves a non-cancerous enlargement of the prostate gland, with urinary symptoms that can significantly affect quality of life.
In recent years, advances in urologic surgery have made increasingly less invasive techniques available, with the aim of reducing hospital stay, lowering the risk of complications, and limiting side effects affecting sexual function. Among these, the so-called MIST—Minimally Invasive Surgical Techniques—are among the most discussed and requested options. But precisely for that reason, it is essential to avoid generalizations.
“There is no single technique that is right for everyone,” says Professor Pierluigi Bove, urologist, Associate Professor of Urology at the University of Rome Tor Vergata and Head of U.R.M.I. – Robotic and Minimally Invasive Urology at Policlinico Tor Vergata. “Every patient is different and deserves a personalized approach, not a standardized solution.”
What MIST are
Minimally invasive techniques for BPH are based on the idea of removing or reducing obstructive prostatic tissue using less aggressive tools than traditional surgery. Some techniques, such as Rezūm, use water vapor to create localized necrosis within the prostate; others, such as UroLift, implant small devices to mechanically widen the urinary channel; others rely on laser technologies or water-based ablation (Aquablation).
The benefits most commonly associated with MIST include:
- shorter operative times,
- a lower risk of retrograde ejaculation,
- the possibility of outpatient treatment (for some of them).
But it would be a mistake to assume they are always the best choice.
The importance of a complete clinical assessment
The choice of treatment for BPH should never be driven by trends or by what is promoted too lightly in the media. The risk is that poorly informed patients request inappropriate procedures, based on generalized promises or standardized protocols that do not consider the specific features of an individual case.
“For medicine to be effective, it must be precise. And when surgery is done well, it is always personalized,” Professor Bove emphasizes.
A thorough clinical assessment should consider at least:
- prostate volume,
- prostate morphology (how it grows and where it exerts pressure),
- the patient’s age,
- any associated conditions,
- and—last but not least—the patient’s expectations.
Not all techniques are suitable for everyone
One of the most underestimated risks of indiscriminate adoption of MIST is failing to achieve the expected results—or worse, creating dissatisfaction in patients who were not ideal candidates.
For example:
- Rezūm works well in smaller prostates with predominantly central growth;
- UroLift is not indicated when there is a large median lobe;
- some techniques can lead to prolonged bleeding episodes if applied to very large prostates;
- others, while preserving ejaculation, may not be effective in fully resolving obstructive symptoms.
“There are patients who are highly motivated to preserve ejaculation, but if the prostate is too large, they need to know that the results of a minimally invasive technique will likely be disappointing,” Prof. Bove explains. “The truth has to be said beforehand, not managed afterward.”
When technology is not enough: the value of clinical intelligence
In an era where there is a tendency to reduce everything to automatic protocols and quick fixes, one simple but crucial principle must be reaffirmed: no algorithm can replace clinical sensitivity and a physician’s experience. Even in the most straightforward cases, a deep understanding of the patient—their history, anxieties, and life goals—plays a decisive role in choosing the right intervention.
“Experience is needed, the ability to ‘read’ the patient is needed, understanding their psychology is needed—and above all, comprehensive surgery that truly knows all the options,” Prof. Bove reiterates.
The risk of MIST overuse by less experienced operators
One of the most concrete concerns in today’s debate about MIST is excessive or inappropriate use by professionals with limited surgical training. Some techniques, such as Rezūm, are relatively easy to learn from a technical standpoint, but that does not mean they are easy to apply correctly to every patient.
The result? Procedures proposed as “standard” even to those who do not have the clinical characteristics to truly benefit, with inevitable cases of dissatisfaction or persistent postoperative symptoms.
Professor Bove addresses this risk firmly:
“The fact that a technique is simple to perform does not justify indiscriminate use. Clinical common sense and surgical competence must always guide the decision.”
An experienced operator, on the other hand, can evaluate true compatibility between patient and technique, and propose only procedures that have a solid clinical basis for achieving good outcomes.
Alternatives: laser, enucleation, and tailored surgery
Beyond MIST, there are several other modern techniques that may be more effective in complex settings or in very large prostates.
Among the most established options are:
- Holmium or Thulium laser: allow vaporization or enucleation of prostatic tissue with excellent results even in large prostates, though with a higher risk of retrograde ejaculation.
- Endoscopic enucleation techniques: now represent the standard of care for many patients, thanks to their effectiveness, durability, and safety—especially in experienced hands.
The goal is not to “demonize” or “sanctify” any technique, but to bring the discussion back to a serious, clinical, competent level. Modern prostate surgery should be a complete toolbox, not a one-size-fits-all screwdriver.
Informing without creating illusions: the role of communication
Many patients approach prostate surgery with high expectations, often shaped by promotional spots, social media videos, or enthusiastic testimonials. It is the physician’s role to transform expectations into awareness, by explaining clearly:
- what the proposed technique can do,
- what side effects may occur,
- what results are realistically expected in the short and long term,
- what alternatives exist.
Only in this way can postoperative disappointment be avoided—disappointment that often comes not from a clinical failure, but from a communication gap between doctor and patient.
The future will not be only about technology
The future of prostate surgery will certainly be shaped by further technological innovation: even more precise lasers, AI-supported preoperative planning, 3D simulations, and robotics that becomes increasingly accessible. However, no technology will ever replace an empathetic doctor–patient relationship, or the surgeon’s critical ability to choose intelligently and responsibly.
“Medicine will never be an algorithm,” Professor Bove says. “And good surgery will never be a shortcut.”
MIST are an important option in the treatment of BPH, but they are not a universal solution. Modern medicine—and urologic surgery in particular—must always follow the path of personalization, multidisciplinary competence, and clinical common sense.
In a world that tends to simplify everything, it is the responsibility of physicians to preserve complexity where it is needed, to protect patients from wrong choices, and to restore surgery to its most noble role: treating with precision, awareness, and respect for the person.
References:
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