Incidence of Acute Urinary Retention/Failure to Void after Transurethral Interventions for Benign Prostatic Enlargement: Results from a Systematic Review and Meta-Analysis of Comparative Randomized Studies by the FUTURE Collaborative of the Endourological Society

Abstract

Objective:

To perform a systematic review and meta-analysis to assess the incidence of acute urinary retention (AUR)/failure to void after transurethral surgeries for benign prostatic enlargement, comparing Ablation, Enucleation, and Resection (TURP) techniques.

Materials and Methods:

A systematic literature search was performed on October 13, 2025 using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar TURP (M-TURP) or bipolar TURP (B-TURP) vs Ablation vs Enucleation procedures. Incidence of AUR/failure to void following the index surgery was evaluated using the Cochran–Mantel–Haenszel method and reported as risk ratio (RR), 95% confidence interval (CI), and p values. Statistical significance was set at p < 0.05.

Evidence Synthesis:

A total of 61 studies were included, with 1497 patients in the Enucleation, 2512 patients in the Ablation, and 4007 patients in the TURP groups. The pooled incidence of AUR/failure to void was 3.7% (72/1944 patients) after M-TURP, 3.0% (47/1553 patients) after B-TURP, 9.0% (226/2512 patients) after Ablation, and 2.4% (36/1497 patients) after Enucleation. Meta-analysis showed no significant difference between Enucleation and TURP (RR 0.90, 95% CI 0.61–1.32, p = 0.59; I² = 0%) in AUR/failure to void rate. Conversely, Ablation was associated with a significantly higher incidence of AUR/failure to void compared with TURP (RR 1.79, 95% CI 1.38–2.31, p < 0.001; I² = 22%). Subgroup analyses revealed that this difference persisted for diode laser (RR 4.53, 95% CI 1.24–16.47), monopolar electrovaporization (RR 3.24, 95% CI 1.90–5.55), and Neodymium (Nd):YAG laser/RR 2.61, 95% CI 1.54–4.42) ablation techniques. No significant difference was found between M-TURP, B-TURP, and Enucleation, and between B-TURP and Ablation. Conversely, AUR/failure to void incidence favored M-TURP over Ablation (RR 1.88, 95% CI 1.40–2.52, p < 0.001).

Conclusions:

Enucleation procedures demonstrate comparable safety to TURP regarding postoperative AUR/failure to void, whereas Ablation procedures are associated with a significantly higher incidence of postoperative retention events, particularly with energy modalities such as monopolar electrocautery, diode, and Nd:YAG lasers.

Keywords

benign prostatic hyperplasia transurethral resection of prostate urinary retention ablation enucleation

Introduction

Benign prostatic enlargement (BPE) represents the most common cause of lower urinary tract symptoms (LUTS) among middle-aged and elderly men. Surgical intervention is recommended when pharmacological therapy causes side effects or fails to achieve adequate symptom control or when complications secondary to bladder outlet obstruction occur.¹ Since its introduction in the late 1930s, monopolar transurethral resection of the prostate (M-TURP) has remained the standard surgical approach for patients with prostate volumes between 30 and 80 mL for many decades.² However, over the past 30 years, novel transurethral enucleation and ablation techniques have demonstrated comparable or superior efficacy, along with reduced morbidity, even in patients with larger glands.^3,4 These technological advances have expanded the armamentarium of surgical options available to urologists, yet have also introduced complexity in treatment selection and counseling.

Non-clot acute urinary retention (AUR) or failure to void following BPE surgery represents a distressing complication that negatively impacts patient satisfaction, prolongs hospital stay, increases healthcare costs, and may even compromise the perceived success of the intervention. Despite being a clinically relevant outcome, the comparative incidence of postoperative AUR across different surgical modalities has not been systematically evaluated. Understanding the risk of postoperative retention associated with various transurethral techniques is important for informed surgical decision-making, appropriate patient counseling, and optimization of perioperative management protocols.

This systematic review and meta-analysis aims to comprehensively assess the incidence of AUR/failure to void following transurethral surgical treatments for BPE, comparing Ablation, Enucleation, and traditional TURP techniques. By synthesizing evidence from randomized controlled trials, this study seeks to provide high-quality evidence to guide clinical practice and inform shared decision-making between patients and urologists regarding the optimal surgical approach for BPE.

Evidence Acquisition

Aim of the review

The primary end point of this study was to assess the incidence of AUR/failure to void incidence across three transurethral procedures: Ablation, Enucleation, and TURP. Secondary end point included evaluation of AUR/failure to void according to the electrocautery modality used in TURP, i.e., monopolar vs bipolar.

Literature search

This review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework.⁵ A comprehensive literature search with no date restriction was performed on October 13, 2025, using PubMed, Cochrane Central Register of Controlled Trials, and Scopus. Medical Subject Heading terms and keywords were used as follows: (prostatic hyperplasia OR BPH OR benign prostatic enlargement OR benign prostatic obstruction) AND (Prostate resection OR Prostate enucleation OR Prostate vaporization OR ablation OR monopolar transurethral OR bipolar transurethral OR MTURP OR BTURP OR plasmakinetic OR PKRP OR PKEP OR PKERP OR TURis OR photovaporization or PVP OR PVEP OR holmium OR HoLEP OR thulium OR ThuLEP OR ThuVEP OR ThuFLEP diode OR DiLEP OR BTUEP OR MTUEP OR TUNA OR TUMT OR Aquablation OR Rezum OR Water vapor thermal therapy). Animal and pediatric studies were excluded. Only studies in English were accepted. This review was registered in PROSPERO (registration CRD420251179728).

Selection Criteria

The PICOS (Patient Intervention Comparison Outcome Study type) model was used to frame and answer the clinical question. Population: men who underwent transurethral surgical procedure for clinical BPE; Intervention: transurethral ablation or enucleation procedures; Comparison: monopolar/bipolar TURP; Outcome: incidence of non-clot AUR/failure to void following the index surgery; Study type: prospective randomized studies.

Transurethral procedures were stratified into two groups according to the technique employed (Enucleation and Ablation), irrespective of the energy applied. The Enucleation cohort encompassed procedures utilizing laser energy, bipolar electrocautery, or monopolar electrocautery. The ablation cohort comprised of bipolar and monopolar electrocautery, thermal energy, waterjet, and laser-based vaporization techniques. Transurethral resection procedures were classified separately and included both monopolar (M-TURP) and bipolar (B-TURP) resection modalities.

Study screening and selection

Two independent authors performed the screening of all retrieved records using Covidence Systematic Review Management® (Veritas Health Innovation, Melbourne, Australia), with a third senior author resolving disagreements. Study selection adhered to predefined PICOS criteria, restricted to prospective randomized controlled trials. For the purposes of this systematic review and meta-analysis, AUR/failure to void was operationalized as any documented inability to void spontaneously following catheter removal, as reported by the original study authors. This included patients who failed to void after the first catheter removal and those who required recatheterization because of urinary retention after a successful first trial to void.

Studies were excluded if they: (1) lacked AUR/failure to void data; (2) reported zero AUR/failure to void events across all groups; (3) constituted non-primary research (reviews, abstracts, correspondence, case reports, editorials) or observational designs (retrospective/prospective non-randomized); (4) were not in English. The full text of the screened articles was selected if deemed relevant to the purpose of this study.

Statistical analysis

The incidence of AUR/failure to void was assessed using the Cochran-Mantel-Haenszel Method with the random effect model and reported as risk ratio (RR), 95% confidence interval (CI), and p value. Analyses were two-tailed, and the significance was set at p < 0.05 and a 95% CI. A sub-analysis was conducted to explore potential differences in the incidence of AUR/failure to void following M-TURP and B-TURP. In addition, a sensitivity analysis was performed, excluding studies with overall high risk of bias.

Studies comparing more than two interventions were handled by analyzing each pair of treatments separately. When a treatment group was included in multiple comparisons, its data were proportionally distributed among them. This meant dividing both the number of events and the total number of participants for binary outcomes (i.e., AUR/failure to void).⁶

In accordance with recommendations from the Cochrane Handbook for Systematic Reviews of Interventions, studies reporting zero AUR/failure to void events across all treatment arms were excluded from the meta-analysis.⁷ In fact, double-zero event trials contribute no comparative information regarding relative risk between interventions, and their inclusion with continuity corrections may introduce greater bias than their exclusion, particularly when analyzing outcomes that are not exceedingly rare.^8,9

Study heterogeneity was evaluated utilizing the I² value, with values >50% indicating substantial heterogeneity. Meta-analysis was conducted using Review Manager (RevMan) 5.4 software by the Cochrane Collaboration. We used OpenMeta[Analyst] software (http://www.cebm.brown.edu/openmeta/#) to perform the single-arm pooling analyses using a double–arcsine transformation.

The quality assessment of the included studies was conducted using the Cochrane Risk of Bias tool (i.e., RoB 2).¹⁰ In addition, publication bias was assessed using funnel plots for visual inspection of asymmetry for the major comparisons (Ablation vs TURP and Enucleation vs TURP). Egger’s regression test was performed to statistically evaluate funnel plot asymmetry when ≥ 10 studies were available for analysis and a p value < 0.10 was considered indicative of potential publication bias, as recommended for Egger’s regression test.^11,12

Evidence Synthesis

The initial literature search retrieved 3364 articles. Upon removing 859 duplicated studies, 2505 studies were left for screening. Another 2327 articles were further excluded after the title and abstract screening because of their lack of relevance to this study’s purpose. The full texts of the remaining 178 studies were assessed, and 117 articles were additionally excluded per predefined criteria. Finally, 61 studies were accepted and included in the final analysis. The full list of included studies is available in Supplementary Appendix SA1. Figure 1 shows the 2020 PRISMA flow diagram. Twenty-one studies compared Enucleation vs TURP (Table 1). Forty studies compared Ablation vs TURP (Table 2).

FIG. 1.

PRISMA flow diagram of the study. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1.

Characteristics of Included Studies Comparing TURP vs Enucleation

Author year of publication	Interventions	Inclusion criteria	Exclusion criteria	Randomized patients	Mean age (±SD) or Median (interquartile range)	Mean PV (±SD) or median (interquartile range), mL	Length of follow-up
Basić 2013	HoLEP vs M-TURP	PVR <50ml, PV ≤50 g, repeated episodes of acute urinary retention, indwelling urinary catheter, recurrent UTI, recurrent haematuria because of BPH and IPSS score >19	Voiding disorders out of BPH origin, previous urethral, bladder neck or prostatic surgery, and history of PCa	40 patients HoLEP 20 M-TURP 20	HoLEP 63.3 (±7.4) M-TURP 65.1 (±6.9)	HoLEP (48.8 ± 4.9) M-TURP 42.6 (±4.4)	12 Months
Bozzini 2017	ThuLEP vs B-TURP	bothersome LUTS because of BPH with indications for surgical intervention regardless of the patient age, IPSS, and prostatic size	IPSS <8 and/or Qmax ≥15 mL/s and PVR <50 mL, small adenomas <20 g measured by transrectal ultrasound, urethral stricture, neurogenic bladder, vesicoureteric reflux, huge retentive bladder diverticulum, previous prostatic surgeries, previous or subsequent diagnosis of prostatic adenocarcinoma, anticoagulant drugs.	208 patients ThuLEP 102 B-TURP106	ThuLEP 72.5 (±17.54) B-TURP 70.7 (±16.09)	ThuLEP 89.7 (±45.1) B-TURP 81.9 (±39.4)	3 months
Chen 2013	HoLEP vs B-TURP	Indications for the surgical treatment of BPH	Severe pulmonary or heart disease; bladder calculus; neurogenic bladder dysfunction; bladder/prostate cancer; previous prostate surgery; urethral stricture; coagulopathy	280 patients HoLEP 140 B-TURP 140	HoLEP 72.11 (±7.8) B-TURP 73.48 (±8.8)	HoLEP 56.70 (±28.41) B-TURP 60.31 (±22.41)	24 months
Desai 2024	ThuLEP vs B-TURP	BPH-associated LUTS indicated for surgery with prostate gland >60 g, those with bothersome LUTS, Qmax <15 mL/s, refractory to medical therapy, refractory AUR, patients with upper urinary tract changes, increased serum creatinine levels secondary to prostatomegaly, and patients with histologically benign enlargement of prostate when serum PSA >4 ng/mL	neurogenic bladder, urinary tract stricture, prostate cancer, active UTI, uncontrolled bleeding diathesis, history of previous surgeries of prostrate or urethra, and bladder calculi	72 patients ThuLEP 36 B-TURP 36	ThuLEP 67.69 (±5.81) B-TURP 68.06 (±5.80)	ThuLEP 79.78 (±13.45) B-TURP 78.83 (±15.98)	3 months
Enikeev 2019	ThuFlep vs M-TURP	PV <80 cc; IPSS >20; Qmax <10 mL/sec	Prostate cancer; bladder stones; acute urinary retention; urethral strictures, neurogenic bladder; anticoagulant therapy	60 vs 60 (120)	66.9 (6.2)	67.1 (7.0)	12 months
Fayad 2015	100 W- HoLEP vs B-TURP	Indications for the surgical treatment of BPH	Patients with mild symptoms (IPSS <8, Q max >15 mL/s, and/or minimal PVR). PV <20 g at TRUS; Urethral stricture; Neurogenic bladder; Vesicoureteric reflux; Huge retentive bladder diverticulum; Previous prostatic surgeries; PCa; Anticoagulant drugs.	60 vs 60 (120)	HoLEP 60.9 (±4.0) B-TURP 60.4 (±3.9)	HoLEP 68.2 (±11.2) B-TURP 67.2 (±9.7)	12 months
Fuschi 2022	100 W- HoLEP vs B-TURP	PV 40–100 mL and >75 y.o. with BPO refractory to medical therapy, PVR 150 mL, recurrent AUR, recurrent hematuria, recurrent UTI, or impaired renal function	PCa, previous prostatic or urethral surgery, neurogenic LUTS.	96 HoLEP vs 104 B-TURP	HoLEP 79.2 (±3.9) B-TURP 80.1 (±0.9)	HoLEP 76.1 (±0.8) B-TURP 65.6 (±0.9)	12 months
Gupta 2006	TURP vs TUVRP vs HoLEP	Patients with BPH who were candidates for TURP and with glands of >40 g	Any patient with a previous history of prostatic and urethral surgery, neurovesical dysfunction, PCa	150 patients TURP 50 TUVRP 50 HoLEP 50	TURVP 67.68 (±9.8) TURP 65.67 (±7.5) HoLEP 65.88 (±10.1)	TURVP 62.6 (±14.8) TURP 59.8 (±16.5) HoLEP 57.9 (±17.6)	12 Months
Jiang 2024	HoLEP vs B-TURP	Age ≥60 years old with complete clinical data; urgent urination, frequent urination, dysuria, incontinence; Diagnosis of BPH confirmed by digital rectal examination, B-ultrasound, and PSA, and supported negative pathological biopsy results; failed conventional pharmacological treatment or refused conservative treatment, with indications for surgical intervention; voluntary participation in this study	Severe cardiopulmonary disease, coagulation dysfunction or those recently taking anticoagulant drugs; acute prostatitis, neurogenic bladder or detrusor weakness of bladder because of various causes; psychiatric illness or those currently on antipsychotic medications; patients who have previously undergone other prostate surgery, as well as those with prostate cancer, glandular cystitis, bladder tumors, or urethral stricture; patients with poor compliance, difficulties in follow-up or lacking necessary data for research parameters after enrollment.	220 patients HoLEP 110 B-TURP 110	HoLEP 71.95 (±6.82) B-TURP 70.34 (±7.80)	HoLEP 47.10 (±20.59) B-TURP 45.56 (±28.39)	6 months
Kayal 2020	HoLEP vs B-TURP	Age 50–80 years; symptomatic BPH requiring surgical intervention; PV ≤100 mL as measured by ultrasonography; no active UTI; normal preoperative renal function tests.	PV >100 mL; urinary retention requiring prolonged catheterization; prostate cancer, confirmed or suspected based on PSA levels or biopsy; active UTI at the time of surgery; presence of significant comorbidities (e.g., uncontrolled diabetes, severe cardiac disease) .	100 patients HoLEP 50 B-TURP 50	HoLEP 65.4 (±7.2) B-TURP 66.2 (±7.5)	HoLEP 65.2 (±12.3) B-TURP 64.8 (±11.7)	6 months
Kuntz 2004	HoLEP vs M-TURP	IPPS 12 or greater, Qmax 12 mL/sec or (voided volume 150 mL or more), PVR above 50 mL, urodynamic obstruction in pressure flow studies (Schafer grade 2 or greater) and PV <100 cc, as estimated by transrectal ultrasound	Prostate cancer; previous urethral or prostatic surgery	200 patients HoLEP 100 M-TURP 100	HoLEP 68.0 (±7.3) M-TURP 68.7 (±8.2)	HoLEP 53.5 (±20.0) M-TURP 49.9 (±21.1)	12 months
Lin 2025	DiLEP vs B-TURP	Patients eligible for transurethral surgery because of BPH-associated LUTS with a PV greater than 30 mL		81 patients DiLEP 41 B-TURP 40	DiLEP 69.2 (±8.7) B-TURP 70.7 (±7.5)	DiLEP 75.1 (±35.8) B-TURP 72.8 (±22.4)	12 nonths
Luo 2014	BEP vs B-TURP	Qmax <15 mL/s; IPSS >12; medical therapy failure; PV >20 mL with no upper limit	abnormal digital rectal examination, increased serum PSA; neurogenic bladder; history of prostatic or urethral surgery	310 patients BEP 155 B-TURP 155	BEP 70 (±5.7) B-TURP 69.8 (±5.9)	BEP 61.8 (±18.7) B-TURP 61.7 (±19.0)	24 months
Mavuduru 2009	HoLEP vs M-TURP	BPH with surgical indications	history of previous prostatic or urethral surgery; PCa	30 patients HoLEP 15 M-TURP 15	HOLEP 69.86 (±9.6) M-TURP 66.46 (±5.79)	HoLEP 36.53 (±12.33) M-TURP 36.33 (±11.4)	9 months
Montorsi 2008	HoLEP vs M-TURP	age <75 years; Qmax <15 mL/sec; PVR <100 mL; medical therapy failure; PV <100 mL, urodynamic obstruction (Schafer >2)	neurogenic bladder; PCa; any previous prostatic, bladder neck or urethral surgery	100 patients HoLEP 52 M-TURP 48	HoLEP 52 M-TURP 48	HoLEP 70.3 (±36.7) M-TURP 56.2 (±19.4)	21 months
Shoji 2020	ThuLEP vs B-TURP	Age 50–90 years; diagnosis of mild or severe BPH based on the IPSS, IPSS QOL, Qmax, PVR and PV; symptoms not improved by medication; patients provided informed consent.	Other diseases that affected urinary function; patients who had preoperative treatment.	140 patients ThuLEP 70 B-TURP 70	ThuLEP 72 (57–83) B-TURP 73 (55–86)	ThuLEP 53 (40–149) B-TURP 53 (34–116)	12 months
Tan 2003	HoLEP vs M-TURP	PV 40 to 200 mL; Qmax 15 mL/sec or less, IPSS 8 or greater, PVR <400 mL and Schafer grade 2 or greater	Catheterized patients and those with a history of urethral or prostatic surgery	60 patients HoLEP 30 M-TURP 30	HoLEP 71.7 (±1.1) M-TURP 70.3 (±1.0)	HoLEP 77.8 (±5.6) M-TURP 70.0 (±5.0)	12 months
Zhang 2019	DiLEP vs B-TURP	BPH with surgical indications; PV ≤80 mL	neurogenic bladder, urethral stricture, prostate carcinoma, and a history of urethral or prostate surgery	152 patients DiLEP 72 B-TURP 72	DiLEP 73.7 (±8.4) B-TURP 71.5 (±8.9)	DiLEP 56.2 (±11.9) B-TURP 55.5 (±13.1)	12 months
Zhu 2013	BEP vs B-TURP	Urodynamically proven obstruction, Qmax less than 10 mL per second, IPSS >19, age 50–70 years, PV 70–200 mL on TRUS, PSA <4 ng/mL and failure of medical therapy (adrenoreceptor blocker and 5-reductase inhibitor for at least 6 months)	Neurogenic bladder, urethral stricture, bladder tumor, prostate cancer or previous prostate, bladder neck or urethral surgery, PSA >4 ng/mL or greater, or prostate biopsy within 3 months	80 patients 40 BEP 40 B-TURP	64.1 (±4.8) BEP 64.8 (±3.9) B-TURP:	113.8 (±32.0) BEP 109.4 (±32.4) B-TURP	60 months

AUR = acute urinary retention; AUR = acute urinary retention; B = bipolar; BEP = bipolar enucleation of the prostate; BPE = benign prostatic enlargement; BPH = benign prostatic hyperplasia; DiLEP = 1470 nm diode laser enucleation; HoLEP = holmium laser enucleation of the prostate; IPSS = International Prostate Symptom Score; LUTS = lower urinary tract symptoms; M = monopolar; PCa = prostate cancer; PSA = prostate-specific antigen; PV = prostate volume; PVR = post-voiding residual; Qmax = maximum flow rate; QoL = quality of life; SD = standard deviation; ThuFlep = Thulium fiber laser enucleation of the prostate; ThuLEP = Thulium laser enucleation of the prostate; TURP = transurethral resection of the prostate; TURVP = transurethral vaporesection of the prostate; UTI = urinary tract infection.

Table 2.

Characteristics of Included Studies Comparing TURP vs Ablation

Author, year of publication	Interventions	Inclusion criteria	Exclusion criteria	Randomized patients, Ablation vs TURP	Mean age (±SD) or Median (interquartile range)	Mean PV (±SD) or median (interquartile range), mL	Length of follow-up
Ahmed 1997	TUMT vs TURP	Symptomatic uncomplicated BPH: >1 year history AUA score >=12Flow rate <15 mL/sPVR <300 mLPdet max 70 cm H₂OProstate volume 25–100 mL Obstructed as assessed on the Abrams-Griffith nomogram Aged ≥55 years Informed consent Suitable for either treatment	General: (e.g., mental incapacity, severe cardiovascular disease, ‘active’ drugs)Technically unsuitable: Metallic implants Cardiac pacemaker Rectal surgery or disease (except hemorrhoids) Pelvic mass or surgeryPrevious prostatic surgeryProstatic abscessUncontrolled coagulation disorderActive UTIUrological:Prominent middle lobeMeatal stricturePrevious drug treatment for BPH‘Complicated’ BPH:Acute or chronic urinary retentionUpper tract dilatationObstructive uropathy (serum creatinine >150 mmol/L) Bladder calculiBladder diverticulaRecurrent UTIRecurrent prostatic hematuria	60 patients 30 TUMT 30 TURP	TUMT 69.36 (range 56–88)TURP 69.45 (range 58–82)	TUMT 36.6 (95% CI 31.8–41.4)TURP 46.1 (95% CI 38.1–54.1)	6 months
Bachmann 2014	180 GLL-PVP vsM- or B-TURP	Consent and agree to attend all study visits. LUTS Subject able to complete self-administered questionnaires. Subject is a surgical candidate for either the XPS or the TURP procedure and may be randomized into either arm. 40–80 years of age. IPSS >12; Qmax <15 mL/s. PV <100 mL by TRUS. ASA score ≤3. Normal serum creatinine	Life expectancy <2 years. Subject has an active UITI; chronic prostatitis or chronic pelvic pain syndrome (e.g., nonbacterial chronic prostatitis). Urethral stricture or bladder neck contracture within the last 180 days. Two or more urethral strictures and/or bladder neck contractures within 5 years. Lichen sclerosus. Neurogenic bladder or other neurological disorder. Polyneuropathy (e.g., diabetic). Lower urinary tract surgery. Stress urinary incontinence that requires treatment or daily pad or device use. Intermittent self-catheterization. PVR >400 mL in the 14 days aysprior to the surgical procedure. Bladder stones. PCa; bladder cancer. Damage to external urinary sphincter. Disorder of the coagulation cascade or disorders that affect platelet count or function. Acute myocardial infarction, open heart surgery, or cardiac arrest <180 days. Immunocompromised	281 patients 139 GLL-PVP142 TURP	GLL-PVP 65.9 (±6.8) TURP 65.4 (±6.6)	GLL-PVP 48.6 (±19.2) TURP 46.2 (±19.1)	24 months
Bouchier-Hayes 2010	M-TURP vs 80 W GLL-PVP	Age >50 years; Qmax <15 mL/s; IPSS >11; PV on TRUS 15–85 mL; Obstructed on urodynamics/; Able to fill questionnaires; Able to give fully informed consent	Patients with neurogenic bladder; PCa; chronic retention; on α-blockers or permanent anticoagulation	119 patients 59 M-TURP60 GLL-PVP	M-TURP 66.36 (55–80)GLL-PVP 65.06 (51–81)	M-TURP 33.36 (15.3–67.54) GLL-PVP 38.78 (15.02–82.6)	12 months
Capitán 2011	120 W GLL-PVP vs TURP	IPSS >15 after failed medical therapy, PV <80 cm³ on TRUS, Qmax <15 mL/s, and patient understanding and signed written informed consent	Patients with detrusor overactivity or hypocontractility on urodynamic study; urethral stricture; PCa; previous prostate, bladder neck, or urethral surgery.	100 patients 50 GLL-PVP50 M-TURP	GLL-PVP 69.8 (±8.44) M-TURP 67.7 (±6.7)	GLL-PVP 51.29 (±14.72)M-TURP 53.10 (±13.75)	24 months
Carter 1999	Hybrid KTP/Nd:YAG laser ablation vs M-TURP	Symptomatic BPH who matched the inclusion criteria of BLUES protocol	PCa, history of urinary retention, PV on TRUS ≥100 mL, suspected neurogenic bladder dysfunction.	204 patients 101 Hybrid KTP/Nd:YAG laser 103 M-TURP	Hybrid KTP/Nd:YAG laser 67.9 (±7.8)M-TURP 67 (±7.5)	Hybrid KTP/Nd:YAG laser 41.6 (±17.3) M-TURP 41.7 (±19.4)	12 months
Cetinkaya 1996	TUVPvsM-TURP	Moderate or severe symptoms of prostatism and a maximum urinary flow rate (Qmax) of <15 mL/s	Previously undergone a prostate operation or who had any abnormality of kidney and liver function, urethral strictures, neurogenic deficits, bladder stones, or those with confirmed or suspected PCa	46 patients 23 TUVP 23 M-TURP	TUVP 68.4 (±8.3) M-TURP 62.5 (±10.1)	TUVP 48.4 (±9.7) M-TURP 48.8 (±15.4)	3 months
Cetinkaya 2015	980 nm diode laser PVP vs M-TURP	BPH refractory to medical treatment, recurrent urinary retention, prostate volume <80 mL, Qmax ≤15 mL/s (under medical treatment), IPSS ≥15, IPSS-QoL ≥3	Patients with prostate or bladder cancer, neurogenic bladder dysfunction, bladder stones, urethral structures, or previous bladder, urethral, or prostate surgery were excluded	72 patients36 PVP36 TURP	PVP 63.1 (±9.1) TURP 64.7 (±10.2)	PVP 50.6 (±16) TURP 54.8 (±22.7)	13 months
Cimentepe 2003	TUNA vs M-TURP	Lower urinary tract symptoms because of BPH, Age >40 years, Qmax <15 mL/secIPSS >13 Prostate weight 20–70 g No suspicion of prostate malignancy	Urethral stricture, Bladder neck contracture, Previous prostate surgery, Bladder stones or tumors, Neurogenic bladder, Prominent median lobe	59 patients26 TUNA 33 TURP	TUNA 60.1 (±7.3)TURP 63.3 (±5.9)	TUNA 67.4 (±29.4)TURP 76.1 (±50.1)	18 months
Cowles 1995	M-TURP vs PVP	BPH, Age >50 years	Urinary retention, ASA >3. PCa, Prostate length <2.4 cm	115 patients56 PVP59 TURP	PVP 65.8 (±6.7)TURP 67 (±7.8)	PVP 42.2 (±19) TURP 38.6 (±20)	12 months
Dahlstrand 1993	TUMT vs M-TURP	BPH, Prostate length 35-50 mm, ASA 1–3, Madsen SS >7, Q-max <15 × 2	Dementia, neurogenic bladder, Peripheral arterial disease, total hip replacement, catheter dependent, median lobe, bladder stones, urethral stricture, bladder cancer, prior radiation, prior prostate surgery, alpha blockers within 4 weeks, PVR >350	83 patients39 TUMT44 TURP	68 TUMT70 TURP	33 TUMT37 TURP	2–12 months
Dahlstrand 1995	TUMT vs M-TURP	BPH, Prostate length 35-50 mm, ASA 1–3, Madsen SS >7, Q-max <15 × 2	Dementia, neurogenic bladder, Peripheral arterial disease, total hip replacement, catheter dependent, median lobe, bladder stones, urethral stricture, bladder cancer, prior radiation, prior prostate surgery, alpha blockers within 4 weeks, PVR >350	75 patients35 TURP37 TUMT	TUMT 67 (±9) TURP 70 (±6)	TUMT 43.4 (±4.4)TURP 44.8 (±5.9)	24 months
Ekengren 2000	TUVP vs TURP	Patients with urinary outflow obstruction	NA	54 patients26 TUVP28 TURP	TUVP: 71 (49–82)TURP: 70 (48–83)56.9 (±1.2)	TUVP: 50 mL (25–90)TURP: 39 mL (20–80)50.9 (±5.3)	12 months
Elsakka 2016	B-TUVP vs M-TURP	Patients with LUTS secondary to bladder outlet obstruction with an IPSS >= 8, Qmax <15 m/s, not responding to medical treatment, and/or BPH complications such as refractory retention or recurrent hematuria, and prostate size <80 mL	Patients unfit for surgery and those suspected of prostatic carcinoma	82 patients40 B-TUVP42 M-TURP	B-TUVP55.6 (±3.1)M-TURP	B-TUVP53.8 (±8.1)M-TURP	6 months
Falahatkar 2014	B-TUVP vs B-TURP	Age >50 years, prostate volume of 30-80 mL, serum PSA <4 ng/mL, IPSS ≥20, Qmax ≤10 mL/s and failed BPH-relatedmedical therapy	Abnormal DRE or ultrasonography with suspicion of PCa, history of PCa, serum PSA ≥4 ng/mL, previous urethral or prostate surgery, urethral stricture, neurogenic bladder, bladder calculi, BPH-related hydronephrosis, anticoagulant therapy, coagulation disorders, renal insufficiency and severe co-morbidities or co—existing diseases	88 patients39 Bipolar TUVP49 B-TURP	B-TUVP: 70.97 (±3.79)B-TURP: 69.14 (±4.09)	B-TUVP: 46.92 (±4.67)B-TURP: 47.14 (±4.44)	3 months
Fowler 2005	M-TUVP vs M-TURP	1. The patient should be a candidate for surgical treatment of bladder outlet obstruction.2. The patient must have completed pretreatment evaluation in accordance with currently accepted criteria for prostate surgery.3. The patient must be able to give written, informed consent to randomization and treatment.	1. Any patient who has had previous bladder outlet surgery. 2. Any patient with a physical status greater than ASA 3. 3. Any patient with a clinically significant acute illness. 4. Any patient taking medication that would, in the investigator’s opinion, preclude entry into the trial. 5. Any patient with known disease of the central or peripheral nervous system. 6. Any clinical evidence of carcinoma of the prostate.	235 patients115 M-TUVP120 M-TURP	M-TUVP 70.2M- TURP 69.7	TUVP 54.3TURP 51.1	24 months
Francisca 2000	TUMT vs M-TURP	Age 45 years and older, PV ≥30 cm³, prostaticurethral length ≥25 mm, a Madsen symptom score ≥8, Qmax ≤15 mL/s and a PVR ≤350 mL	Acute prostatitis or urinary tract infection, evidence of prostate carcinoma, an isolated obstructed prostatic middle lobe, diabetes mellitus, intravesical pathology, neurological disorders, or current treatment with drugs that may influence the bladder function	147 patients TUMT 74TURP 73	TUMT 67 (±8.4)TURP 65 (±8.3)	TUMT 50 (±19.4)TURP 52 (±19.2)	12 months
Gallucci 1998	M-TUVP vs M-TURP	Diagnosis of symptomatic benign prostatic hyperplasia (BPH) with urodynamically assessed obstruction	Complete urinary retention, bladder calculi, neurogenic bladder, prostate weight >170 g, bladder cancer, mental or psychological illness and PCa	150 patients80 M-TURP 70 M-TUVP	not reported	36.59 (±1.37) M-TURP 36.61 (±1.52) M-TUVP	12 months
Geavlete 2011	B-TUVP vs B-TURP vs M-TURP	Qmax <10 mL/s, IPSS >19, PV between 30 and 80 mL	severe comorbidities, previous prostate surgery, history of PCa, abnormal DRE, and/or increased PSA	510 patients170 each group	not reported	B-TUVP 54.1 (31–78) B-TURP 53.7 (30–79)M-TURP 54.8 (32–80)	18 months
Geavlete 2014	Continuous B-TUVP vs standard B-TUVP vs M-TURP	Qmax <10 mL/s; IPSS >19	severe associated comorbidities, previous prostate surgery or history of PCa	60 C-BPVP,60 S-BPVP 60 M-TURP	Overall 68.9 (52–84)	C-BPVP 50.6S-BPVP 51.9M-TURP 52.4	6 months
Geavlete 2015	B-TUVP vs B-TURP vs BEP vs open prostatectomy	PV >80 mL, Qmax <10 mL/second, IPSS >19, or urinary retention imposing catheter indwelling	Associated comorbidities preventing surgery from being performed (such as severeheart, respiratory, hepatic, or renal failure, ongoing anticoagulant therapy that could not be stopped 7 days before the intervention for cardiovascular reasons, unstable angina, recentstroke, or myocardial infarction), previous prostate surgery,urethral strictures, and not BPH-related voiding disorders	320 patientsB-TUVP 80 B-TURP 80 BEP 80 open prostatectomy 80	B-TUVP 67.5 (±9.1)B-TURP 69.5 (±7.2)BEP 68.5 (±8.5)open prostatectomy 68.7 (±8.6)	B-TUVP 126.7 (±33.1)B-TURP 121.8 (±30.4)BEP 122.6 (±30.7)open prostatectomy 128.7 (±32.7)	12 months
Gilling 2020	M-TURP vsAquablation	Age 45–80 years, LUTS secondary to BPH, PV 30-80mL, IPSS ≥12, Qmax <15mL/s	History of PCa or bladder cancer, neurogenic bladder, bladder calculus or significant bladder diverticulum, active UTI, treatment for chronic prostatitis, diagnosis of urethral stricture, meatal stenosis or bladder neck contracture, damaged external urinary sphincter, stress urinary incontinence, PVR >300 mL or AUR, use of self-catheterization, or prior prostate surgery. Use of anticoagulants or bladder anticholinergics, or severe cardiovascular disease	181 patientsAquablation 116 M-TURP 65	Aquablation 66.0 (±7.3)M-TURP 65.8 (±7.2)	Aquablation 54.1 (±16.2)M-TURP 51.8 (±13.8)	60 months
Hammadeh 1998	M-TUVP vs M-TURP	LUTS and BOO because of BPH, IPSS ≥13, QOL index ≥3, and Qmax <15 mL/s	Neurogenic bladder, PCa, previous prostatic or urethral surgery, bladder stone, or receiving anticoagulant therapy	104 patients 52 M-TUVP 52 M-TURP	M-TURP 70.2 (±7.2) M-TUVP 67.5 (±6.7)	M-TURP 27 (±12.2) M-TUVP 32 (±9.1)	5 years
Hassan 2024	980-nm diode laser ablation vs M-TURP			56 patients28 Diode laser ablation 28 M-TURP	Diode laser ablation 66.32 (±7.58)M-TURP 63.13 (±9.23)	Diode laser ablation 56.98 (±12.86)M-TURP 59.52 (±11.31)	12 months
Horasanli 2008	Potassium titanyl phosphate PVP vs TURP	LUTS because of BPH, with a prostate volume of 70 to 100 mL, Qmax =<15 mL/s, or PVR >150 mL in conjunction with IPSS greater than 7	Neurogenic bladder disorder, urethral strictures, PVR >400 mL, history of PCa or any previous prostatic, bladder neck, or urethral surgery; presence of an indwelling catheter	76 patients37 M-TURP39 PVP	M-TURP 68.3 (±6.7) PVP 69.2 (±7.1)	M-TURP 88 (±9.2) PVP 86.1 (±8.8)	6 months
Kabalin 1993	Nd:YAG laser ablation vs M-TURP	Age >50 years; Qmax <15 mL/sec; symptoms requiring surgery	ASA IV; coagulation disorders; anticoagulant medications	25 patients13 Nd:YAG laser ablation 12 M-TURP	Nd:YAG laser ablation 65M-TURP 69	Nd:YAG laser ablation 24 (range 15–45)M-TURP 17 (range 10–30)	6 months
Karadag 2014	B-TUVP vs B-TURP	Moderate to severe LUTS, based on IPSS, requiring surgery,recurrent urinary retention, failed medical therapy (at least21 days) and obstructive pressure flow study or Qmax <10 mL/s	Suspicion of prostatic adenocarcinoma, if they had an abnormal DRE or elevated PSA, known urethral stricture, or neurogenic bladder and a history of prostate surgery	183 patients87 B-TUVP 96 B-TURP	B-TUVP 67.98 (±6.06)B-TURP 66.72 (±6.04)	B-TUVP 50.9 (±16.5)B-TURP 50.6 (±16.9)	12 months
Keoghane 1996	Nd:YAG laser ablation vs M-TURP	Patients who need surgical treatment for BPH	Previous surgery or instrumentation for BPH; prostatic malignancy: patients who were unable to speak or understand sufficient English to answer the question or if they refused consent	148 patients 72 Nd:YAG laser ablation 76 M-TURP	Nd:YAG laser ablation 69M-TURP 70	Nd:YAG laser ablation 54.2 (±26.3)M-TURP 51.9 (±24.1)	3 months
Kumar 2013	GreenLight HPS 120 W laser vs M-TURP vs B-TURP	Age ≥50 years; IPSS >7, (3) PV 20–80 cc; Qmax <15 mL/sec	History of prostate, bladder, or urethral surgery, or spinal surgery or spinal trauma; neurological disease; PVR >300 mL; indwelling Foley catheter, where indication for catheterization was chronic retention (PVR >300 mL); prostate or bladder cancer; urethral stricture; antiplatelet drugs in whom drugs could not be safely stopped perioperatively; patients who did not give written informed consent	175 patients 58 GreenLight HPS 120 W laser 60 M-TURP 57 B-TURP	GreenLight HPS 120 W laser 64.58 (±6.64)M-TURP 63.68 (±6.57)B-TURP 62.31 (±6.36)	GreenLight HPS 120 W laser 52.79 (±16.13)M-TURP 52.20 (±15.93)B-TURP 50.26 (±16.50)	12 months
Küpeli 1998	M-TUVP vs M-TURP	IPSS ≥7, Qmax ≤15 mL/sec	Histopathologic diagnosis of PCa, PV >60 mL	66 patients30 M-TUVP 36 M-TURP	M-TVP 65.7M-TURP 62.4	M-TUVP 43.57M-TURP 41.46	12 months
Lukacs 2012	120 W GLL-PVP vs M-TURP	IPSS >12 and QOL score 3;Qmax <12 mL/s, PV between 25 mL and 80 mL; PVR <300 mL; Normal DRE; PSA <4 ng/mL or negative prostate biopsy if PSA between 4 and 10 ng/mL for patients <75 years of age or with life expectancy >10 years	Patients with urinary catheter before intervention; UTI; impaired renal function; unstable cardiac or pulmonary disease; bladder disease or neurological disease affecting bladder function; altered urinary sphincter function; urethral stricture; bladder neck stenosis, active hematuria, or bladder stones; history of prostate or urethral surgery; anorectal disease; antiaggregant/anticoagulation therapy that cannot be stopped or replaced without risk for the patient; severe coagulopathy; ASA score >3; patient unable to complete questionnaires or having no medical insurance	139 patients70 M-TURP 69 GLL-PVP	M-TURP 67.6 (±7.6)GLL-PVP 66.9 (±7.8)	M-TURP 50.11 (±14.73)GLL-PVP 50.54 (±16.53)	12 months
Mohanty 2012	80 W GLL-PVP vs M-TURP	Age >50 years, IPSS >7 PV (TRUS) between 20 and 80 cc; Qmax <15 mL/sec	History of prostate, bladder, or urethral surgery. Or spinal surgery or spinal trauma. Neurological disease. PVR >300cc. Indwelling Foley’s catheter where indication for catheterization was chronic retention (PVR >300) . PCa, bladder cancer, urethral stricture Alpha blocker/5 alpha reductase inhibitor drugs/herbal medications believed to be active in prostate. Patients on antiplatelet drugs where drugs could not be safely stopped perioperatively. Patients who did not give written informed consent	117 patients57 M-TURP 60 GLL-PVP	M-TURP 65.74 (±9.09) GLL-PVP 66.68 (±8.62)	M-TURP 49.02 (±15.93) GLL-PVP 44.77 (±14.09)	12 months
Nuhoğlu 2005	M-TUVP vs M-TURP	IPSS >15; Qmax <10 mL/sec.	History of prostate or urethral surgery, suspected PCA, and neurogenic bladder	77 patients37 M-TUVP40 M-TURP	M-TUVP 64.5 (±8.7)M-TURP 65.1 (±9.4)	M-TUVP 39 (±8.1)M-TURP 39 (±7.7)	60 months
Purkait 2017	120 W GLL-PVP vs B-TURP	BPH leading to refractory urinary retention, recurrent urinary tract infections, lower urinary tract symptoms (LUTS) refractory to medical treatment, renal insufficiency, bladder stones, and recurrent hematuria	History of prostate, bladder, urethral, spinal surgery or spinal trauma, hypocontractile bladder on urodynamic study, PCa, carcinoma of the bladder, urethral stricture, and patients who did not give consent for the study	117 patients60 GLL-PVP 57 B-TURP	GLL-PVP 63.6 (±8.12) B- TURP 65.3 (±7.86)	GLL-PVP 70.3 (±15.5) B-TURP 69.6 (±16.3)	48 months
Razzaghi 2014	980 nm diode laser vaporization vs M-TURP	BPH with lower urinary tract symptoms despitemaximal medical therapy, frequent urinary tract infections, hematuria unresponsive to medical therapy, high serum creatinine that decreased with urethral catheter placement, and urinary retention despite medical therapy.	History of neurogenic bladder, previous prostate surgery, anticoagulant medication, urethral stricture, bladder stone, diagnosis of PCa, prostate volume >100 mL on TRUS, and disability or refusal to give a fully informed consent	102 patients50 Diode Laser Vaporization 52 M-TURP	Diode laser vaporization 68.5 (±8.8) M-TURP 68.2 (±7.8)	Diode laser vaporization 61.1 (±16.1)M-TURP 59.6 (±14.1)	24 months
Samir 2024	Rezum vs B-TURP	50–80 years; PV 50–120 mL; sexually active; Q max <10 mL/s; IPSS >20, who were unresponsive to treatment with alpha blockers	PCa; neurogenic bladder, urethral stricture, urinary bladder stone, or previous prostatic surgery	100 patients50 Rezum 50 B-TURP	Rezum 66.7 (±7.3) B-TURP 63.7 (±8.9)	Rezum 71.9 (±17) B-TURP 74.1 (±18.6)	24 months
Shingleton 1999	TURP vs 40 W KTP/60 W Nd:YAG laser	Men older than 45 years of age with documented obstructed voiding symptoms in whom alpha-blocking medical therapy had failed Qmax <15mL/s No history of PCa Ability to tolerate regional or general anesthesia	None mentioned	100 patients50 KTP/Nd:YAG laser50 TURP	KTP/Nd:YAG laser 68.2 (±7.9)TURP 67.4 (±7.39)	KTP/Nd:YAG laser 32.2 (±21.4)TURP 29.6 (±15.4)	12 months
Telli 2015	120 W GLL-PVP vs M-TURP	Qmax <15mL/s or PVR <150cc; International Prostate Symptom Score (IPSS) >7 PV <80 mL	Neurogenic bladder disorder, urethral strictures, history of PCa or any previous prostatic, bladder neck or urethral surgery	101 patients62 M-TURP 39 GLL-PVP	M-TURP 69 (56–87) GLL-PVP 67 (51–87)	M-TURP 55 (40–72) GLL-PVP 60 (41–75)	24 months
vanMelick 2003	M-TURP vs Nd:YAG laser ablation vs M-TUVP	Age >45 years; LUTS associated with BPH; patients had to be urodynamically equivocal or obstructed. PV 20–65 cc	PCa; neurogenic bladder; severe urinary tract infection or hematuria; significant cardiovascular disease; history of other specific urinary tract surgeries	141 patients50 M-TURP45 Nd:YAG laser ablation46 M-TUVP	M-TURP 66 (±8)Nd:YAG laser ablation 67 (±9)M-TUVP 64 (±10)	M-TURP 37 (±11) Nd:YAG laser ablation 38 (±9)M-TUVP 35 (±12)	12 months
Wagrell 2002	TUMT vs M-TURP	Symptomatic BPH, IPSS of 13 or greater, PV 30–100 mL, Qmax <13 mL/sec	Not reported	146 patientsTUMT 100 TURP 46	TUMT 67 (±8) TURP 69 (±8)	TUMT 48.9 (±15.8) TURP 52.7 (±17.3)	12 months
Xue 2013	120 W GLL-PVP vs M-TURP	IPSS >15, failure of previous medical treatment, Qmax <15 mL/s, PV <100 mL on TRUS, willingness to sign a written informed consent form	Detrusor overactivity or hypocontractility on urodynamic study, urethral stricture, PCa, and previous prostate, bladder neck, or urethral surgery. Patients presenting with PSA >4 ng/mL, abnormal DRE, and suspicious TRUS undergoing biopsy	200 patients100 M-TURP100 GLL-PVP	M-TURP 71.0 (±10.8) GLL-PVP 72.1 (±11.3)	M-TURP 67.3 (±24.7) GLL-PVP 65.8 (±23.6)	36 months
Zhang 2011	Channel M-TURP and ILC vs M-TURP vs ILC	Age >65 years; Q max <10 mL/s, and moderate or severe LUTS; IPSS >10. Urodynamics were performed for all patients	Bladder calculus, bladder diverticulum, neurogenic bladder, or diabetes with abnormal cystometry, severe peripheral arterial insufficiency, PVR >350 mL, prostatic urethra <25 mm, urethral stricture, a history of any previous prostatic, bladder neck or urethral surgery, and the presence of an indwelling catheter were excluded	150 patients50 ILC+M-TURP 50 ILC 50 M-TURP	72.4 (±5.6)71.2 (±5.8)ILC70.5 (±5.4)M-TURP	53.1 (±4.8) ILC+M-TURP 52.0 (±5.1)ILC54.2 (±5.7)M-TURP	48 months

ASA = American Society of Anaesthesiologists; AUA = American Urological Association; BLUES = British Laser Urological Evaluation Society; BOO = Bladder Outlet Obstruction; 95% CI = 95% confidence interval; DRE = digital rectal examination; GLL-PVP = Green light laser photovaporization of the prostate; HPS = high performance system; ILC = interstitial laser coagulation; IRFT = Interstitial Radiofrequency Therapy; LUTS = lower urinary tract symptoms; Nd:YAG LASER ABLATION = contact laser prostatectomy; PCa = prostate cancer; TRUS = transrectal ultrasound; TUMT = transurethral microwave thermotherapy; TUNA = transurethral needle ablation; TUVP = Transurethral Electrovaporization of the Prostate; YAG = Yttrium Aluminum Garnet.

Study quality assessment

Across all included studies, there were 1497 patients in the Enucleation group, 2512 in the Ablation group, and 4007 in the TURP group, with 1944 receiving M-TURP and 1553 patients receiving B-TURP (one study included M-TURP and B-TURP patients within the same group).

Supplementary Figure S1 shows the details of quality assessment for included studies. Twenty-four (39%) studies demonstrated low risk of bias across all domains, 25 (41%) studies showed some concerns in overall risk of bias, and the remaining 12 (20%) studies had high overall risk of bias.

Incidence of AUR/failure to void following M-TURP

The pooled incidence of AUR/failure to void in patients who underwent M-TURP ranged from 1.1% to 28.3% with a pooled rate of 3.7% (Supplementary Fig. S2).

Incidence of AUR/failure to void following B-TURP

The pooled incidence of AUR/failure to void in patients who underwent B-TURP ranged from 1.0% to 11.3% with a pooled rate of 3.0% (Supplementary Fig. S3).

Incidence of AUR/failure to void following ablation

The pooled incidence of AUR/failure to void in patients who underwent Ablation ranged from 1.8% to 30.8% with a pooled rate of 9.0% (Supplementary Fig. S4).

Incidence of AUR/failure to void following enucleation

The pooled incidence of AUR/failure to void in patients who underwent Enucleation ranged from 0.4% to 16.7% with a pooled rate of 2.4% (Supplementary Fig. S5).

AUR/failure to void: Enucleation vs TURP

Meta-analysis for 21 studies (1497 Enucleation and 1406 TURP cases) showed no significant difference in the incidence of AUR/failure to void between Enucleation and TURP groups (RR 0.90, 95% CI 0.61–1.32, p = 0.59) (Fig. 2). There was no significant heterogeneity among the studies (I² = 0%). Sub-group analysis demonstrated no difference between TURP and any energy source employed for Enucleation. Supplementary Figure S6 shows the funnel plot of the relationship between individual study effect sizes. The Egger’s regression test does not indicate significant funnel plot asymmetry (t = −1.24, df = 20, p = 0.23). The bias estimate was −0.62 (Standard Error = 0.50), providing no evidence of small-study effects or publication bias. Sensitivity analysis confirmed no significant difference in the incidence of AUR/failure to void between Enucleation and TURP groups (RR 0.76, 95% CI 0.49–1.18, p = 0.22) (Supplementary Fig. S7).

FIG. 2.

Forrest plot of acute urinary retention/failure to void in studies comparing Enucleation vs TURP. TURP = transurethral resection of the prostate.

Regarding the influence of the type of electrocautery used for resection, meta-analysis showed no significant difference between M-TURP (377 cases) and Enucleation (357 cases) (RR 0.87, 95% CI 0.45–1.67, p = 0.68) or B-TURP (1091 cases) and Enucleation (1179) (RR 0.95, 95% CI 0.60–1.51, p = 0.84) (Fig. 3). Sensitivity analysis confirmed no significant difference in the incidence of AUR/failure to void between Enucleation and M-TURP (RR 0.91, 95% CI 0.45–1.84, p = 0.79) and B-TURP groups (RR 0.74, 95% CI 0.44–1.26, p = 0.27) (Supplementary Fig. S8).

FIG. 3.

Forrest plot of acute urinary retention/failure to void in studies comparing Enucleation vs TURP, subgroup analysis for monopolar and bipolar TURP.

AUR/failure to void: Ablation vs TURP

Meta-analysis for 40 studies (2512 Ablation and 2601 TURP cases) showed that the incidence of AUR/failure to void significantly favored the TURP group (RR 1.79, 95% CI 1.38–2.31, p < 0.001) (Fig. 4). Study heterogeneity was low (I² = 22%). Sub-group analysis demonstrated that the difference favored the TURP group compared with 980 Nm diode laser Ablation (RR 4.53, 95% CI 1.24–16.47, p = 0.02), monopolar electro vaporization (RR 3.24, 95% CI 1.90–5.55, p < 0.001), and Neodymium (Nd):YAG laser ablation (RR 2.61, 95% CI 1.54–4.42, p = 0.0004) only. Supplementary Figure S9 shows the funnel plot of the relationship between individual study effect sizes. The Egger’s regression test indicates significant funnel plot asymmetry (t = 2.68, df = 39, p = 0.01), with a bias estimate of 0.94 (Standard Error = 0.35), suggesting the presence of small-study effects consistent with potential publication bias. Sensitivity analysis confirmed that the incidence of AUR/failure to void significantly favored the TURP group (RR 1.65, 95% CI 1.24–2.20, p = 0.0007) (Supplementary Fig. S10)

FIG. 4.

Forrest plot of acute urinary retention/failure to void in studies comparing Ablation vs TURP.

Regarding the influence of the type of electrocautery used for resection, meta-analysis showed no significant difference between B-TURP (462 cases) and Ablation (370 cases) (RR 1.59, 95% CI 0.75–3.40, p = 0.23). However, the incidence of AUR/failure to void favored M-TURP (1944 cases) compared with Ablation (1967 cases) (RR 1.88, 95% CI 1.40–2.52, p < 0.001) (Fig. 5).

FIG. 5.

Forrest plot of acute urinary retention/failure to void in studies comparing Ablation vs TURP, subgroup analysis for monopolar and bipolar TURP.

Sensitivity analysis confirmed no significant difference between Ablation and B-TURP group (RR 1.59, 95% CI 0.75–3.40, p = 0.23) and a significant difference in the incidence of AUR/failure to void, favoring M-TURP compared with Ablation (RR 1.71, 95% CI 1.21–2.41, p = 0.002) (Supplementary Fig. S11).

Discussion

The last 30 years have introduced numerous new technologies aimed at enhancing what has been widely regarded as the “gold standard” in the surgical treatment of BPE, namely TURP. However, no BPE surgical procedure is without complications, and some patients suffer from postoperative bothersome LUTS such as frequency, urgency, incontinence, decreased force of stream, and even AUR, which has been reported to be between 5% and 35% following TURP.¹³

AUR/failure to void post-BPE surgery remains one of the most frequent perioperative and early complications.¹⁴ Yet, AUR can be recurrent in some patients, which prolongs the hospital stay, leads to increased patient discomfort and dissatisfaction, and increases hospital costs. In this review, we assessed and compared the AUR/failure to void rate for BPE intervention across 61 randomized controlled trials involving over 8000 patients comparing TURP vs Enucleation and Ablation. The most important finding of our analysis is the higher incidence of postoperative AUR following ablation procedures (9.0%) compared with both TURP (3%−3.7%) and Enucleation techniques (2.4%). Conversely, Enucleation procedures demonstrated comparable safety profiles to TURP, with no significant difference in postoperative retention rates, suggesting that these techniques have achieved functional equivalence with the historical gold standard in this important outcome domain. To our knowledge, this is the first review on this subject.

The nearly threefold increase in retention risk associated with Ablation represents a clinically meaningful difference that warrants careful consideration during treatment selection. The differential retention rates observed across surgical modalities partially reflect fundamental differences in tissue handling and wound healing characteristics. Enucleation techniques, which involve anatomical dissection along natural tissue planes, typically achieve more complete adenoma removal with well-defined tissue boundaries and minimal residual tissue.¹⁵ This anatomical completeness is one important reason behind the low retention rates observed with Enucleation.

An important consideration when interpreting the higher retention rates following Ablation procedures is the fundamental difference in their mechanism of action compared to TURP and Enucleation techniques. Unlike TURP and Enucleation, certain Ablation modalities, particularly thermal therapies such as TUMT, TUNA, and Rezum, rely on delayed tissue necrosis and subsequent sloughing to achieve their therapeutic effect. Yet, tissue sloughing occurring during the early postoperative period and potentially greater inflammatory responses also trigger bladder irritability and detrusor dysfunction. This temporal dissociation between the procedure and actual tissue removal may contribute to the observed higher rates of postoperative AUR/failure to void. However, the subgroup analyses revealed important nuances regarding specific ablation modalities. Ablation using older energy sources, particularly 980 nm diode laser (RR 4.53), monopolar electrocautery (RR 3.24), and Nd:YAG laser (RR 2.61), demonstrated significantly higher retention rates compared with TURP. This finding likely reflects the technological limitations of these early-generation ablative platforms, including less precise tissue vaporization, greater inflammatory response, and incomplete tissue removal, leading to residual obstructive tissue or edema. The effect of greater inflammatory response after Nd:YAG laser ablation was highlighted by Cowles et al., who argued that the significantly higher rate of postoperative AUR in the visual laser ablation group compared with the M-TURP group (30.4% vs 8.5%) was probably related to the tendency to remove the catheter too early.¹⁶

Interestingly, more contemporary Ablation techniques like GreenLight™ photoselective and Bipolar vaporization of the prostate showed trends toward similar AUR/failure to void rate to TURP in our study, though statistical significance varied, suggesting that technological refinements may be progressively narrowing this performance gap.

Incomplete tissue removal is another reason why patients treated with early-generation ablative platforms experienced a higher rate of AUR/failure to void. In fact, Keoghane et al. found that the rate of AUR was 28% in patients undergoing Nd:YAG laser ablation versus 12% in M-TURP patients.¹⁷ Among those patients, 22% of laser patients subsequently underwent early TURP for residual tissue compared with no patient in the TURP arm. This finding is in line with a recent review that demonstrated the higher reoperation rate for residual adenoma following Ablation procedures compared with TURP.¹⁵

Regarding the causes of AUR/failure to void following Enucleation, prolonged morcellation time has been hypothesized as a main factor. Indeed, the bladder is over-distended to greater than its maximal capacity during morcellation, and likely this over-distention adversely affects the bladder detrusor muscle and results in postoperative voiding dysfunction, particularly de novo AUR.¹⁸ The pathophysiologic mechanism by which bladder overdistention induces microscopic tissue damage, intramural ischemia, and neuronal injury within the smooth muscle layers of the bladder wall, culminating in detrusor myogenic failure 24 hours to 1 week following the inciting event, is the postulated etiology and has been elucidated in rat model studies.¹⁹

Some patients experience delayed AUR occurring after an initial successful trial of void. In a series of 500 men who underwent HoLEP, Gopalakrishnan et al. showed that delayed AUR occurred in 5.8% of cases and was associated with a higher rate of intraoperative urethral dilation because of the incapability of the urethral meatus to accommodate the cystoscope.²⁰ All patients in this series had a successful same-day trial of void, but delayed AUR was presumably mediated by inflammatory changes and mucosal edema, which characteristically evolve over the initial 1–3 days post-injury, consistent with the typical inflammatory cascade. In such a patient, 24–48 hours of postoperative catheterization could be a viable option to avoid emergent hospital access to have a catheter replacement.

Detrusor underactivity represents another potential cause of AUR/failure to void regardless of the type of BPE surgery. Multiple studies indicate that inadequate detrusor function is a primary factor contributing to the elevated post-operative voiding failure rates observed in many patients undergoing TURP.^21–23 In fact, impaired bladder contractility can result from prolonged preoperative obstruction, causing permanent structural alterations. Sustained bladder outlet resistance triggers progressive muscular hypertrophy, ultimately producing a bladder with reduced capacity and diminished compliance.²⁴ Furthermore, compromised vascular perfusion and compression from chronic bladder distention can lead to collagen accumulation, resulting in increased bladder wall thickness and poor contractility.²⁴ In a consecutive series of 379 TURP patients, Reynard et al. found that there was no case of failure to void in those presenting with LUTS alone, whereas the rate was 10%, 38%, and 44% in patients presenting with preoperative AUR, chronic retention, and acute on chronic retention, respectively.²¹ The role of preoperative detrusor function on postoperative TURP outcome was also confirmed in 81 men undergoing TURP and assessed preoperatively using a multichannel flow/pressure study.²³ The authors found that age >80 years, preoperative AUR, large retention volume (1500 mL), and maximal detrusor pressure less than 28 cm H₂O were factors associated with postoperative failure to void.²³

The comparable retention rate between M-TURP (3.7%) and B-TURP (3%) indicates that the type of electrocautery modality has minimal influence on this outcome. This contrasts with other perioperative outcomes where bipolar technology has demonstrated advantages, particularly regarding bleeding complications.²⁵ The finding that M-TURP showed significantly lower retention rates compared with Ablation, whereas B-TURP did not reach statistical significance versus Ablation, may reflect sample size limitations in the bipolar comparisons rather than true biological differences.

All the above findings carry substantial implications for clinical practice and patient counseling. First, a bladder catheter might be kept longer after treatment in patients undergoing Ablation, especially using older energies and in patients requiring intraoperative urethral dilatation. This may reduce the postoperative AUR/failure to void rate. Second, Ablation procedures should be performed in patients with lower prostate volume because the reoperation rate for residual adenoma after Ablation is much higher (6.2%) than after Enucleation (0.7%) and TURP (2.3%).¹⁵ This variation may potentially be attributed to insufficient energy output during the procedure, resulting in incomplete tissue removal, possibly because of suboptimal tissue ablation by lower-performance laser systems used in the late 1990s and early 2000s, particularly in large volume prostates. However, Campobasso et al. showed in a large multicenter study of patients undergoing standard or anatomical GreenLight™ photoselective vaporization of the prostate that postoperative AUR was associated with an adenoma volume less than 40 mL.²⁶ This finding may be, again, attributable to inefficient vaporization secondary to inadequate adenoma ablation, with consequent excessive energy absorption by prostatic tissue, potentially resulting in inflammatory and irritative effects leading to AUR, as the authors suggested. Third, patients with a history of preoperative retention or with detrusor underactivity should be counseled of the risk of postoperative AUR/failure to void, and probably they should be offered Enucleation instead of Ablation or TURP not only because the former showed a lower rate of AUR/failure to void in our analysis, but also because after establishing the learning curve, Enucleation may provide a more complete adenoma removal compared to TURP and Ablation, potentially explaining its superior outcomes in men with detrusor underactivity.^27,28

Take-home messages

Several key insights emerge from our analysis, supported by its methodological strengths such as exclusive inclusion of randomized controlled trials providing the highest quality comparative evidence. In addition, this study encompasses a comprehensive literature search ensuring maximal data capture, robust statistical approaches with appropriate handling of multi-arm trials, and a large sample size providing substantial statistical power for detecting clinically meaningful differences.

The comparable retention rates after Enucleation and TURP provide reassuring safety data supporting the continued adoption of Enucleation techniques, which have already demonstrated advantages in other outcome domains, including reduced bleeding, shorter catheterization times and hospital stay, and improved efficacy, particularly in large prostates.²⁹

For Ablation procedures, our findings suggest that patient selection and technique refinement remain critical. Although Ablation offers certain advantages over TURP, including reduced bleeding risk and potential for office-based delivery in select cases, the higher retention risk must be weighed against these benefits.

Surgeons employing Ablation techniques should consider strategies to mitigate retention risk, including ensuring adequate tissue vaporization, prolonged catheterization protocols in high-risk patients, and judicious patient selection favoring smaller glands and lower-risk profiles.

Surgeons should consider integrating our findings into preoperative counseling, particularly when discussing Ablation procedures, especially in patients with risk factors for postoperative retention such as advanced age, preoperative catheter dependence, significant preoperative residual urine, or large prostate volumes.

Study limitations

Several limitations warrant consideration. The definition and reporting of AUR varied across included studies, with some reporting failure to void after catheter removal and others documenting clinically significant retention requiring recatheterization. This heterogeneity may have introduced measurement variability, though the overall low statistical heterogeneity (I² = 0–22% across comparisons) suggests reasonable consistency. Moreover, the presence of significant funnel plot asymmetry and small-study effects in the ablation analyses suggests potential publication bias, which may have led to an overestimation of the true effect size for postoperative AUR/failure to void in this subgroup. Consequently, the magnitude of the observed difference between Ablation and TURP should be interpreted with caution. In contrast, no evidence of publication bias was detected for Enucleation, supporting the robustness of those results. The included studies demonstrated considerable heterogeneity in reporting baseline patient characteristics, with inconsistent documentation of prostate volume subgroups and patient age distributions. As a consequence, we could not analyze the influence of potentially important variables such as prostate volume and patient age, as these variables stratified by prostate size or age groups were inconsistently reported across studies. The inability to account for these baseline differences across treatment groups represents an important limitation, as both prostate size and advanced age are established risk factors for postoperative retention that may have influenced our observed outcomes. Furthermore, the quality assessment revealed that only 39% of studies demonstrated low risk of bias across all domains, with 41% showing some concerns and 20% high risk of overall bias, potentially introducing performance and detection biases but sensitivity analyses did not materially alter the pooled effect estimates, and the direction and magnitude of the effect remained consistent with the primary analysis, thereby supporting the robustness of our findings. A further limitation of our analysis is the inability to distinguish between early postoperative AUR and delayed AUR. Unfortunately, most included studies did not consistently report the timing of AUR events, precluding meaningful subgroup analysis. Yet, the definition and diagnostic criteria for AUR/failure to void varied across included studies. Although most studies defined AUR as the need for recatheterization after a failed voiding trial, the specific clinical assessment methods were inconsistently reported. This heterogeneity in outcome definition may have introduced measurement variability and could affect the generalizability of our findings. Finally, the unequal sample sizes across comparison groups, particularly the relatively smaller B-TURP cohort, may have limited statistical power for certain subgroup analyses.

Conclusion

From a patient and surgeon perspective in the modern era, any BPE intervention should minimize morbidity, improve symptoms and quality of life, and provide durable outcomes. Our comprehensive systematic review demonstrates that Enucleation procedures achieve comparable safety to TURP with respect to postoperative AUR/failure to void, supporting their continued adoption as effective alternatives to traditional resection. Conversely, Ablation procedures, particularly those employing older energy modalities, demonstrate significantly higher retention rates that should inform patient counseling.

Future studies should employ standardized definitions of postoperative AUR, with consistent reporting of timing, severity, and resolution. Investigation of patient-specific risk factors predicting postoperative retention across different surgical modalities would enable more personalized risk stratification and potentially guide technique selection. Finally, as Ablation technologies continue to evolve, ongoing surveillance of retention outcomes with newer-generation platforms is essential to determine whether technological refinements have successfully addressed the higher retention rates observed with earlier devices.

Authors’ Contributions

Conception and design: D.C. Acquisition of data: All authors. Statistics: D.C. Drafting of the article: D.C. Critical revision for important intellectual content: K.R.G. Supervision: S.K.-K.Y. and V.G. All the authors participated in article writing, review, and approval of the final version of the article for submission.

Footnotes

Author Disclosure Statement

J.M.D. is a Consultant for Boston Scientific, and S.D. is a Consultant for Boston Scientific, received research funding from Dornier, and is on the advisory board for Andromeda. The remaining authors declare no conflicts of interest.

Funding Information

No funding was received for this article.

Supplemental Material

Abbreviations

References

Bushman

. Etiology, epidemiology, and natural history of benign prostatic hyperplasia. Urol Clin North Am, 2009; 36(4):403–415; doi: 10.1016/j.ucl.2009.07.003

Gravas

, Cornu

, Gacci

, et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), Incl. Benign Prostatic Obstruction (BPO). 2023. Available from: https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Non-Neurogenic-Male-LUTS-2022.pdf [Last accessed: August 12, 2023].

Huang

S-W

, Tsai

C-Y

, Tseng

C-S

, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: Systematic review and network meta-analysis. Bmj, 2019; 367:l5919; doi: 10.1136/bmj.l5919

Castellani

, Pirola

, Rubilotta

, et al. Greenlight laserTM photovaporization versus transurethral resection of the prostate: A systematic review and meta-analysis. Res Rep Urol, 2021; 13:263–271; doi: 10.2147/RRU.S277482

Page

, McKenzie

, Bossuyt

, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Bmj, 2021; 372:n71; doi: 10.1136/bmj.n71

Axon

, Dwan

, Richardson

. Multiarm studies and how to handle them in a meta‐analysis: A tutorial. Cochrane Evid Synth Methods, 2023; 1(10):e12033; doi: 10.1002/cesm.12033

Higgins

, Thomas

, Chandler

, et al. Chapter 10: Analysing Data and Undertaking Meta-Analyses. In: Cochrane Handbook for Systematic Reviews of Interventions. (John Wiley & Sons. ed) Chichester (UK); 2019.

Bradburn

, Deeks

, Berlin

, et al. Much ado about nothing: A comparison of the performance of meta-analytical methods with rare events. Stat Med, 2007; 26(1):53–77; doi: 10.1002/sim.2528

Sweeting

, Sutton

, Lambert

. What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med, 2004; 23(9):1351–1375; doi: 10.1002/sim.1761

10.

Sterne

JAC

, Savović

, Page

, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ, 2019; 366:l4898; doi: 10.1136/bmj.l4898

11.

Sterne

JAC

, Sutton

, Ioannidis

JPA

, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. Bmj, 2011; 343(7818):d4002; doi: 10.1136/bmj.d4002

12.

Egger

, Smith

, Schneider

, et al. Bias in meta-analysis detected by a simple, graphical test. Br Med J, 1997; 315(7109):629–634; doi: 10.1136/bmj.315.7109.629

13.

Chughtai

, Simma-Chiang

, Kaplan

. Evaluation and management of post-transurethral resection of the prostate lower urinary tract symptoms. Curr Urol Rep, 2014; 15(9):434; doi: 10.1007/s11934-014-0434-1

14.

Rassweiler

, Teber

, Kuntz

, et al. Complications of transurethral resection of the prostate (TURP)–incidence, management, and prevention. Eur Urol, 2006; 50(5):969–979; discussion 980; doi: 10.1016/j.eururo.2005.12.042

15.

Castellani

, Tramanzoli

, Chiacchio

, et al. Reoperation rate for residual/regrowth adenoma following transurethral interventions for benign prostatic enlargement: Results from a systematic review and meta-analysis of comparative randomized studies. J Endourol, 2024; 38(6):605–628; doi: 10.1089/end.2023.0766

16.

Cowles

3rd , Kabalin

, Childs

, et al. A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia. Urology, 1995; 46(2):155–160; doi: 10.1016/s0090-4295(99)80185-x

17.

Keoghane

, Lawrence

, Gray

, et al. The Oxford Laser Prostate Trial: Economic issues surrounding contact laser prostatectomy. Br J Urol, 1996; 77(3):386–390; doi: 10.1046/j.1464-410x.1996.81811.x

18.

Kim

, Yoo

, Choo

, et al. Factors affecting de novo urinary retention after Holmium laser enucleation of the prostate. PLoS One, 2014; 9(1):e84938; doi: 10.1371/journal.pone.0084938

19.

de Souza

GMP

, Costa

, Bruschini

, et al. Morphological analysis of the acute effects of overdistension on the extracellular matrix of the rat urinary bladder wall. Ann Anat, 2004; 186(1):55–59; doi: 10.1016/S0940-9602(04)80122-5

20.

Gopalakrishnan

, Useva

, Kumar

, et al. Delayed urinary retention after holmium laser enucleation of prostate. Urology, 2025; 205:215–221; doi: 10.1016/j.urology.2025.06.018

21.

Reynard

, Shearer

. Failure to void after transurethral resectionof the prostate and mode of presentation. Urology, 1999; 53(2):336–339; doi: 10.1016/S0090-4295(98)00515-9

22.

Mayer

, Kroeze

SGC

, Chopra

, et al. Examining the “gold standard”: A comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes. BJU Int, 2012; 110(11):1595–1601; doi: 10.1111/j.1464-410X.2012.11119.x

23.

Djavan

, Madersbacher

, Klingler

, et al. Urodynamic assessment of patients with acute urinary retention: Is treatment failure after prostatectomy predictable? J Urol, 1997; 158(5):1829–1833; doi: 10.1016/s0022-5347(01)64139-9

24.

Mirone

, Imbimbo

, Longo

, et al. The detrusor muscle: An innocent victim of bladder outlet obstruction. Eur Urol, 2007; 51(1):57–66; doi: 10.1016/j.eururo.2006.07.050

25.

Alexander

, Scullion

, Omar

, et al. Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev, 2019; 12(12):CD009629; doi: 10.1002/14651858.CD009629.pub4

26.

Campobasso

, Acampora

, De Nunzio

, et al. Post-operative acute urinary retention after greenlight laser. Analysis of risk factors from a multicentric database. Urol J, 2021; 18(6):693–698; doi: 10.22037/uj.v18i.6489

27.

Cho

, Ha

, Park

, et al. Impact of detrusor underactivity on surgical outcomes of laser prostatectomy: Comparison in serial 12-month follow-up outcomes between potassium-titanyl-phosphate photoselective vaporization of the prostate (pvp) and holmium laser enucleation of the prostate (HoLEP). Urology, 2016; 91:158–166; doi: 10.1016/j.urology.2015.11.052

28.

Woo

, Ha

, Lee

, et al. Comparison of surgical outcomes between holmium laser enucleation and transurethral resection of the prostate in patients with detrusor underactivity. Int Neurourol J, 2017; 21(1):46–52; doi: 10.5213/inj.1732640.320

29.

Zhang

, Yuan

, Ma

, et al. Efficacy and safety of enucleation vs. resection of prostate for treatment of benign prostatic hyperplasia: A meta-analysis of randomized controlled trials. Prostate Cancer Prostatic Dis, 2019; 22(4):493–508; doi: 10.1038/s41391-019-0135-4

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

12.04 MB