Transperineal prostate laser ablation (TPLA) is an innovative, minimally invasive treatment for lower urinary tract symptoms caused by benign prostatic enlargement (LUTS/BPE). It offers a promising alternative to traditional surgical approaches, potentially reducing complications while preserving sexual function. This systematic review and meta-analysis evaluate the available evidence on TPLA’s efficacy and clinical outcomes.

Pubmed, Embase, Scopus, and Cochrane Library databases were searched from inception to July 2024. Random-effects model was employed to compute mean differences for continuous endpoints. Heterogeneity was evaluated by prediction interval and I-squared statistics. Additionally, a sensitivity analysis was performed to identify potential sources of heterogeneity. GRADE approach rated the certainty of the evidence and results were reported following the PRISMA statement guidelines. All statistical analyses were performed in R software version 4.4.1 (R Foundation for Statistical Computing).

In our pooled analysis, maximum urinary flow rate (Qmax) showed progressive improvement following treatment, increasing significantly at twelve months follow up (MD 6.32 mL/s; 95% CI 4.69 to 7.95; p<0.001; I2 = 81%). TPLA led to a substantial reduction in International Prostatic Symptoms Score (IPPS) as early as one month (MD −4.48; 95% CI −6.92 to −2.03; p<0.001; I2 = 41%), with further decreases up to twelve months (MD −12.62; 95% CI −14.87 to −10.37; p<0.001; I2 = 90%). Prostate volume and post-void residual (PVR) also declined over twelve months (MD −21.23 cm³; 95% CI −32.65 to −9.81; p<0.001; I2 = 84%, and MD −73.24 mL; 95% CI −96.91 to −49.57; p<0.001; I2 = 89%, respectively). TPLA improved quality of life by reducing the IPSS Q8 score at twelve months (MD −3.07; 95% CI −3.51 to −2.62; p < 0.001; I2 = 89%). Regarding sexual function, ejaculatory function improved at three and six months (MD 2.01; 95% CI 0.71 to 3.31; p = 0.002; I2 = 32%, and MD 3.28; 95% CI 1.93 to 4.6; p < 0.001; I2 = 0%.) and stabilized at twelve months (MD 1.64; 95% CI −0.47 to 3.75; p = 0.127; I2 = 85%), while erectile function remained unaffected throughout twelve months (MD 0.54; 95% CI −0.62 to 1.69; p = 0.363; I2 = 0%). In comparative analyses, TPLA was non-inferior to TURP in LUTS treatment, with better ejaculatory function preservation (MD 4.78; 95% CI 0.65 to 8.91; p = 0.023; I2 = 83%), though TURP provided greater Qmax improvement (MD −10.73mL/s; 95% CI −17.55 to −3.92; p = 0.002; I2 = 67%). Both procedures showed no significant difference in erectile function, while TPLA had shorter operating time (MD −43.46min; 95% CI −47.26 to −39.65; p < 0.001; I2 = 4%) and hospital stay (MD −0.54 days; 95% CI −0.73 to −0.35; p < 0.001; I2 = 0%). In the sensitivity analysis,  at 12 months, excluding one study revealed TPLA significantly improved ejaculatory function (MD 2.75; CI 95% 1.63–3.86; I² = 0%). leave-one-out sensitivity analysis of the RCTs found no major heterogeneity sources, except in Qmax and PVR, where the exclusion of one study reduced heterogeneity without changing results.

In this meta-analysis of 17 studies, TPLA demonstrated favorable outcomes for LUTS/BPE without a negative impact on sexual function. This minimally invasive treatment was found to have advantages over TURP, such as, ejaculatory function preservation, reduced operative time, and shorter hospital stay.

TPLA is an effective and minimally invasive treatment for LUTS/BPE, offering significant symptom relief, improved urinary flow, and preserved sexual function. Compared to TURP, TPLA provides advantages in ejaculatory function preservation, shorter operative time, and reduced hospital stay. Despite the results, higher quality studies and longer follow-ups are needed to confirm the evidence.