Efficacy and safety of en bloc versus three-lobe enucleation technique for the management of benign prostatic obstruction: A systematic review and meta-analysis

Benign prostatic obstruction (BPO) is a common condition in aging men that often requires surgical intervention when medical therapy fails. Anatomical Endoscopic Enucleation of the Prostate (AEEP) has become an established minimally invasive treatment, with en bloc and three-lobe techniques being the most commonly used approaches. This systematic review and meta-analysis aimed to compare perioperative outcomes, surgical efficiency, and postoperative recovery between en bloc and three-lobe enucleation techniques. A comprehensive literature search was conducted in PubMed, Wiley Online Library, Scopus, Embase, SpringerLink, and the Cochrane Library for studies published up to May 2024. Eligible studies directly compared en bloc and three-lobe enucleation techniques and reported relevant perioperative and postoperative outcomes. Data were analyzed in accordance with PRISMA guidelines, and the risk of bias was assessed using the ROBINS-I tool. Six retrospective observational studies involving a total of 1,765 patients were included. En bloc enucleation was associated with a significantly shorter enucleation time compared with the three-lobe technique. No significant differences were observed in enucleation efficiency or resected prostate volume between the two techniques. Postoperative urodynamic outcomes showed slightly greater improvements in postvoid residual volume and maximum urinary flow rate with the three-lobe technique. No significant differences were found in International Prostate Symptom Score improvement or the incidence of postoperative urinary incontinence. Most included studies demonstrated a moderate risk of bias. Both en bloc and three-lobe enucleation techniques are effective and safe for the management of BPO. En bloc enucleation offers the advantage of reduced operative time, whereas the three-lobe technique may provide modestly better postoperative urodynamic outcomes. Further high-quality randomized controlled trials are required to confirm these findings and evaluate long-term outcomes.