Not All LISTs for BPH Are Trying to Solve the Same Problem

ICUA Viewpoint · BPH & prostate surgery

Minimally invasive treatments for benign prostatic hyperplasia are often discussed as if they belonged to one coherent family. In reality, some are designed to preserve function and reduce treatment burden, while others aim to deliver more durable deobstruction. Treating them as equivalents creates more confusion than clarity.

Over the past few years, the treatment landscape for benign prostatic hyperplasia has become increasingly crowded with acronyms, devices, and promises. UroLift, Rezūm, iTIND, Aquablation, PAE, TPLA, Optilume… These procedures are often grouped under a single umbrella: MISTs or LISTs, meaning minimally or least invasive surgical treatments.

The problem is that once everything is placed under the same label, a misleading idea quickly follows: that all of these options are competing in the same therapeutic space and differ only in technology. That is not true.

The reality is more uncomfortable, but also more clinically useful: these procedures are not trying to solve the same clinical problem.

The problem with the umbrella label

When we talk about LISTs for BPH, we often mix procedures with very different goals.

Some are primarily designed to offer lower burden, less impact on ejaculation, a more acceptable patient experience, and faster recovery. Others aim to go further and deliver stronger and more durable deobstruction, coming much closer to what we expect from effective surgery. And some are still trying to define their true role.

This is the central weakness of the current field: the phrase “minimally invasive” has become too broad and too comfortable. It may help marketing, but it does not always help explanation.

The right question is not “which technique is best”

The right question is this:

What problem is each technique actually trying to solve, and what functional or therapeutic price does it ask the patient to pay in return?

Because in BPH treatment there is always a trade-off. No technique gives everything to everyone.

In general, the less invasive a treatment is, the more likely it is to depend on favorable anatomy, to sacrifice some deobstructive power, and to make durability and retreatment more important.

In other words, many of these techniques do not truly compete with enucleation. They compete with something else: fear of surgery, the desire to preserve ejaculation, the wish to avoid anesthesia or hospitalization, or the search for symptom relief that is “good enough” without committing to definitive surgery.

That is not a flaw. It is a different clinical proposition.

Functional compromise procedures

This group clearly includes techniques such as UroLift and iTIND.

Their main attraction is not maximal deobstruction. It is a combination of low procedural burden, better ejaculatory preservation, and relatively fast recovery.

They do have a real niche, especially in carefully selected patients with small or moderate prostates, favorable anatomy, and a very strong priority to preserve sexual function or avoid a more ablative treatment.

But that is precisely why we should be honest: these procedures do not appear to be designed to compete with prostate enucleation in terms of deobstructive strength and long-term durability.

They are not meant to solve every form of BPH. They are meant to solve a specific form of BPH in a specific kind of patient.

The intermediate space: Rezūm

Rezūm probably occupies the most interesting niche in the current LIST field.

It is not just a compromise treatment like an implant or a mechanical remodeling device. But neither is it a high-powered deobstructive procedure on the level of enucleation. It sits somewhere in between.

That is why it generates so much interest. It offers a compelling proposition: real tissue treatment, a lower-burden narrative, reasonably attractive functional outcomes, and good patient and physician acceptance.

The problem is not its original niche. The problem appears when the technique is pushed beyond that niche.

Over the past few years, there has been a clear movement toward larger prostates. That is precisely where caution matters most. A procedure may be feasible in expert hands without having established a convincing comparative role against more powerful options.

Rezūm has a place. But that place should be defined by honest comparison, not by enthusiasm alone.

The important exception: Aquablation

If there is one technique that breaks the conceptual umbrella of LISTs, it is Aquablation.

It is often presented alongside other minimally invasive therapies, but clinically it behaves very differently. It is not simply a friendlier or more function-preserving option. It is a procedure with much stronger deobstructive potential, and medium-term data place it closer to effective surgery than to compromise treatments.

That is why discussing Aquablation on the same plane as UroLift or iTIND creates confusion.

Not because it does not share the ambition of reducing morbidity, but because its therapeutic proposition is different: not merely to ease symptoms, but to deliver substantial deobstruction while trying to preserve a more favorable functional profile than some traditional surgeries.

The main driver of the market: sexual function

A large part of the success of this field cannot be explained by flow rates or IPSS scores alone. It is explained by something far more human and far more powerful: the preservation of sexual function, especially ejaculation.

And that matters. Greatly.

The mistake would be to treat this endpoint as a minor detail. It is not. For many patients, preserving ejaculation is not a luxury. It is a central priority.

But the opposite mistake is just as common: talking about sexual outcomes as if they could be separated from all the other outcomes.

The key question is not “which technique best preserves ejaculation?”. The key question is: what is the patient willing to trade in order to preserve it?

Because the price may be lower deobstructive power, more retreatment, greater dependence on favorable anatomy, or less robust outcomes when obstruction is significant.

Anatomical selection: where honesty is won or lost

This is one of the most important points in the entire debate.

LISTs should not be discussed as if they were interchangeable options chosen by taste. In practice, success depends heavily on prostate size, the presence of a median lobe, the severity of obstruction, bladder function, and patient priorities.

The more this is simplified in commercial messaging, the further the conversation drifts from real medicine.

A procedure can be excellent in one patient and unconvincing in another without saying anything negative about the procedure itself. It simply means that not everything is suitable for everyone.

So what is the real role of LISTs versus HoLEP?

Our view is that most LISTs do not truly compete with HoLEP in complete and durable deobstruction.

They compete in another arena: acceptability, lower perioperative burden, ejaculatory preservation, and lower perceived aggressiveness.

That is their value. And that value is legitimate.

But precisely because it is legitimate, it does not need to be exaggerated or presented as if it were equivalent to enucleation.

The partial exception is Aquablation, which enters much more clearly into the territory of strong deobstructive efficacy. The rest, in different ways, mostly inhabit the space of balance and functional compromise.

Conclusion

The modern discussion of LISTs for BPH should not begin with technology. It should begin with a simple clinical question:

What is the patient willing to give up in exchange for lower treatment burden?

In some cases, the answer will be durability. In others, deobstructive power. In others, ejaculation. And in others, the desire to avoid a more invasive surgical pathway.

Understanding that does not weaken the role of LISTs. On the contrary, it gives them a more honest and more useful place.

Because the future of this field will not depend only on how much technology it accumulates, but on how clearly it explains the real trade-off it offers the patient.

ICUA take-home message
Most LISTs are not “small HoLEPs”. They are different tools for different patients, with real benefits, real limitations, and a role that only becomes clear when their trade-offs are discussed honestly.

Dr. Fernando Gómez Sancha's English Blog

Saturday, April 18, 2026