Function-preserving plasma kinetic enucleation of the prostate with bladder neck and 12 o'clock urethral mucosal preservation for large-volume benign prostatic hyperplasia: a single-center retrospective case series

Background Large-volume benign prostatic hyperplasia (BPH) poses a significant surgical challenge, as conventional transurethral resection yields suboptimal tissue removal efficiency and high rates of ejaculatory dysfunction. While endoscopic enucleation techniques (e.g., HoLEP and PKEP) offer improved efficacy, the systematic preservation of functional anatomical structures — particularly the bladder neck and anterior urethral mucosa — remains inadequately addressed in current practice. Objective To evaluate the safety, efficacy, and functional outcomes of function-preserving plasma kinetic enucleation of the prostate (FP-PKEP) — a modified technique incorporating systematic preservation of the bladder neck circular fibers and the 12 o'clock urethral mucosal strip — in patients with large-volume BPH. Methods This single-center, retrospective case series included 52 consecutive patients with large-volume BPH (prostate volume >80 mL, International Prostate Symptom Score [IPSS] > 20, maximum urinary flow rate [Qmax] < 10 mL/s) who underwent FP-PKEP between January 2025 and December 2025. The primary outcome was the change in IPSS at 3 months postoperatively; secondary outcomes included Qmax, post-void residual urine volume (PVR), quality of life (QoL) score, perioperative safety parameters, and functional preservation outcomes (urinary continence and ejaculatory function at 6 months). Results All 52 patients (mean age 67.8 ± 7.2 years; mean prostate volume 93.7 ± 15.2 mL) successfully underwent FP-PKEP without conversion. Mean operative time was 72.5 ± 15.8 min; postoperative hemoglobin decrease was 9.8 ± 4.2 g/L; catheterization duration was 2.8 ± 0.9 days; and hospital stay was 4.2 ± 1.3 days. At 3 months, IPSS decreased from 26.1 ± 3.0 to 6.8 ± 2.6 ( P < 0.001), and Qmax increased from 7.2 ± 1.6 to 21.2 ± 4.5 mL/s ( P < 0.001). Transient stress urinary incontinence occurred in 4 patients (7.7%), all requiring no more than one pad per day and resolving within 1 month without surgical intervention. Among the 16 patients who were sexually active before surgery, antegrade ejaculation was preserved in 14 (87.5%) and suspected retrograde ejaculation was recorded in 2 (12.5%). No clinically apparent cases of permanent urinary incontinence, bladder neck contracture, or urethral stricture were observed during the 6-month follow-up. Conclusions In this uncontrolled case series, FP-PKEP showed a favorable safety profile and achieved significant relief of bladder outlet obstruction, with promising early urinary continence and ejaculatory outcomes. The systematic preservation of the bladder neck and 12 o'clock urethral mucosa warrants further evaluation in prospective randomized controlled trials, as these preliminary findings are exploratory and hypothesis-generating.