--- title: The question about prostate surgery men ask last, and should ask first publication: Medical Insights Korea section: columns category: Prostate canonical_url: https://medicalinsightskorea.com/columns/urology/the-question-about-prostate-surgery-men-ask-last author: Jung Ho Cho, Specialist in Urology author_type: contributing clinician, not editorial staff author_practice: Goldman Urology Clinic, Gangnam author_credential_issued_by: Ministry of Health and Welfare, Republic of Korea author_profile: https://medicalinsightskorea.com/authors/jung-ho-cho editorial_note: Signed opinion by the named clinician. Written by them, edited and translated by Medical Insights Korea. Not a reported article, and not a clinical review of this publication's reporting. published: 2026-10-13T08:00:00+09:00 modified: 2026-10-13T08:00:00+09:00 content_type: opinion license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL. --- # The question about prostate surgery men ask last, and should ask first A urologist on what changes about ejaculation after an operation for benign prostatic hyperplasia, why erections are a separate question, and what the evidence for preserving antegrade ejaculation actually shows. ## Answer Most operations for benign prostatic hyperplasia leave erections intact but change ejaculation, because removing or dividing the tissue around the bladder neck allows semen to pass backwards into the bladder rather than forwards, and while techniques that spare tissue near the ejaculatory structures do preserve antegrade ejaculation in a proportion of men — reported at 72 to 99.6 percent across fifteen studies of robotic waterjet ablation — sparing the ejaculatory hood alone did not significantly improve preservation after holmium laser enucleation in a Korean comparative study. ## Key takeaways - Retrograde ejaculation, in which semen passes backwards into the bladder instead of forwards, is the commonest sexual change after transurethral surgery for benign prostatic hyperplasia. - Erectile function and ejaculatory function are separate outcomes. A systematic review of fifteen studies of robotic waterjet ablation covering 1,533 men found erectile function stable in every study reviewed. - Antegrade ejaculation was preserved in 72 to 99.6 percent of men after robotic waterjet ablation across those fifteen studies, and a randomised trial against transurethral resection showed lower rates of ejaculatory dysfunction maintained to five years. - A Seoul National University study of 52 sexually active men found ejaculation preserved in 46.2 percent after holmium laser enucleation with the ejaculatory hood spared, against 26.9 percent with the conventional technique, a difference that did not reach statistical significance. - The authors of that study concluded that preserving the hood alone does not prevent retrograde ejaculation after holmium laser enucleation, and that part of the apical tissue would have to be preserved as well. - A systematic review of 47 studies of minimally invasive treatments found minimal impact on ejaculatory function for water vapour therapy and the prostatic urethral lift, while evidence after prostate artery embolisation and the temporary nitinol device remained limited. - Retrograde ejaculation does not damage the body and does not usually remove the sensation of orgasm, but it does affect fertility, which is why it matters more for a man of 52 than for a man of 75. - Evidence for ejaculation-preserving techniques is limited by a scarcity of randomised trials and by follow-up that rarely extends beyond twelve months. ## Full article A man comes in because he is up four times a night. We talk about the flow rate, the residual volume, the size of the prostate, the tablets he has been taking for three years and whether they are still doing anything. We agree an operation is reasonable. He stands up to leave, puts his hand on the door, and asks the question he has been carrying the whole time: will I still be able to finish normally? It is almost always asked at the door. I have come to think that is a problem with how the consultation is structured rather than with the patient, because it is a question that should change the operation, and by the door it is too late to. ### What actually changes, and what does not Two different things get confused under the word “function”. Erection is one. Ejaculation is another. They involve different nerves, different muscles and different anatomy, and transurethral surgery for benign prostatic hyperplasia does not treat them alike. Erections are generally left alone. The systematic review of robotic waterjet ablation published in the International Journal of Impotence Research in 2026 searched the literature to January 2025, found fifteen studies covering 1,533 men, and reported erectile function stable across all of them. Ejaculation is the one that changes. At the moment of ejaculation the bladder neck normally closes, so semen has nowhere to go but forwards. An operation for an enlarged prostate works by removing or dividing the obstructing tissue, and that tissue sits around the bladder neck and the prostatic urethra. Take enough of it away and the bladder neck no longer closes. The semen goes backwards into the bladder instead, and is passed later in the urine. This is retrograde ejaculation. It is the commonest sexual consequence of these operations and it is not a complication in the sense of something having gone wrong — it is a predictable result of the mechanism by which the operation relieves the obstruction. > **Worth separating in the consultation** > Retrograde ejaculation does not damage the body, does not shorten life, and does not usually remove the sensation of orgasm. What it does remove is the ejaculate, and with it natural fertility. That distinction is why the question is weighted completely differently for a man of 52 who may want another child and a man of 75 who does not. ### The attempt to spare it, and what the Korean data showed If retrograde ejaculation follows from removing tissue near the ejaculatory structures, the obvious response is to remove less of it. The tissue in question sits around and above the verumontanum, and in surgical shorthand it is the ejaculatory hood. The technique that preserves it is hood sparing. A Korean study put that idea to the test and reported the result honestly. Between June 2010 and July 2011, 52 sexually active men with adequate ejaculate underwent holmium laser enucleation of the prostate at Seoul National University Hospital. Twenty-six had the ejaculatory hood spared, with paracollicular and supracollicular tissue more than a centimetre proximal to the verumontanum preserved. Twenty-six had the conventional operation. Age, prostate volume, erectile function score, operating time and weight of tissue removed did not differ between the groups. **46.2% vs 26.9%** — Ejaculation preserved after holmium laser enucleation with the ejaculatory hood spared, against the conventional technique (P = 0.249) _Source: International Journal of Impotence Research, 2015_ The direction favoured hood sparing and the difference did not reach statistical significance. In the hood-sparing group semen was unchanged in four men, reduced in eight and absent in seventeen; in the conventional group it was unchanged in none, reduced in seven and absent in nineteen. The authors concluded that hood sparing applied to holmium laser enucleation could not improve the preservation rate, and offered a reason: enucleation is designed to strip out the apical tissue completely, and a preserved hood sitting above an apex that has been cleared is not enough on its own. For antegrade ejaculation to survive, they argued, part of the apical tissue would have to be preserved as well. I quote that study rather than a more flattering one because it is the honest shape of the problem. The thing that preserves ejaculation is the same thing that limits how much obstruction is relieved. Any technique claiming both has to show its working. ### Where the newer techniques sit The question since has been whether an operation can be planned around that trade-off rather than forced to choose. Robotic waterjet ablation maps the prostate on ultrasound before any tissue is touched and resects to a plan, without heat; the plan can be drawn to leave the zone near the verumontanum alone. Across the fifteen studies in the 2026 review, antegrade ejaculation was preserved in between 72 and 99.6 percent of men, and a randomised trial against transurethral resection found significantly lower rates of ejaculatory dysfunction in the waterjet group, held for up to five years. That range — 72 to 99.6 percent — is wide enough to be worth reading twice. It reflects different patient groups, different definitions of preservation and different lengths of follow-up, and the review's own conclusion names the limitation plainly: few randomised trials, and little follow-up beyond twelve months. A separate systematic review of 47 studies of the office-based treatments, published in Prostate Cancer and Prostatic Diseases in 2024, found a similar picture from the other end. Water vapour therapy improved symptom scores by 47 to 56 percent and had an impact on sexual function scores of between one and three percent. The prostatic urethral lift improved symptom scores by 35 to 58 percent with a positive effect on sexual function. For prostate artery embolisation and the temporary nitinol device, the review found the evidence on ejaculatory outcomes still too thin to summarise. ### What I now ask before the door Three questions, early in the consultation rather than at the end of it. Does this man still ejaculate, and does it matter to him? Does he want more children? And how much obstruction is there to relieve — because a prostate of 120 grams with retention is a different conversation from a prostate of 45 grams with a tolerable flow. The answers do not always change the operation. Sometimes the degree of obstruction decides it and the ejaculation has to be spent to buy the flow, and a man told that plainly in advance accepts it very differently from a man who discovers it afterwards. But often enough the answers do change it, and they can only do so if they are on the table before the date is set rather than after. The question asked at the door is not a postscript. It is one of the inputs. **More on prostate surgery and what it costs** - [Age is not the first thing to check before prostate surgery](https://medicalinsightskorea.com/columns/urology/age-is-not-the-first-thing-to-check-before-prostate-surgery) — What matters more than the number on the chart - [Will I be incontinent after prostate surgery?](https://medicalinsightskorea.com/faq/will-i-be-incontinent-after-prostate-surgery) - [Will the prostate tablet make me dizzy?](https://medicalinsightskorea.com/faq/will-the-prostate-tablet-make-me-dizzy) ## Sources - Bettencourt A, Wu J, Borrell JA, Furtado TP, Mills JN, Jayadevan R, Eleswarapu SV. Ejaculatory function after robotic waterjet ablation for the treatment of benign prostatic hyperplasia: a systematic review. International Journal of Impotence Research 2026;38(2):67-75. doi:10.1038/s41443-025-01087-6. PMID:40369187. https://doi.org/10.1038/s41443-025-01087-6 - Kim M, Song SH, Ku JH, Kim HJ, Paick JS. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate. International Journal of Impotence Research 2015;27(1):20-24. doi:10.1038/ijir.2014.22. PMID:25007827. https://doi.org/10.1038/ijir.2014.22 - Gemma L, Pecoraro A, Sebastianelli A, Spatafora P, Sessa F, Nicoletti R, Gravas S, Campi R, et al. Impact of minimally invasive surgical procedures for Male Lower Urinary Tract Symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review. Prostate Cancer and Prostatic Diseases 2024;27(3):404-421. doi:10.1038/s41391-024-00795-2. PMID:38355729. https://doi.org/10.1038/s41391-024-00795-2 - Sibona M, Destefanis P, Vercelli E, Secco S, Gontero P, Cindolo L. Ejaculation physiology and dysfunction after BPH surgery: the role of the new MISTs. Prostate Cancer and Prostatic Diseases 2023;26(3):475-482. doi:10.1038/s41391-023-00686-y. PMID:37500787. https://doi.org/10.1038/s41391-023-00686-y - Luo Z, Chen G, Niu C, Jeong YB, Kam SC, Shin YS. Research progress on ejaculatory function preservation in minimally invasive surgical treatments for benign prostatic hyperplasia: a narrative review. Translational Andrology and Urology 2025;14(9):2754-2768. doi:10.21037/tau-2025-393. PMID:41132354. https://doi.org/10.21037/tau-2025-393 ## Citation Jung Ho Cho (2026). "The question about prostate surgery men ask last, and should ask first". Medical Insights Korea. https://medicalinsightskorea.com/columns/urology/the-question-about-prostate-surgery-men-ask-last Retrieved from https://medicalinsightskorea.com/columns/urology/the-question-about-prostate-surgery-men-ask-last