Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis

Abstract

Objective To assess the efficacy and safety of different endoscopic surgical treatments for benign prostatic hyperplasia. Design Systematic review and network meta-analysis of randomised controlled trials. Data sources A comprehensive search of PubMed, Embase, and Cochrane databases from inception to 31 March 2019. Study selection Randomised controlled trials comparing vapourisation, resection, and enucleation of the prostate using monopolar, bipolar, or various laser systems (holmium, thulium, potassium titanyl phosphate, or diode) as surgical treatments for benign prostatic hyperplasia. The primary outcomes were the maximal flow rate (Qmax) and international prostate symptoms score (IPSS) at 12 months after surgical treatment. Secondary outcomes were Qmax and IPSS values at 6, 24, and 36 months after surgical treatment; perioperative parameters; and surgical complications. Data extraction and synthesis Two independent reviewers extracted the study data and performed quality assessments using the Cochrane Risk of Bias Tool. The effect sizes were summarised using weighted mean differences for continuous outcomes and odds ratios for binary outcomes. Frequentist approach to the network meta-analysis was used to estimate comparative effects and safety. Ranking probabilities of each treatment were also calculated. Results 109 trials with a total of 13 676 participants were identified. Nine surgical treatments were evaluated. Enucleation achieved better Qmax and IPSS values than resection and vapourisation methods at six and 12 months after surgical treatment, and the difference maintained up to 24 and 36 months after surgical treatment. For Qmax at 12 months after surgical treatment, the best three methods compared with monopolar transurethral resection of the prostate (TURP) were bipolar enucleation (mean difference 2.42 mL/s (95% confidence interval 1.11 to 3.73)), diode laser enucleation (1.86 (−0.17 to 3.88)), and holmium laser enucleation (1.07 (0.07 to 2.08)). The worst performing method was diode laser vapourisation (−1.90 (−5.07 to 1.27)). The results of IPSS at 12 months after treatment were similar to Qmax at 12 months after treatment. The best three methods, versus monopolar TURP, were diode laser enucleation (mean difference −1.00 (−2.41 to 0.40)), bipolar enucleation (0.87 (−1.80 to 0.07)), and holmium laser enucleation (−0.84 (−1.51 to 0.58)). The worst performing method was diode laser vapourisation (1.30 (−1.16 to 3.76)). Eight new methods were better at controlling bleeding than monopolar TURP, resulting in a shorter catheterisation duration, reduced postoperative haemoglobin declination, fewer clot retention events, and lower blood transfusion rate. However, short term transient urinary incontinence might still be a concern for enucleation methods, compared with resection methods (odds ratio 1.92, 1.39 to 2.65). No substantial inconsistency between direct and indirect evidence was detected in primary or secondary outcomes. Conclusion Eight new endoscopic surgical methods for benign prostatic hyperplasia appeared to be superior in safety compared with monopolar TURP. Among these new treatments, enucleation methods showed better Qmax and IPSS values than vapourisation and resection methods. Study registration CRD42018099583.

Surgical outcome of anatomical endoscopic enucleation of the prostate: A systemic review and meta‐analysis

“…(2019) revealed EEP achieved better functional outcomes (Qmax and IPSS) than resection and vapourisation methods at 6 and 12 months post‐operatively, and the difference remained significant 24 and 36 months after the operation. While the criteria of enrolment were a little different across these studies and the present study, our results were generally in line with the findings of the above studies (Arcaniolo et al., 2019; Huang et al., 2019; Wroclawski et al., 2019), suggesting that EEP has become a new standard of the surgical treatment for BPH. There are some limitations in the current study.…”

Modern best practice in the management of benign prostatic hyperplasia in the elderly

“…Enucleation of the prostate utilizes various laser technologies [Holmium-LEP (HoLEP), Thulium-LEP (ThuLEP), Greenlight-LEP (GreenLEP) and Diode-LEP (DiLEP)] to transurethrally enucleate the adenoma to allow for its removal from the capsule. In a recent meta-analysis that compared various laser enuclea tion, resection, and vaporization techniques with monopolar and bipolar TURP in 13 34 The worst performing method was diode laser vaporization [-1.90 (-5.07 to 1.27)]. IPSS at 12 months after treatment showed similar results.…”

Retrograde Ejaculation—a Commonly Unspoken Aspect of Prostatectomy for Benign Prostatic Hypertrophy

“…A 2005 review article has listed the incidence of several complications following radical prostatectomy: mortality <0.3%, impotence >50%, ejaculatory dysfunction 100%, orgasmic dysfunction 50%, incontinence <5%-30%, pulmonary embolism <1%, rectal injury <1%, urethral stricture <5%, and transfusion 20% (McCullough, 2005). In a 2019 systematic review and network meta-analysis, RE was reported in 17 out of 109 trials (Huang et al, 2019).…”