Complications and functional outcomes of endoscopic enucleation of the prostate: a systematic review and meta-analysis of randomised-controlled studies

Abstract

Introduction There are several endoscopic enucleation procedures (EEP) using different energy sources: holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), Greenlight ® (GreenVEP) and diode (DiLEP) lasers, and plasma kinetic enucleation of the prostate (PKEP). The comparative outcomes among these EEPs are unclear. We aimed to compare the peri-operative and post-operative outcomes, complications and functional outcomes among different EEPs. Material and methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Only randomised-controlled trials (RCT) comparing EEPs were included. The risk of bias was assessed using the Cochrane tool for RCTs. Results The search identified 1153 articles and 12 RCTs were included. The number of RCTs for each comparison was, HoLEP vs ThuLEP; n = 3, HoLEP vs PKEP; n = 3, PKEP vs DiLEP; n = 3, HoLEP vs GreenVEP; n = 1, HoLEP vs DiLEP; n = 1, ThuLEP vs PKEP; n = 1. Operative time was shorter and blood loss was lower with ThuLEP compared with HoLEP, whereas operative time was shorter for HoLEP compared with PKEP. Blood loss was lower with HoLEP and DiLEP compared with PKEP. There were no Clavien-Dindo IV–V complications, and the incidence of Clavien-Dindo I complications was lower with ThuLEP compared with HoLEP. No significant differences were detected among EEPs regarding urinary retention, stress urinary incontinence, bladder neck contracture or urethral stricture. Lower International Prostate Symptom Score (IPSS) and higher quality of life (QoL) scores were in favour of ThuLEP compared with HoLEP at 1 month. Conclusions EEP improves symptoms and uroflowmetry parameters with a low incidence of high-grade complications. ThuLEP was associated with shorter operative time, lower blood loss, and lower incidence of low-grade complications compared with HoLEP.

Thulium fiber laser vs. holmium laser enucleation of the prostate: results of a prospective randomized non-inferiority trial

“…However, in our study the subjective questionnaire scores and objective functional assessment did not differ between the two groups at 3 months of follow-up. This finding is in line with the exploratory analyses of the randomized prospective study by Enikeev et al and the review of Pang et al [ 10 , 24 ].…”

Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients

“…Our series, being more recent, concretely demonstrates the evidence of various EEP techniques, approaches, safety, and utility of enucleation even in large and very large prostates. This is another proof of concept that the statement EEP is a truly size-independent procedure once the learning curve is mastered [ 16 ], even if complications are a part of every surgery and EEP is no exception [ 17 ].…”

“…In our series, 86.1% of patients had no complications with a similar rate among the groups. However, post-operatively need for prolonged bladder irrigation for hematuria, (3.85%), bleeding needing surgical hemostasis (1.4%), and need for blood transfusion (0.6%) albeit low was all seen in Group 2 and was perhaps multifactorial attributed to shape and anatomical factors influencing dissection of the prostate, the efficacy of the laser energy devices used, technique, surgeon skill and patient factors [ 5 , 11 , 12 , 17 ]. This is why the enucleation, morcellation, and total surgical time were significantly longer in Group 2.…”

“…Even ureteral orifice injury needing a double J stent was reported only in group 2. This complication typically happens in large prostates where the median lobe extends well beyond the trigone [ 12 , 17 ]. As is seen in our series, patients with very large prostates must be counseled that at times the entire lobe cannot be extracted by sheer size or even inadvertently missed tissue may need secondary morcellation or even cystostomy and extraction [ 5 , 17 , 18 ].…”

“…This complication typically happens in large prostates where the median lobe extends well beyond the trigone [ 12 , 17 ]. As is seen in our series, patients with very large prostates must be counseled that at times the entire lobe cannot be extracted by sheer size or even inadvertently missed tissue may need secondary morcellation or even cystostomy and extraction [ 5 , 17 , 18 ]. Despite these reported complications, the size, laser type, and technique did not affect postoperative catheter time, overall early and late postoperative complications, and 30-day readmission rates among the groups in our series.…”