A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update

doi:10.1016/j.eururo.2014.06.017

European Urology

Volume 67, Issue 6, June 2015, Pages 1066-1096

https://doi.org/10.1016/j.eururo.2014.06.017 Get rights and content

Abstract

Context

A number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).

Objective

To conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.

Evidence acquisition

A systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.

Evidence synthesis

A total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.

Conclusions

This meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.

Patient summary

Bipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.

Introduction

Lower urinary tract symptoms (LUTS) are a common complaint in older men [1]. Surgical intervention is the standard treatment for patients with bothersome LUTS due to benign prostatic obstruction (BPO) unwilling to try medical therapies, in cases where medical therapies were not effective, and in cases of complicated LUTS [1]. In the past 2 decades, a wide range of innovative transurethral procedures have challenged the supremacy of the two standard surgical options (monopolar transurethral resection of the prostate [M-TURP] and open prostatectomy [OP]) [2]. These alternative transurethral procedures embrace all laser therapies, encompassing the various types of lasers and modalities of prostatic tissue ablation (enucleation, vaporization, and resection) and bipolar devices permitting bipolar TURP (B-TURP) or bipolar enucleation.

A number of systematic reviews have summarized the growing evidence supporting the use of these new techniques [2], [3], [4], [5], [6]. In this rapidly moving field, our objective was to conduct an updated systematic review and meta-analysis gathering all the level of evidence (LE) 1 information available in the literature about transurethral procedures for surgical management of LUTS/BPO, by focusing on commercially available and emerging techniques.

Section snippets

Literature search and inclusion of studies

A systematic review was conducted, based on a literature search through the PubMed/Medline, Embase, Scopus, and ISI Web of Knowledge. Three authors participated in the process of literature search and data acquisition process (J.N.C., G.N., and S.M.). The literature search aimed at identifying all the papers reporting the results of randomized controlled trials (RCTs) in full-length articles published in English, German, Dutch, Italian, or French between 1992 (date of the first publications

Evidence synthesis

The initial search yielded 1719 records. After removal of duplicates, 1161 articles were considered and reviewed based on title and abstract. At the end of the process, 170 papers were reviewed in full text and 69 RCTs were finally included [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50],

Conclusions

The literature contains numerous LE 1 trials assessing efficacy and complications of transurethral procedures for BPO relief. However, the quality of the studies is rather low. Long-term assessment is lacking, evaluation of sexual adverse events is not sufficient, and no data allow the choice of a particular technique based on patient characteristics.

As TURP is still seen as the reference treatment, bipolar TURP has shown favorable outcomes with lower short-term complications. PVP shows results

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Cited by (574)

Influence of Prostate Volume on the Incidence of Complications and Urinary Incontinence Following Thulium Fiber Laser Enucleation of the Prostate: Results from Multicenter, Real-world Experience of 2732 patients
2024, European Urology Open Science
The use of the new thulium fiber laser in enucleation of the prostate (ThuFLEP) has been introduced recently.
To evaluate complications and urinary incontinence (UI) after ThuFLEP in small and large prostate volume (PV).
We retrospectively reviewed patients who underwent ThuFLEP in six centers (from January 2020 to January 2023). The exclusion criteria were concomitant lower urinary tract surgery, previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy.
Patients were divided into two groups: group 1: PV ≤80 ml; group 2: PV >80 ml. Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of overall UI.
There were 1458 patients in group 1 and 1274 in group 2. There was no significant difference in age. The median PV was 60 (61-72) ml in group 1 and 100 (90-122) ml in group 2. En bloc enucleation was employed more in group 1, while the early apical release technique was used more in group 2. The rate of prolonged irrigation for hematuria, urinary tract infection, and acute urinary retention did not differ significantly. Blood transfusion rate was significantly higher in group 2 (0.5% vs 2.0%, p = 0.001). There was no significant difference in the overall UI rate (12.3% in group 1 vs 14.7% in group 2, p = 0.08). A multivariable regression analysis showed that preoperative postvoiding urine residual (odds ratio 1.004, 95% confidence interval 1.002-1.007, p < 0.01) was the only factor significantly associated with higher odds of UI. A limitation of this study was its retrospective nature.
Complications and UI rates following ThuFLEP were similar in patients with a PV up to or larger than 80 ml except for the blood transfusion rate that was higher in the latter.
In this study, we looked at outcomes after thulium fiber laser in enucleation of the prostate stratified by PV. We found that blood transfusion was higher in men with PV >80 ml, but urinary incontinence was similar.
Modified holmium laser enucleation for benign prostatic obstruction to preserve sexual and ejaculatory function
2024, French Journal of Urology
To report ejaculatory and urinary results in patients who underwent holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe (MLHoLEP).
Patients with lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) who underwent MLHoLEP to preserve ejaculatory function in a single center were retrospectively identified. Urinary function was assessed using International Prostate Score Symptom (IPSS), IPSS-Quality of Life index (IPSS-QoL), peak urinary flow (Qmax) and postvoid residual (PVR). Erectile function was assessed using International Index of Erectile Function (IIEF-5). In patients with preoperative antegrade ejaculation, retrograde ejaculation was routinely screened at each follow-up visit. Sexual and urinary functions at 3 and 12 months were compared with baseline values.
A total of 55 patients met our inclusion criteria. A significant improvement in the IPSS, IPSS-QoL, PVR and Qmax was found at 3 and 12 months, compared with baseline (all P < 0.05). Eight patients (14.5%) required surgical reintervention due to persistant LUTS/BPO. No significant changes in the erectile function were found at 3 (P = 0.3) and 12 months (P> 0.9). In patients with preoperative antegrade ejaculation (n = 32), only four cases of de novo retrograde ejaculation were recorded postoperatively.
MLHoLEP represents a new alternative for men with LUTS/BPO who wish to preserve their ejaculatory function. Patients should be aware that improvement in urinary function may be inferior to the traditional technique, with a higher reintervention rate due to persistent LUTS.
Grade 4.
Rapporter les résultats sur la fonction sexuelle et urinaire chez des patients ayant subi une énucléation de la prostate au laser Holmium (HoLEP) avec énucléation sélective du lobe médian (MLHoLEP).
Les patients présentant des symptômes des voies urinaires inférieures (SBAU) ou une hypertrophie bénigne de prostate (HBP) et ayant subi une MLHoLEP pour conserver les éjaculations antérogrades dans un seul centre ont été rétrospectivement identifiés. La fonction urinaire a été évaluée à l’aide de l’International Prostate Score Symptom (IPSS), de l’IPSS-QoL (IPSS-QoL), du débit urinaire maximal (Qmax) et du résidu post-mictionnel (RPM). La fonction érectile a été évaluée à l’aide de l’indice international de la fonction érectile (IIEF-5). Chez les patients présentant une éjaculation antérograde préopératoire, l’éjaculation rétrograde a fait l’objet d’un dépistage systématique à chaque visite de suivi. Les fonctions sexuelles et urinaires à 3 et 12 mois ont été comparées aux valeurs initiales.
Au total, 55 patients répondaient à nos critères d’inclusion. Une amélioration significative de l’IPSS, de l’IPSS-QoL, du PVR et du Qmax a été constatée à 3 et 12 mois, par rapport aux valeurs initiales (toutes p < 0,05). Huit patients (14,5 %) ont dû subir une réintervention chirurgicale en raison de la persistance de SBAU. Aucune modification significative de la fonction érectile n’a été constatée à 3 (p = 0,3) et 12 mois (p > 0,9). Chez les patients présentant une éjaculation antérograde préopératoire (n = 32), seuls quatre cas d’éjaculation rétrograde de novo ont été enregistrés en postopératoire.
La MLHoLEP représente une nouvelle alternative pour les hommes souffrant de SBAU liée à une HBP et qui souhaitent conserver leurs éjaculations antérogrades. Les patients doivent être conscients que l’amélioration de la fonction urinaire peut être inférieure à la technique traditionnelle, avec un taux de réintervention plus élevé en raison de la persistance des SBAU.
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ICS educational module: The practice of uroflowmetry in adults
2024, Continence
To present the body of evidence behind the International Continence Society (ICS) educational module on “Practice of uroflowmetry in adults” which consists of a PowerPoint® presentation.
This evidence review has been prepared by a working group instituted by the ICS Urodynamics Committee. The method used included systematic literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel.
A total of 104 articles were included in this systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Evidence analysis was conducted along the following themes: physiology of voiding, pathophysiology of lower urinary tract dysfunction, technique of uroflowmetry, quality check of the uroflowmetry test, interpretation and reporting of uroflowmetry findings.
Uroflowmetry is the most commonly utilized diagnostic test in the evaluation of adults presenting with lower urinary tract symptoms. The practice of uroflowmetry exhibits variations which might lead to inconclusive or inaccurate assessments. The ICS educational module on the Practice of Uroflowmetry in Adults provides up-to-date and evidence-based guidance in an effort to establish standards in the technique, interpretation, and reporting of uroflowmetry.
Evaluation of Private Payer and Patient Out-of-Pocket Costs Associated With the Surgical Management of Benign Prostatic Hyperplasia
2024, Urology
To evaluate and compare the financial burden of various surgical interventions for the management of benign prostatic hyperplasia (BPH).
We identified commercially insured men with a diagnosis of BPH who underwent a procedure of interest (simple prostatectomy (SP), transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photovaporization of the prostate (PVP), prostatic urethral lift (PUL), or water vapor thermal therapy (WVTT)) between 2015 and 2021 with the OptumLabs Data Warehouse. Primary outcome was total health care costs (THC) which included both patient out-of-pocket (OOP) and health plan paid costs for the index procedure and combined follow-up years 1-5. A generalized linear model was used to estimate adjusted costs controlling for demographic and clinical characteristics. Patients undergoing WVTT were excluded from extended follow-up analyses due to limited data.
Among 25,407 patients with BPH, 10,117 (40%) underwent TURP, 6353 (25%) underwent PUL, 5411 (21%) underwent PVP, 1319 (5%) underwent SP, 1243 (5%) underwent WVTT, and 964 (4%) underwent HoLEP. Index procedure costs varied significantly with WVTT being the least costly [THC: $2637 (95% confidence interval (CI): $2513-$2761)], and SP being the costliest [THC: $14,423 (95% CI: $12,772-$16,075)]. For aggregate index and 5-year follow-up costs, HoLEP ($31,926 [95% CI: $29,704-$34,148]) was the least costly and PUL ($36,596 [95% CI: $35,369-37,823]) was the costliest.
BPH surgical treatment is associated with significant system-level health care costs. The level of impact varies between procedures. Minimally invasive options, such as WVTT, may offer initial cost reductions; however, HoLEP and SP are associated with lower follow-up costs.
Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Obstruction: 5-year Outcomes of a Randomised, Open-label, Noninferiority Trial
2024, European Urology Focus
Prostatic artery embolisation (PAE) and transurethral resection of the prostate (TURP) are two of the surgical options for treatment of lower urinary tract symptoms/benign prostatic obstruction (LUTS/BPO). Our aim was to compare the efficacy and safety of PAE and TURP for LUTS/BPO treatment at long-term follow-up.
We conducted a randomised, open-label, single-centre trial at a Swiss tertiary care centre. The main outcome was the change in International Prostate Symptom Score (IPSS) after PAE versus TURP. Secondary outcomes included patient-reported outcomes, functional measures, and adverse events assessed at baseline and at 3, 6, 12, 24, and 60 mo. Between-group differences in the change from baseline to 5 yr were tested using two-sided Mann-Whitney and t tests.
Of the 103 patients with refractory LUTS/BPO who were randomised between 2014 and 2017, 18/48 who underwent PAE and 38/51 who underwent TURP reached the 60-mo follow-up visit. The mean reduction in IPSS from baseline to 5 yr was −7.78 points after PAE and −11.57 points after TURP (difference 3.79 points, 95% confidence interval [CI] −0.66 to 8.24; p = 0.092). TURP was superior for most patient-reported secondary outcomes except for erectile function. At 5 yr, PAE was less effective than TURP regarding objective parameters, such as the improvement in maximum urinary flow rate (3.59 vs 9.30 ml/s, difference −5.71, 95% CI −10.72 to −0.70; p = 0. 027) and reduction in postvoid residual volume (27.81 vs 219.97 ml; difference 192.15, 95% CI 83.79–300.51; p = 0.001).
The improvement in LUTS/BPO at 5 yr after PAE was inferior to that achieved with TURP. The limitations of PAE should be considered during patient selection and counselling.
In this study, we show the long-term results of prostate artery embolisation (PAE) in comparison to transurethral resection of the prostate (TURP) for the treatment of benign prostate enlargement causing urinary symptoms. PAE shows good long-term results in properly selected patients, although the improvements are less pronounced than with TURP.
This trial is registered on ClinicalTrials.gov as NCT02054013.
Initial experience with thulium fiber laser for prostate enucleation: Analysis of the intraoperative and short-term outcomes in a prospective, multicenter cohort
2024, Actas Urologicas Espanolas
Aunque la enucleación prostática con láser de holmio se ha convertido en poco tiempo en el patrón oro para el tratamiento quirúrgico de la hiperplasia prostática benigna, el láser de fibra de tulio (TFL) se ha propuesto como otra alternativa eficaz y segura para la enucleación prostática. El objetivo de este estudio es describir nuestra experiencia inicial con el TFL para la enucleación endoscópica de la próstata.
Se incluyeron en el análisis todos los pacientes con indicación de enucleación prostática con TFL, independientemente del volumen prostático, el uso de catéter y la gravedad de los síntomas, en 3 centros. Se recogieron las características preoperatorias, el tiempo intraoperatorio, las variables funcionales a los 3 meses de seguimiento y las complicaciones.
Se incluyeron 56 pacientes con una edad media de 68,7 años. La eficiencia de enucleación y morcelación fue de 2,04 y 7,47 g/min, respectivamente. La mediana de estancia hospitalaria fue de un día. Los datos funcionales comparables, antes de la cirugía y 3 meses después, fueron: volumen prostático medio 88,9 vs. 21,3 g, flujo urinario máximo 13,2 vs. 27,3 ml/s, volumen residual posmiccional 149 vs. 7,8 ml, nivel de antígeno prostático específico 11,2 vs. 1 ng/ml, y puntuación del International Prostate Symptom Score 20,75 vs. 3,96. Del total de 56 pacientes, 14 (25%) presentaron complicaciones de grado ≤ 2 según la clasificación de Clavien-Dindo.
Aunque existen más pruebas en otras indicaciones urológicas, desde el primer caso de enucleación prostática descrito en 2021 han surgido datos que avalan la idoneidad del TFL para la enucleación prostática. A la luz de los buenos resultados intraoperatorios y funcionales obtenidos en nuestro seguimiento a corto plazo, nuestro estudio parece corroborar las experiencias satisfactorias previas. Sin embargo, todavía se necesitan resultados del seguimiento a largo plazo.
El TFL representa una tecnología novedosa para la enucleación prostática, con resultados intraoperatorios y funcionales a corto plazo satisfactorios, y un perfil de seguridad similar al observado en las técnicas más utilizadas para esta indicación. Se requieren más estudios con periodos de seguimiento más largos que comparen sus resultados con los de técnicas previamente utilizadas.
Holmium laser enucleation of the prostate has rapidly become the gold standard for the surgical treatment of benign prostate hyperplasia, although thulium fiber laser (TFL) has also been postulated as an effective and safe alternative for prostate enucleation. The aim of this study is to describe our initial experience with the TFL for endoscopic enucleation of the prostate.
All patients proposed to TFL prostate enucleation were included in the analysis, regardless their prostate volume, catheter status and severity of symptoms, in 3 centers. Preoperative characteristics, intraoperative times and functional 3-months follow-up variables were collected, along with complications.
Fifty-six patients were available, with a mean age of 68.7 years. Enucleation and morcellation efficiencies were 2.04 and 7.47 g/min, respectively. Median hospital stay was one day. Comparable functional data, pre and 3-month post-surgery was: mean prostate volume 88.9 vs 21.3 g, maximum urinary flow 13.2 vs 27.3 ml/s, post-void residual volume 149 vs 7.8 ml, prostatic specific antigen level 11.2 vs 1 ng/ml, and International Prostate Symptom Score score 20.75 vs 3.96. Fourteen out of 56 (25%) patients presented with complications grade ≤ 2, according to the Clavien-Dindo classification.
With wider evidence for other urological indications, very recent evidence about the suitability of TFL for prostate enucleation has arisen, since the first case described in 2021. Our results seem to back up these previous successful experiences as long as we obtained good intraoperative and short term follow-up functional results. However, there is still a need of longer follow-up data.
TFL represents a novel technology for prostate enucleation, with a good intraoperative and short follow-up functional results, and a safety profile similar to the observed for those techniques that have been wider used for this indication. Further studies with longer follow-up periods and comparative with these other techniques are necessary.

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Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Introduction

Section snippets

Literature search and inclusion of studies

Evidence synthesis

Conclusions

Eur Urol

Eur Urol

Eur Urol

Eur Urol

Control Clin Trials

Urology

Urology

J Urol

Eur Urol

Eur Urol

Eur Urol

Urology

J Urol

Asian J Surg

J Urol

Urology

J Urol

J Urol

Urology

J Urol

Eur Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

Urology

Eur Urol

Eur Urol

Eur Urol

Urology

Eur Urol

Urology

Eur Urol

J Urol

Eur Urol

Eur Urol

J Sex Med

Alternative approaches to endoscopic ablation for benign enlargement of the prostate: systematic review of randomised controlled trials

BMJ

Systematic review of surgical treatments for benign prostatic hyperplasia and presentation of an approach to investigate therapeutic equivalence (non-inferiority)

BJU Int

Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia cases—a medium term, prospective, randomized comparison

BJU Int