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.

Fig 1

Different endoscopic surgical methods for benign prostate hyperplasia. (A) Enucleation methods: peeling the entire prostate adenoma from the prostate capsule using end-firing laser fibre or designed bipolar loop, then morcellating the adenoma with a shaver (B) Resection methods: resecting the enlarged prostate adenoma with monopolar or bipolar resection loop, piece by piece. (C) Vapourisation methods: vapourising the enlarged prostate adenoma with side-firing laser fibre or mushroom-like bipolar electrode

Fig 2

Network treatment comparisons for all studies investigating new surgical methods for benign prostate hyperplasia. Figure shows treatment comparisons (all included studies, irrespective of the outcomes), Qmax values at six months after surgical treatment, and Qmax values at 12 months after surgical treatment. Node size corresponds to the number of trials in which the treatments were studied; interventions that are compared directly are joined with a line, the thickness of which corresponds to the number of trials that assessed the comparisons; the number of trials is shown on the line. Abbreviations of surgical methods are listed in table 1

Fig 3

Network meta-analysis of functional outcomes of new surgical methods compared with monopolar transurethral resection of the prostate (TURP) for benign prostate hyperplasia. Common heterogeneity variables for all comparisons in this network meta-analysis included: τ=1.99, 1.13, 1.05, and 0.72 for Qmax values at 6, 12, 24, and 36 months after surgical treatment, respectively, and τ=1.60, 1.08, 0.98, and 0.75 for IPSS values 6, 12, 24, and 36 months after surgical treatment, respectively. Treatments ranked according to the SUCRA values. SUCRA=surface under the cumulative ranking. Abbreviations of surgical methods are listed in table 1

Fig 4

Network meta-analysis of perioperative parameters and complications of new surgical methods compared with monopolar transurethral resection of the prostate for benign prostate hyperplasia. Common heterogeneity variables for all comparisons in this network meta-analysis included: τ=0.39, 12.3, 0.56, 0.05, 0, and 0 for haemoglobin declination, duration of catherisation, clot retention, blood transfusion, recatheterisation, and recurrence, respectively. Treatments ranked according to the SUCRA values. *0 events in either new method or monopolar TURP groups. SUCRA=surface under the cumulative ranking; the unit for catheterisation duration and decline in haemoglobin is hours and 10 g/L, respectively. Abbreviations of surgical methods are listed in table 1