Transurethral procedures in the treatment of benign prostatic hyperplasia: A systematic review and meta-analysis of effectiveness and complications

Feng Sun, Xincheng Sun, Qinglu Shi, Yuzhang Zhai, Feng Sun, Xincheng Sun, Qinglu Shi, Yuzhang Zhai

Abstract

Background: With the progress of surgical techniques and instruments, various minimally invasive surgical therapies were developed to treat benign prostatic hyperplasisa (BPH). However, the efficacy and safety of different transurethral procedures for the treatment of BPH are still undefined.

Method: A systematic search was performed for all randomized controlled trials (RCTs), which compared the transurethral procedures for BPH from 1995 to 2016. The clinical baseline characteristics, International Prostate Symptom Score (IPSS), quality of life (QoL), postvoid residual (PVR), maximum flow rate (Qmax), short-term and long-term complications were analyzed using RevMan and ADDIS software.

Result: Eighty-eight randomly controlled trials and fifteen procedures were included in the network meta-analysis. HoLEP greatly inproved PVR. TmLRP had the best efficacy in improving QoL score. Diode laser vaporization of prostate was superior in improving IPSS and Qmax. Diode laser through vaporization required the shortest time in catheterization, while Nd:YAG was the longest procedure. For the hospitalization time, TUR was the longest and HoLEP was the shortest. TmLRP was related to the lowest postoperative hemoglobin decrease. TmLEP had the least rates of occurrence of hematuria, reoperation and erectile dysfunction. HoLEP was the best choice to reduce the incidence of recatheterization, urinary retention, urinary tract infection, stress urinary incontinence and retrograde ejaculation. The complications such as blood transfusion, urethral stricture, bladder neck contracture were relatively rare in the patients who underwent diode laser vaporization of prostate.

Conclusion: Compared with other transurethral procedures, thulium, holmium and diode lasers were associated with better efficacy and fewer complications.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Flowchart for this network meta-analysis.
Figure 2
Figure 2
Comparison network of included trials. DiLEP = diode laser enucleation of prostate, HoLEP = holmium laser enucleation of prostate, HoLRP = holmium laser resection of prostate, ILC = Intrestitial laser coagulation, M-TURP = monopolar transurethral resection of prostate, PKEP = plasmakinetic enucleation of prostate, PKRP = plasmakinetic resection of prostate, PVP = photoselective vaporization of prostate, TmLRP = thulium laser resection of prostate, TmLEP = thulium laser enucleation of prostate, TURis = bipolar transurethral resection in saline, TUVP =  transurethral electrovaporization of prostate.
Figure 3
Figure 3
Risk of bias for selected trials.
Figure 4
Figure 4
Rank probability of functional outcomes. (A) Rank probability of IPSS; (B) rank probability of Qmax; (C) rank probability of PVR; (D) rank probability of QoL. IPSS = International Prostate Symptom Score.
Figure 5
Figure 5
Rank probability of perioperation-related outcomes. (A) Rank probability of operation time; (B) rank probability of catheterization time; (C) rank probability of hospitalization time.
Figure 6
Figure 6
Rank probability of short-term complications. (A) Rank probability of TURS; (B) rank probability of hematuria; (C) rank probability of postoperative hemoglobin decrease; (D) rank probability of blood transfusion; (E) rank probability of clot retention; (F) rank probability of recatheterization; (G) rank probability of urinary retention; (H) rank probability of dysuria; (I) rank probability of urinary tract infection. TURS = transurethral resection syndrome.
Figure 7
Figure 7
Rank probability of long-term complications. (A) Rank probability of urethral stricture; (B) rank probability of bladder neck contracture; (C) rank probability of stress urinary incontinence; (D) rank probability of reoperation; (E) rank probability of erectile dysfunction; (F) rank probability of retrograde ejaculation.

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