Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: Systematic review and network meta-analysis
Journal
The BMJ
Journal Volume
367
Pages
367l5919
Date Issued
2019
Author(s)
Tsai C.-Y.
Shih M.-C.
Yeh Y.-C.
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. ? Published by the BMJ Publishing Group Limited.
SDGs
Other Subjects
Article; blood transfusion; catheterization; clot retention; effect size; flow rate; human; International Prostate Symptom Score; laser surgery; maximal flow rate; perioperative period; postoperative complication; postoperative period; priority journal; probability; prostate hypertrophy; prostate size; prostatic bipolar enucleation; prostatic bipolar transurethral resection; prostatic bipolar vapourisation; prostatic diode laser enucleation; prostatic diode laser vapourisation; prostatic holmium laser enucleation; prostatic monopolar transurethral resection; prostatic potassium titanyl phosphate laser vapourisation; prostatic thulium laser enucleation; quality of life; recatheterization; recurrent disease; retrograde ejaculation; systematic review; transurethral electrovaporization; transurethral resection; treatment outcome; urethra stenosis; urinary tract infection; urine incontinence; adverse event; male; meta analysis; outcome assessment; procedures; prostate hypertrophy; transurethral resection; Humans; Male; Outcome Assessment (Health Care); Prostatic Hyperplasia; Transurethral Resection of Prostate; Treatment Outcome
Publisher
BMJ Publishing Group
Type
journal article