Comparison of Effectiveness and Postoperative Complications of Different Surgical Methods in the Treatment of Benign Prostatic Hyperplasia

A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

Yujia Fu; Xiaomiao Wen; Yanhai Yin; Chaoqun Wang; Jiren Mai

Disclosures

Transl Androl Urol. 2022;11(6):842-858. 

In This Article

Abstract and Introduction

Abstract

Background: More and more new surgical procedures for the treatment of benign prostate hyperplasia (BPH) are proposed creatively. However, the existing clinical evidence shows that the effectiveness and safety of various procedures exist inconsistent.

Methods: The randomized controlled trials comparing the international prostate score, length of hospital stay, maximum urinary flow rate, operation time, and complication rates of prostatic artery embolization (PAE), Greenlight-XPS Laser prostate vaporization procedure (GLL PVP), diode laser enucleation of prostate (DILEP) and plasmakinetic resection of the prostate (PKRP), transurethral resection of the prostate (TURP) in patients with BPH were screened out in databases. The primary outcome was pooled using a restricted maximum likelihood-based random-effect model and inverse variance-based fixed-effect model. Cochrane Q statistics and I2 statistics were computed to quantify between-study heterogeneity. The risk of bias of each included study was assessed using the revised Cochrane risk of bias tool.

Results: This meta-analysis ultimately included 14 original research papers, with 1,940 participants enrolled. Eight studies were considered to be at moderate risk of bias, while the others were at mild risk of bias. Although the improvement in functional outcome of the DILEP procedure was equivalent to that of the PKRP procedure, the DILEP procedure group had fewer hospital stays than the PKRP group (P=0.01). In addition, even though the performance of the GLL PVP procedure in the improvement of functional outcome was inferior to the counterpart of TURP (P=0.64), it had a much fewer hospital stays (P=0.01). Moreover, there is still insufficient evidence for the improvement of subjective functional indicators of postoperative patients with PAE compared with TURP [international prostate symptom score (IPSS): P=0.73; IPSS QoL: P=0.91], but achieved less satisfactory objective functional outcomes (Qmax: P=0.06; PVR: P=0.00).

Discussion: New surgical procedures such as GLL PVP, PAE, and DILEP were safer than traditional TURP procedures. However, it is not superior to traditional surgery in the improvement of clinical symptoms. In clinical practice, the pros and cons of the new operation and the traditional operation should be carefully weighed, and the operation that is most suitable for the patient's condition should be selected.

Introduction

In men, lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) are prevalent urinary diseases. It is estimated that the quality of life (QoL) of about 1 in every 3 men over 50 years old is affected by LUTS caused by BPH.[1,2] Even BPH with moderate and severe symptoms can even affect the mental state of patients.[3,4] Although drug treatment, such as finasteride and dutasteride, can control clinical symptoms to a certain extent, surgical treatment is still the most effective way to treat BPH. Among the surgical options, transurethral prostatectomy (TURP), which involves removing the hyperplastic prostate piece by piece through a unilateral electrode, has been the most widely used in the clinic since 1970. The long-term effectiveness of this procedure in improving a series of clinical indicators of BPH [such as maximum urinary flow rate (Qmax), international prostate symptom score (IPSS), QoL score, and so on] has been explored in many observational studies and randomized controlled trials (RCTs).[5–8] However, complications such as massive hemorrhage or TURP syndrome are also common.[9] A study showed that TURP was associated with incidence rate and even mortality of complications.[10] Since entering the new century, studies have explored the effectiveness and safety of new surgical methods for the treatment of BPH, such as the use of bilateral electrodes or various laser systems (holmium laser, potassium titanium phosphate laser, thulium laser, diode laser, and so on), prostatic artery embolization (PAE), plasmakinetic resection of the prostate (PKRP), transurethral GreenLight™ laser photovaporization of the prostate (GLL PVP), and so on. These new procedures are safer than traditional TURP procedures, with less risk of surgical bleeding, transprostatectomy syndrome, and decreased hemoglobin levels. Overall, all procedures can be divided into four categories: resection, vaporization, enucleation, and arterial embolization. Resection is the process of cutting out the enlarged prostate tissue piece by piece. Vaporization is the process of using electrodes such as lasers or plasma to vaporize prostate tissue to high temperatures. Enucleation is the process of removing the entire prostate tissue from the internal capsule. Arterial embolization, on the other hand, is a procedure in which the blood supply to the prostate is blocked by direct injection of small particles. Resection usually requires the most prostate tissue to be removed, whereas vaporization usually removes less tissue due to the risk of damaging the sphincter.[11]

More and more clinical RCTs are exploring the efficacy and safety of new BPH surgery. However, there are conflicting conclusions about the relative efficacy of different surgical procedures and the corresponding clinical endpoints in the existing evidence. Specifically, Zhang et al.[12] and Xu et al.[13] compared diode laser enucleation with plasma endoprostate enucleation in a RCT and found that the former can significantly reduce the International Prostate Symptom Score (IPSS) compared with the latter. Wu et al.[14] came to the opposite conclusion. Similar contradictory conclusions between the various surgical procedures can also be found in many other RCTs.[15–20] This is partly because most RCTs have very limited sample sizes, short follow-up, and are mostly single-center studies. So the results are not necessarily general. Systematic reviews and meta-analysis methods can generate more reliable evidence-based medical evidence by combining the results of as many studies as possible. Therefore, this study systematically quantified the relative efficacy and safety of various surgical procedures by systematically searching relevant literature. We present the following article in accordance with the PRISMA reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-22-377/rc).

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