CRD summary

This review found that minimally invasive surgical therapies were as effective and safe as transurethral resection of the prostate. Treatment complications varied between techniques and the authors recommended that an individual patient's clinical profile should be assessed to identify the most appropriate treatment. Their conclusions should be treated with some caution given identified limitations in the review.

Authors' objectives

To determine the status of transurethral resection of the prostate (TURP) and minimally invasive surgical therapies (MIST) in relation to their efficacy and safety.

Searching

MEDLINE was searched from 1997 to 2009. Keywords were documented in the report. Reference lists of all included studies were consulted.

Study selection

Eligible studies had to be randomised controlled trials (RCTs) that compared TURP as a reference procedure and ablative treatments with immediate tissue removal: bipolar techniques, holmium laser enucleation of the prostate (HoLEP) or potassium titanyl phosphate (KTP) laser vaporisation of the prostate. Relevant functional outcomes were International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate and postvoid residual urine (PVRU). Treatment-related adverse events were documented.

Most studies compared MIST to TURP; the others compared MIST to simple open prostatectomy. Where reported, mean age ranged from 59 to 74 years and operating time ranged from 30.2 minutes to 135.9 minutes. Follow-up ranged from 1.2 months to five years.

All authors received a list of publications identified by the search and were involved in screening studies for inclusion in the review. Disagreements were to be resolved by consensus.

Assessment of study quality

The authors did not state how validity was assessed.

Data extraction

Complication rates were calculated by dividing the total number of specific complications by the total patients treated by each transurethral procedure. A data extraction form was used.

It was unclear how many reviewers were involved in data extraction.

Methods of synthesis

Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare specific operative procedures with TURP. Functional results were summarised as differences in means. The Q statistic was calculated to assess heterogeneity. For each treatment, complications were categorised as intraoperative, perioperative or late and then tabulated. Overall numbers of complications in each time category and overall complications for each treatment were pooled in meta-analyses using random-effects models.

Results of the review

Twenty-three RCTs (2,245 participants) were included in the review.

HoLEP had a statistically significantly higher IPSS reduction than TURP (mean difference 1.309, 95% CI 0.747 to 1.870). Other MISTs were not statistically significantly different from TURP for this measure. No statistically significant differences were found between treatments in terms of quality of life. KTP data could not be pooled and analysed.

HoLEP had a statistically significant higher increase in maximum flow rate compared to TURP (mean difference 1.687, 95% CI 0.711 to 2.664). No other statistically significant differences were found between treatments for this outcome. No statistically significant differences were found between TURP and any of the MISTs for PVRU.

Type, category (minor versus major) and number of complications varied specifically for each of the transurethral techniques. KTP laser showed statistically fewer intraoperative complications than TURP (OR 0.220, 95% CI 0.086 to 0.563). Other treatments were not significantly different from TURP.

Compared to TURP, bipolar TURP (OR 0.647, 95% CI 0.438 to 0.956) and bipolar transurethral vaporisation of the prostate (OR 0.525, 95% CI 0.303 to 0.910) had statistically fewer perioperative complications; other comparisons were not significantly different. No statistically significant differences were noted for late complications. There were no statistically significant differences between treatments in overall morbidity. Specific adverse events related to the techniques were detailed in the paper.

Authors' conclusions

This meta-analysis demonstrated statistically comparable efficacy and overall morbidity for MISTs versus contemporary TURP, but there were only a limited number of RCTs and few long-term data were available. Type, category and number of complications vary between techniques.

CRD commentary

This review was based on defined inclusion criteria for interventions, outcomes and study design. No specific criteria for participants were noted. Searching was restricted to one database with some reference checking, which raised the possibility that some studies were missed. It was unclear whether unpublished material was eligible for inclusion in the review, which opened up the possibility of publication bias. It appeared that study validity was not assessed, so the influence of any potentially biased studies was unknown. Procedures were put in place to minimise bias during study selection of studies; it was unclear whether more than one reviewer was involved in data extraction. It was unclear whether pooling was appropriate in the face of heterogeneity. In view of these limitations, the reviewers' conclusions should be treated with some caution.

Implications of the review for practice and research

Practice: Individual clinical profiles should be assessed to identify the most appropriate technique. HoLEP needed to be applied outside of experienced centres under the mentorship of established HoLEP surgeons to shorten the learning curve.

Research: Further RCTs with longer follow-up were needed to evaluate bipolar TUVP and other recently introduced techniques. Further long-term data were needed for bipolar TURP.

Funding

None stated.

Bibliographic details

Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S, Montorsi F, Speakman MJ, Stief CG. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. European Urology 2010; 58(3): 384-397. [PubMed: 20825758]

Original Paper URL

http://dx.doi.org/10.1016/j.eururo.2010.06.005

Indexing Status

Subject indexing assigned by NLM

MeSH

Humans; Male; Prostatic Hyperplasia /complications; Prostatism /etiology /surgery; Transurethral Resection of Prostate /adverse effects; Treatment Outcome

AccessionNumber

12010006327

Database entry date

08/06/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.