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European Urology Focus Sep 2023Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or... (Review)
Review
CONTEXT
Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or vaporisation. Apart from established ablation modes according to the European Association of Urology guidelines, various technologies have emerged as safe/effective alternatives but remain under investigation.
OBJECTIVE
To explore short-term benefits/harms of emerging technologies for surgical management of LUTS/BPO.
EVIDENCE ACQUISITION
A systematic literature search was conducted using MEDLINE, EMBASE, and CENTRAL via Ovid up to June 18, 2022. We included randomised controlled trials (RCTs) exploring aquablation, prostatic arterial embolisation (PAE), Rezum, prostatic urethral lift (PUL), and temporary implantable nitinol device (iTIND) versus sham/transurethral resection of the prostate (TURP).
EVIDENCE SYNTHESIS
We included ten RCTs (1108 men). Aquablation versus TURP: insignificant change in International Prostate Symptoms Score (IPSS; mean difference [MD] 0.0, 95% confidence interval [CI] -2.44 to 2.44), quality of life (QoL; MD 0.30, 95% CI -0.81 to 0.21), maximum urinary flow rate (Qmax; MD -0.30, 95% CI -3.71 to 3.11), retreatment (risk ratio [RR] 0.18, 95% CI 0.02-1.66), and urinary incontinence (UI; RR 0.71, 95% CI 0.26-1.95). PAE versus monopolar TURP (M-TURP): insignificant change in IPSS (MD 3.33, 95% CI -28.39 to 35.05), QoL (MD 0.12, 95% CI -0.30 to 0.54), International Index of Erectile Function (IIEF-5; MD 3.07, 95% CI -1.78 to 7.92), and UI (RR 0.15, 95% CI 0.01-2.86), and significant change in Qmax (MD -9.52, 95% CI -14.04 to -5.0), favouring M-TURP. PAE versus bipolar TURP: insignificant change in IPSS (MD -2.80, 95% CI -6.61 to 1.01), QoL (MD -0.69, 95% CI -1.46 to 0.08), Qmax (MD -3.51, 95% CI -8.08 to 1.06), UI (RR 0.14, 95% CI 0.01-2.51), and retreatment (RR 1.91, 95% CI 0.19-19.63). PUL versus TURP: insignificant change in QoL (MD 0.40, 95% CI -0.29 to 1.09), UI (RR 0.13, 95% CI 0.02-1.05), and retreatment (RR 0.48, 95% CI 0.12-1.86), and significant change in IPSS (MD 3.40, 95% CI 0.22-6.58), and IIEF-5 (MD 3.00, 95% CI 0.41-5.59) and Qmax (MD -9.60, 95% CI -13.44 to -5.76), favouring PUL and TURP, respectively. Rezum and iTIND have not been evaluated in RCTs against TURP to date.
CONCLUSIONS
Supporting evidence for clinical use of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits/harms should be investigated further in high-quality RCTs.
PATIENT SUMMARY
This review summarises the evidence for the clinical use of aquablation, prostatic arterial embolisation (PAE), prostatic urethral lift (PUL), Rezum, and temporary implantable nitinol device (iTIND) to manage lower urinary tract symptoms secondary to benign prostatic obstruction. The supporting evidence for the clinical usage of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits and harms should be investigated further in high-quality randomised controlled trials.
PubMed: 37741783
DOI: 10.1016/j.euf.2023.09.003 -
Prostate Cancer and Prostatic Diseases Dec 2023Anatomical endoscopic enucleation of the prostate (AEEP) is recommended for first line surgical treatment of benign prostatic obstruction (BPO) caused by moderate and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anatomical endoscopic enucleation of the prostate (AEEP) is recommended for first line surgical treatment of benign prostatic obstruction (BPO) caused by moderate and large prostatic adenoma. However, its role in the retreatment setting after failed previous surgical treatment for BPO remains uncaptured. In this scope, we performed a systematic review and meta-analysis aiming to assess the safety and efficacy of AEEP in the retreatment setting.
METHODS
We searched PubMed, Cochrane Library and Embase databases from inception to March 2022 for prospective or retrospective studies involving patients undergoing prostatic enucleation for recurrent or residual BPO after previous standard or minimally invasive surgical treatments for BPO. Based on data availability, we performed a meta-analysis comparing AEEP in patients with recurrent or residual BPO versus AEEP for primary BPO.
PROSPERO
CRD42022308941).
RESULTS
We included 15 studies in the systematic review and 10 in the meta-analysis (6553 patients, 841 with recurrent or residual BPO and 5712 with primary BPO). All included studies involved patients undergoing HoLEP or ThuLEP. In terms of Qmax, post-void residual, International Prostate Symptom Score, removed adenoma, operative time, duration of catheterization and hospital stay, as well as complications, HoLEP for recurrent or residual BPO was equally effective compared to HoLEP for primary BPO up to 1 year postoperatively. Importantly, the beneficial effect of HoLEP on the retreatment setting was observed after previous standard or minimally invasive surgical treatments for BPO. The overall strength of evidence for all outcomes was deemed very low.
CONCLUSIONS
HoLEP may be safely and effectively used in experienced hands for the surgical treatment of recurrent or residual BPO in patients with large or moderate prostates following previous open, endoscopic or minimally invasive surgical treatment for BPO.
Topics: Humans; Male; Prospective Studies; Prostate; Prostatic Hyperplasia; Prostatic Neoplasms; Retreatment; Retrospective Studies; Treatment Outcome; Endoscopy
PubMed: 37193777
DOI: 10.1038/s41391-023-00677-z -
BMC Urology Jan 2024To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the... (Meta-Analysis)
Meta-Analysis
Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.
BACKGROUND
To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH).
METHODS
A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4.
RESULTS
Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term.
CONCLUSION
PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.
Topics: Male; Humans; Prostate; Prostatic Hyperplasia; Treatment Outcome; Transurethral Resection of Prostate; Embolization, Therapeutic; Arteries; Minimally Invasive Surgical Procedures; Lower Urinary Tract Symptoms; Observational Studies as Topic
PubMed: 38281906
DOI: 10.1186/s12894-023-01397-1 -
Prostate Cancer and Prostatic Diseases Sep 2023Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused by large prostate glands. We aimed to provide a wide-ranging analysis of the currently available evidence, comparing safety and effectiveness of robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP), laparoscopic simple prostatectomy (LSP), and laser EEP.
METHODS
A systematic search was performed across MEDLINE, EMBASE, and Web of Science databases for retrospective and prospective studies comparing RASP to OSP or LSP or laser EEP (HoLEP/ThuLEP). Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design the search strategies, selection criteria, and evidence report. A meta-analysis evaluated perioperative safety and effectiveness outcomes. The weighted mean difference and risk ratio were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for RCT article assessing risk of bias.
RESULTS
15 studies, including 6659 patients, were selected for meta-analysis: 13 observational studies, 1 non-randomized prospective study, and 1 randomized controlled trial. RASP was associated with statistically significant longer operative time (OT) and lower postoperative complication rate, length of stay (LOS), estimated blood loss (EBL), and transfusion rate (TR) compared to OSP. LSP showed longer LOS and lower postoperative SHIM score, with no difference in OT, EBL, and complications. Compared to laser EEP, RASP presented longer LOS and catheterization time and higher TR. ThuLEP presented shorter OT than RASP. No difference were found in functional outcomes between groups both subjectively (IPSS, QoL) and objectively (Qmax, PVR).
CONCLUSION
RASP has become a size-independent treatment for the management of BPO caused by a large prostate gland. It can duplicate the functional outcomes of OSP while offering a better safety profile. When compared to LSP, the latter still stands as a valid lower-cost option, but it requires solid laparoscopic skill sets and therefore it is unlikely to spread on larger scale. When compared to laser EEP, RASP offers a shorter learning curve, but it still suffers from longer catheterization time and LOS.
Topics: Humans; Male; Prospective Studies; Prostatectomy; Prostatic Hyperplasia; Quality of Life; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome; Controlled Clinical Trials as Topic
PubMed: 36402815
DOI: 10.1038/s41391-022-00616-4 -
European Urology Focus Apr 20245α-Reductase inhibitors (5-ARIs) are widely prescribed for treatment of benign prostatic obstruction and androgenic alopecia. Several studies with controversial... (Review)
Review
5α-Reductase inhibitors (5-ARIs) are widely prescribed for treatment of benign prostatic obstruction and androgenic alopecia. Several studies with controversial findings regarding 5-ARI exposure have been published over a number of years, and concerns were recently raised about the potential risks of depression and suicide associated with 5-ARIs. To investigate this association, we conducted a systematic review of the literature and a meta-analysis. Five studies involving 2213600 patients met our inclusion criteria. We found no statistically significant association between 5-ARI exposure and the risk of depression (adjusted hazard ratio [aHR] 1.30, 95% confidence interval [CI] 0.85-2.00; p = 0.23) or suicide (aHR 1.30, 95% CI 0.65-2.61; p = 0.45). Subgroup analyses for finasteride and dutasteride revealed similar results. When restricting the analysis to patients without a prior diagnosis of depression, we observed similar findings (aHR for suicide 1.00, 95% CI 0.68-1.46; p = 0.98). PATIENT SUMMARY: We reviewed study data for more than two million patients taking drugs called 5α-reductase inhibitors (5-ARIs), which are widely prescribed for urinary problems caused by benign prostate enlargement and for male-pattern hair loss. In a pooled analysis we found no evidence of an association between 5-ARI use and the risk of depression or suicide.
PubMed: 38692949
DOI: 10.1016/j.euf.2024.04.009 -
Progres En Urologie : Journal de... Nov 2023At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting...
BACKGROUND
At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.
METHODS
Systematic review based on a Pubmed search of surgeries to improve male fertility.
RESULTS
Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.
CONCLUSION
Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.
Topics: Pregnancy; Female; Humans; Male; Semen; Vasovasostomy; Pregnancy Rate; Spermatozoa; Fertility
PubMed: 38012911
DOI: 10.1016/j.purol.2023.09.011 -
Neurourology and Urodynamics Jan 2024Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional... (Meta-Analysis)
Meta-Analysis Review
Functional and safety outcomes after benign prostatic enlargement surgeries in men with detrusor underactivity compared with normal detrusor contractility: Systematic review and meta-analysis.
INTRODUCTION
Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC).
MATERIALS AND METHODS
This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software.
RESULTS
There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eight TURP (transurethral resection of the prostate) studies, four GreenLight PVP (photoselective vaporization of the prostate) studies, two HoLEP (Holmium laser enucleation of the prostate) studies, one GreenLight PVP/HoLEP study, one Holmium laser incision of the prostate study, and one study did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS), lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR) of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up.
CONCLUSION
In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery.
Topics: Male; Humans; Transurethral Resection of Prostate; Urinary Bladder, Underactive; Quality of Life; Retrospective Studies; Prospective Studies; Treatment Outcome; Prostatic Hyperplasia; Urinary Bladder Neck Obstruction; Laser Therapy
PubMed: 38010924
DOI: 10.1002/nau.25336 -
European Urology Oncology Apr 2024It remains unclear to what extent the therapy of the primary local tumor, such as radical prostatectomy (RP) and radiation therapy (RT), improves overall survival in... (Review)
Review
CONTEXT
It remains unclear to what extent the therapy of the primary local tumor, such as radical prostatectomy (RP) and radiation therapy (RT), improves overall survival in patients with low-volume metastatic hormone-sensitive prostate cancer (mHSPC). However, data suggest a benefit of these therapies in preventing local events secondary to local tumor progression.
OBJECTIVE
To evaluate the efficacy of adding local therapy (RP or RT) to systemic therapies, including androgen deprivation therapy, docetaxel, and/or androgen receptor axis-targeted agents, in preventing local events in mHSPC patients compared with systemic therapy alone (ie, without RT of the prostate or RP).
EVIDENCE ACQUISITION
Three databases and meeting abstracts were queried in November 2023 for studies analyzing mHSPC patients treated with local therapy. The primary outcome of interest was the prevention of overall local events (urinary tract infection, urinary tract obstruction, and gross hematuria) due to local disease progression. Subgroup analyses were conducted to assess the differential outcomes according to the type of local therapy (RP or RT).
EVIDENCE SYNTHESIS
Overall, six studies, comprising two randomized controlled trials, were included for a systematic review and meta-analysis. The overall incidence of local events was significantly lower in the local treatment plus systemic therapy group than in the systemic therapy only groups (relative risk [RR]: 0.50, 95% confidence interval [CI]: 0.28-0.88, p = 0.016). RP significantly reduced the incidence of overall local events (RR: 0.24, 95% CI: 0.11-0.52) and that of local events requiring surgical intervention (RR: 0.08, 95% CI: 0.03-0.25). Although there was no statistically significant difference between the RT plus systemic therapy and systemic therapy only groups in terms of overall local events, the incidence of local events requiring surgical intervention was significantly lower in the RT plus systemic therapy group (RR: 0.70, 95% CI: 0.49-0.99); local events requiring surgical intervention of the upper urinary tract was significantly lower in local treatment groups (RR: 0.60, 95% CI: 0.37-0.98, p = 0.04). However, a subgroup analysis revealed that neither RP nor RT significantly impacted the prevention of local events requiring surgical intervention of the upper urinary tract.
CONCLUSIONS
In some patients with mHSPC, RP or RT of primary tumor seems to reduce the incidence of local progression and events requiring surgical intervention. Identifying which patients are most likely to benefit from local therapy, and at what time point (eg, after response of metastases), will be necessary to set up a study assessing the risk, benefits, and alternatives to therapy of the primary tumor in the mHSPC setting.
PATIENT SUMMARY
Our study suggests that local therapy of the prostate, such as radical prostatectomy or radiotherapy, in patients with metastatic hormone-sensitive prostate cancer can prevent local events, such as urinary obstruction and gross hematuria.
PubMed: 38575408
DOI: 10.1016/j.euo.2024.03.007 -
World Journal of Urology Aug 2023To systematically review studies focused on the feasibility and outcomes of outpatient endoscopic enucleation of the prostate for benign prostatic obstruction. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To systematically review studies focused on the feasibility and outcomes of outpatient endoscopic enucleation of the prostate for benign prostatic obstruction.
METHODS
A literature search was conducted through December 2022 using PubMed/Medline, Web of Science, and Embase databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Risk of bias assessment was performed according to the Newcastle-Ottawa Scale for case control studies.
RESULTS
Of 773 studies, ten were included in the systematic review (n = 1942 patients) and four in the meta-analysis (n = 1228 patients). The pooled incidence of successful same-day discharge was 84% (95% CI 0.72-0.91). Unplanned readmission was recorded in 3% (95% CI 0.02-0.06) of ambulatory cases. In the reported criteria-selected patients submitted to SDD surgery, the forest plot suggested a lower rate of postoperative readmission (OR 0.56, 95% CI 0.34-0.91, p = 0.02) and complications (OR 0.69, 95% CI 0.48-1, p < 0.05) rates compared to standard protocols.
CONCLUSION
We provide the first systematic review and meta-analysis on SDD for endoscopic prostate enucleation. Despite the lack of randomized controlled trials, we confirm the feasibility and safety of the protocol with no increase in complications or readmission rate in well-selected patients.
Topics: Male; Humans; Prostate; Prostatic Hyperplasia; Patient Discharge; Treatment Outcome; Transurethral Resection of Prostate
PubMed: 37395755
DOI: 10.1007/s00345-023-04471-3 -
European Urology May 2024Symptomatic benefit and urodynamic obstruction relief represent relevant outcomes of therapies for lower urinary tract symptoms suggestive of benign prostatic... (Review)
Review
Bladder Outlet Obstruction Relief and Symptom Improvement Following Medical and Surgical Therapies for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Systematic Review.
BACKGROUND AND OBJECTIVE
Symptomatic benefit and urodynamic obstruction relief represent relevant outcomes of therapies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). We summarized evidence from studies concurrently assessing variations in terms of symptoms severity and invasive urodynamic measures of obstruction following medical and surgical therapies for LUTS/BPH.
METHODS
We performed a systematic review of PubMed, Scopus, and Web of Science in June 2023.
KEY FINDINGS AND LIMITATIONS
We identified 29 publications: 14 (872 patients) and 15 (851 patients) studies addressing medical and surgical therapies, respectively. The mean percentage total International Prostate Symptom Score (IPSS) improvements ranged from -2.5% to 56.3% and from 35.1% to 82.1% following medical and surgical therapies, respectively. The corresponding mean percentage Bladder Outlet Obstruction Index (BOOI) improvements ranged from 7.8% to 53.5% and from 22.4% to 138.6%, respectively. Holmium laser enucleation of the prostate (HoLEP) provided IPSS improvements in the higher range and the greatest BOOI reduction.
CONCLUSIONS AND CLINICAL IMPLICATIONS
Globally, based on available evidence, more pronounced symptomatic benefits are observed following treatments providing greater deobstructive effect. In detail, patients undergoing surgery exhibit greater IPSS and BOOI improvements than those receiving medical therapy.
PATIENT SUMMARY
Treatments for lower urinary tract symptoms suggestive of benign prostatic hyperplasia providing greater urodynamic improvements also provide greater symptomatic benefit. Surgical procedures provide greater symptomatic and urodynamic outcomes than medical therapies. Maximal obstruction relief, together with symptomatic benefits in the higher ranges, is observed following holmium laser enucleation of the prostate.
PubMed: 38749852
DOI: 10.1016/j.eururo.2024.04.031