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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 -
Translational Andrology and Urology Apr 2022To assess the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for patients with prostate...
A systematic review and meta-analysis of efficacy and safety comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for patients with prostate volume less than 100 mL or 100 g.
BACKGROUND
To assess the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for patients with prostate volume less than 100 mL or 100 g.
METHODS
We searched PubMed, Embase, Cochrane Library and Web of Science from inception to July 2021 to collect randomized controlled trials. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies by using the Cochrane risk of bias tool. Review Manager 5.3 software was used for meta-analysis. We synthesised effect estimates using risk ratios (RR), mean difference (MD), and standardized mean differences (SMD).
RESULTS
A total of eight studies were included, involving 764 patients, 384 patients in the HoLEP group and 380 patients in the TURP group. The meta-analysis showed that the catheterization time (SMD =-1.44; 95% CI: -2.17 to -0.70; P=0.0001), hospital stay (SMD =-1.01; 95% CI: -1.58 to -0.44; P=0.0005), haemoglobin loss (MD =-0.29; 95% CI: -0.52 to -0.07; P=0.01), and transfusion rate (RR =0.16; 95% CI: 0.05-0.49; P=0.001) in the HoLEP group were lower than those in the TURP group. In addition, the 12-month postvoid residual volume (PVR) of the HoLEP group (MD =-9.93 95% CI: -18.59 to -1.27; P=0.02) were superior to the TURP group. Although the operation time of the HoLEP group was longer (MD =17.89; 95% CI: 9.18-26.60; P<0.0001), more tissues were removed (SMD =0.47; 95% CI: 0.10-0.85; P=0.01).
DISCUSSION
Compared with TURP, HoLEP has a shorter catheterization time and hospital stay, with more tissue removed, a lower blood transfusion rate and better results in the short-term follow-up after surgery. Therefore, HoLEP has better efficacy and safety in the treatment of small- and medium-sized benign prostatic obstruction. Our results found that HoLEP is also suitable for patients with prostate volume <100 mL/100 g, suggesting that it is necessary to redefine the prostate size that is best for HoLEP. Overall, the certainty of evidence was assessed to be moderate to low due to potential risk of bias and inconsistent outcome indicators in some studies. More data on the efficacy of HoLEP and TURP on small- and medium-sized prostates are needed to determine the optimal prostate volume of HoLEP.
PubMed: 35558272
DOI: 10.21037/tau-21-1005 -
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 -
BMJ Open Apr 2022To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign...
Reliability and validity of assessment methods available in primary care for bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms: a systematic review.
OBJECTIVES
To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS).
DESIGN
Systematic review with best evidence synthesis.
SETTING
Primary care.
PARTICIPANTS
Men with LUTS due to bladder outlet obstruction or benign prostatic obstruction.
REVIEW METHODS
PubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis.
RESULTS
Of the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence.
CONCLUSION
Clinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.
Topics: Female; Humans; Lower Urinary Tract Symptoms; Male; Primary Health Care; Prostatic Hyperplasia; Reproducibility of Results; Urinary Bladder Neck Obstruction
PubMed: 35487713
DOI: 10.1136/bmjopen-2021-056234 -
Cardiovascular and Interventional... Feb 2021To report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP) for the management... (Comparative Study)
Comparative Study Meta-Analysis
PURPOSE
To report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP) for the management of benign prostatic hyperplasia (BPH).
MATERIALS AND METHODS
A multi-database search for relevant literature was conducted on 15 July 2020 to include studies published on or before that date. Search terms used were: (prostate embolization OR prostatic embolization OR prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction). Risk of bias was assessed using Cochrane Collaboration and ROBINS-I criteria. Random-effects meta-analysis was performed using RevMan 5.3.
RESULTS
Six studies with 598 patients were included. TURP was associated with significantly more improvement in maximum urinary flow rate (Q) (mean difference = 5.02 mL/s; 95% CI [2.66,7.38]; p < 0.0001; I = 89%), prostate volume (mean difference = 15.59 mL; 95% CI [7.93,23.25]; p < 0.00001; I = 88%), and prostate-specific antigen (PSA) (mean difference = 1.02 ng/mL; 95% CI [0.14,1.89]; p = 0.02; I = 71%) compared to PAE. No significant difference between PAE and TURP was observed for changes in International Prostate Symptoms Score (IPSS), IPSS quality of life (IPSS-QoL), International Index of Erectile Function (IIEF-5), and post-void residual (PVR). PAE was associated with fewer adverse events (AEs) (39.0% vs. 77.7%; p < 0.00001) and shorter hospitalization times (mean difference = -1.94 days; p < 0.00001), but longer procedural times (mean difference = 51.43 min; p = 0.004).
CONCLUSION
Subjective symptom improvement was equivalent between TURP and PAE. While TURP demonstrated larger improvements for some objective parameters, PAE was associated with fewer AEs and shorter hospitalization times.
LEVEL OF EVIDENCE II
Level 2a, Systematic Review.
Topics: Aged; Arteries; Embolization, Therapeutic; Humans; Male; Prostate; Prostatic Hyperplasia; Reference Standards; Transurethral Resection of Prostate; Treatment Outcome
PubMed: 33078236
DOI: 10.1007/s00270-020-02657-5 -
Journal of Clinical Medicine Feb 2023Transperineal laser ablation (TPLA) of the prostate is a new minimally invasive treatment option in men with lower urinary tract symptoms (LUTS) due to benign prostatic... (Review)
Review
Transperineal laser ablation (TPLA) of the prostate is a new minimally invasive treatment option in men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE). The aim of this systematic review was to investigate the efficacy and safety of TPLA in the management of BPE. The primary outcomes were the improvement in urodynamic parameters (maximum urinary flow (Q) and postvoiding residue (PVR)) and LUTS relief, assessed using the IPSS questionnaire. The secondary outcomes were the preservation of sexual and ejaculatory functions, assessed with the IEEF-5 and MSHQ-EjD questionnaires, respectively, and rates of postoperative complications. We reviewed the literature for prospective or retrospective studies evaluating the use of TPLA in the treatment of BPE. A comprehensive search in PubMed, Scopus, Web of Science, and ClinicalTrials.gov was performed for English language articles published between January 2000 and June 2022. Pooled analysis of the included studies with available follow-up data for the outcomes of interest was additionally performed. After screening 49 records, six full-text manuscripts were identified, including two retrospective and four prospective non-comparative studies. Overall, 297 patients were included. All the studies independently reported a statistically significant improvement, from baseline, in Q, PVR, and IPSS score at each timepoint. Three studies additionally demonstrated that TPLA did not affect sexual function, reporting no change in the IEEF-5 score, and a statistically significant improvement in MSHQ-EjD score at each timepoint. Low rates of complications were recorded in all the included studies. Pooled analysis showed a clinically meaningful improvement in both micturition and sexual outcomes mean values at 1, 3, 6, and 12 months of follow-up, compared with baseline. Transperineal laser ablation of the prostate for the treatment of BPE showed interesting results in pilot studies. However, higher level and comparative studies are needed to confirm its efficacy in relieving obstructive symptoms and preserving sexual function.
PubMed: 36902647
DOI: 10.3390/jcm12051860 -
European Urology Aug 2021Benign prostatic obstruction (BPO) is associated with sexual dysfunction. Furthermore, numerous BPO interventions may themselves impact sexual function. (Meta-Analysis)
Meta-Analysis
CONTEXT
Benign prostatic obstruction (BPO) is associated with sexual dysfunction. Furthermore, numerous BPO interventions may themselves impact sexual function.
OBJECTIVE
To perform a systematic review with network meta-analysis to evaluate how BPO interventions affect erectile function.
EVIDENCE ACQUISITION
Three databases were searched for randomised controlled trials (RCTs) comparing surgical interventions for BPO. The primary outcome was postoperative International Index of Erectile Function-5 (IIEF-5) score at ten time points up to 72 mo. A random-effects Bayesian network meta-analysis with meta-regression was performed. In comparison to monopolar transurethral resection (mTURP), the mean difference (MD) with 95% credible interval (CrI) and rank probability (rank p) were calculated for interventions. The mean baseline score was studied in meta-regression. τ values were used to quantify heterogeneity.
EVIDENCE SYNTHESIS
A total of 48 papers (33 RCTs, 5159 patients, 16 interventions) were included. Prostatic urethral lift (PUL) ranked highest at 1 mo (MD 3.88, 95% CrI -0.47 to 8.25; rank p = 0.742), 6 mo (MD 2.43, 95% CrI -0.72 to 5.62; rank p = 0.581), 12 mo (MD 2.94, 95% CrI -0.26 to 6.12, rank p = 0.782), and 24 mo (MD 3.63, 95% CrI 0.14 to 7.11; rank p = 0.948), at which point statistical significance was reached. At time points up to 60 mo, there were no statistically significant comparisons for other interventions. Analyses were not possible at 18, 48, or 72 mo. β did not reach statistical significance in meta-regression. τ was highest at 1 mo (0.56) and 60 mo (0.55).
CONCLUSIONS
PUL ranked highly and resulted in erectile function improvement at 24 mo compared to mTURP, but direct evidence is lacking. We did not observe significant differences in erectile function following other interventions up to 60 mo. Owing to heterogeneity, our conclusions are weakest at 1 and 60 mo. Further RCTs comparing sexual function outcomes are recommended, such as PUL versus holmium laser or bipolar enucleation.
PATIENT SUMMARY
Different surgical treatments can be used to treat benign enlargement of the prostate causing urinary problems. We compared the effects of various treatments on erectile function at time points up to 5 years after surgery. Compared to surgical removal of some of the prostate gland (transurethral resection of the prostate, TURP), a technique called prostatic urethral lift resulted in better erectile function scores at 24 months. However, other treatments did not differ in their effect on erectile function.
Topics: Erectile Dysfunction; Humans; Lower Urinary Tract Symptoms; Male; Network Meta-Analysis; Prostatic Hyperplasia; Transurethral Resection of Prostate
PubMed: 34127315
DOI: 10.1016/j.eururo.2021.04.012 -
European Urology Focus Sep 2022While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female... (Review)
Review
Benefits and Harms of Conservative, Pharmacological, and Surgical Management Options for Women with Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.
CONTEXT
While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female BOO.
OBJECTIVE
The aim of this systematic review was to evaluate the benefits and harms of therapeutic interventions for the management of BOO in women.
EVIDENCE ACQUISITION
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The study protocol was registered with PROSPERO (CRD42020183839). A systematic literature search was performed and updated by a research librarian in May 2021. The study population consisted of adult female patients diagnosed with BOO, who underwent treatment.
EVIDENCE SYNTHESIS
Out of 6344 records, we identified 33 studies enrolling 1222 participants, of which only six randomized controlled trials (RCTs) were found. One placebo-controlled crossover randomized trial assessed the role of baclofen in 60 female patients with dysfunctional voiding. The trial met its primary endpoint with a significantly greater decrease in the number of voids per day in the baclofen group (-5.53 vs -2.70; p = 0.001). The adverse events were mild and comparable in both groups (25% vs 20%). One placebo-controlled crossover randomized trial assessed the role of sildenafil in 20 women with Fowler's syndrome. There were significant improvements from baseline in maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and postvoid residual (PVR), but with no statistically significant difference when compared with placebo. In a large RCT including 197 female patients with functional BOO, the alpha-blocker alfuzosin significantly improved IPSS, Qmax, and PVR compared with baseline, but the differences were not statistically significant compared with the placebo group. Several small single-arm prospective series reported improvement of BOO-related symptoms and voiding parameters with urethroplasty, sling revision, urethral dilation, vaginal pessary, and pelvic organ prolapse repair.
CONCLUSIONS
Evidence to support the use of conservative, pharmacological, and surgical treatments for BOO is scarce.
PATIENT SUMMARY
According to the present systematic review of the literature, evidence to support the use of conservative, pharmacological, and surgical treatments for either anatomical or functional bladder outlet obstruction is scarce.
Topics: Male; Adult; Female; Humans; Urinary Bladder Neck Obstruction; Urodynamics; Urology; Baclofen; Urinary Bladder
PubMed: 34702649
DOI: 10.1016/j.euf.2021.10.006 -
European Urology Focus May 2022Low-intensity shockwave therapy (LiST) has emerged as an effective treatment for pain in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and it... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Low-intensity shockwave therapy (LiST) has emerged as an effective treatment for pain in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and it has been postulated that LiST may also be effective in patients with lower urinary tract symptoms (LUTS).
OBJECTIVE
To perform a systematic review and meta-analysis of experimental and clinical studies exploring the effect of LiST on LUTS in an attempt to provide clinical implications for future research.
EVIDENCE ACQUISITION
We systematically searched PubMed, Cochrane Library, and Scopus databases from inception to March 2021 for relevant studies. We provided a qualitative synthesis regarding the role of LiST in LUTS and performed a single-arm, random-effect meta-analysis to assess the absolute effect of LiST on LUTS only in patients with CP/CPPS (PROSPERO: CRD42021238281).
EVIDENCE SYNTHESIS
We included 23 studies (11 experimental studies, seven nonrandomized controlled trials [non-RCTs], and five RCTs) in the systematic review and seven in the meta-analysis. All experimental studies were performed on rats with LUTS, and the clinical studies recruited a total of 539 participants. In patients with CP/CPPS, the absolute effect of LiST on maximum flow rate and postvoid residual was clinically insignificant. However, the available studies suggest that LiST is effective for the management of pain in patients with either CP/CPPS or interstitial cystitis/bladder pain syndrome. Additionally, LiST after intravesical instillation of botulinum neurotoxin type A may enhance its absorption and substitute botulinum neurotoxin type A injections in patients with overactive bladder. Furthermore, the available evidence is inconclusive about the role of LiST in patients with benign prostatic obstruction, stress urinary incontinence, or underactive bladder/detrusor hypoactivity.
CONCLUSIONS
LiST may be effective for some disorders causing LUTS. Still, further studies on the matter are necessary, since the available evidence is scarce.
PATIENT SUMMARY
Low-intensity shockwave therapy represents a safe, easily applied, indolent, and repeatable on an outpatient basis treatment modality that may improve lower urinary tract symptoms.
Topics: Animals; Botulinum Toxins, Type A; Chronic Pain; High-Energy Shock Waves; Humans; Lower Urinary Tract Symptoms; Male; Pelvic Pain; Prostatitis; Rats
PubMed: 33985934
DOI: 10.1016/j.euf.2021.04.021