Alternative approaches to endoscopic ablation for benign enlargement of the prostate: systematic review of randomised controlled trials

doi:10.1136/bmj.39575.517674.BE

Research

Alternative approaches to endoscopic ablation for benign enlargement of the prostate: systematic review of randomised controlled trials

Tania Lourenco, research fellow¹, Robert Pickard, senior clinical lecturer², Luke Vale, professor of health technology assessment¹^,3, Adrian Grant, professor of health services research¹, Cynthia Fraser, information officer¹, Graeme MacLennan, statistician¹, James N’Dow, professor of urology⁴, and the Benign Prostatic Enlargement team

¹ Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, ² Department of Urology, School of Surgical and Reproductive Sciences, Newcastle University, Newcastle upon Tyne, ³ Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, ⁴ Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, AB25 2ZD

Correspondence to: J N’Dow j.ndow{at}abdn.ac.uk

Objective To compare the effectiveness and risk profile of newermethods for endoscopic ablation of the prostate against thecurrent standard of transurethral resection.

Design Systematic review and meta-analysis.

Data sources Electronic and paper records in subject area upto March 2006.

Review methods We searched for randomised controlled trialsof endoscopic ablative interventions that included transurethralresection of prostate as one of the treatment arms. Two reviewersindependently extracted data and assessed quality. Meta-analysesof prespecified outcomes were done using fixed and random effectsmodels and reported using relative risk or weighted mean difference.

Results We identified 45 randomised controlled trials meetingthe inclusion criteria and reporting on 3970 participants. Thereports were of moderate to poor quality, with small samplesizes. None of the newer technologies resulted in significantlygreater improvement in symptoms than transurethral resectionat 12 months, although a trend suggested a better outcome withholmium laser enucleation (random effects weighted mean difference–0.82, 95% confidence interval 1.76 to 0.12) and worseoutcome with laser vaporisation (1.49, –0.40 to 3.39).Improvements in secondary measures, such as peak urine flowrate, were consistent with change in symptoms. Blood transfusionrates were higher for transurethral resection than for the newermethods (4.8% v 0.7%) and men undergoing laser vaporisationor diathermy vaporisation were more likely to experience urinaryretention (6.7% v 2.3% and 3.6% v 1.1%). Hospital stay was upto one day shorter for the newer technologies.

Conclusions Although men undergoing more modern methods of removingbenign prostatic enlargement have similar outcomes to standardtransurethral resection of prostate along with fewer requirementsfor blood transfusion and shorter hospital stay, the qualityof current evidence is poor. The lack of any clearly more effectiveprocedure suggests that transurethral resection should remainthe standard approach.

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Rapid Responses:

Read all Rapid Responses

Transurethral resection, the mother of minimally invasive surgery in urology: beyond the gold standard: Arun Sivanandam, MS, et al.
bmj.com, 10 Jul 2008 [Full text]
Transurethral resection is the gold standard: Said Fadel Mishriki
bmj.com, 14 Jul 2008 [Full text]
The Irreversible Tide of Technological Advancement?: Hashim U Ahmed, et al.
bmj.com, 16 Jul 2008 [Full text]
Author�s reply to comments by Sivanandam and colleagues: Tania Lourenco, et al.
bmj.com, 16 Jul 2008 [Full text]
Is laser associated with more incontinence?: John B Davies
bmj.com, 19 Jul 2008 [Full text]
Author's reply to comments by Davies J.: Tania Lourenco, et al.
bmj.com, 23 Jul 2008 [Full text]