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

Urinary incontinence in men after formal one-to-one pelvic-floor muscle training following radical prostatectomy or transurethral resection of the prostate (MAPS): two parallel randomised controlled trials

BACKGROUND

Urinary incontinence is common immediately after prostate surgery. Men are often advised to do pelvic-floor exercises, but evidence to support this is inconclusive. Our aim was to establish if formal one-to-one pelvic floor muscle training reduces incontinence.

METHODS

We undertook two randomised trials in men in the UK who were incontinent 6 weeks after radical prostatectomy (trial 1) or transurethral resection of the prostate (TURP; trial 2) to compare four sessions with a therapist over 3 months with standard care and lifestyle advice only. Randomisation was by remote computer allocation. Our primary endpoints, collected via postal questionnaires, were participants' reports of urinary incontinence and incremental cost per quality-adjusted life year (QALY) after 12 months. Group assignment was masked from outcome assessors, but this masking was not possible for participants or caregivers. We used intention-to-treat analyses to compare the primary outcome at 12 months. This study is registered, number ISRCTN87696430.

FINDINGS

In the intervention group in trial 1, the rate of urinary incontinence at 12 months (148 [76%] of 196) was not significantly different from the control group (151 [77%] of 195; absolute risk difference [RD] -1·9%, 95% CI -10 to 6). In trial 2, the difference in the rate of urinary incontinence at 12 months (126 [65%] of 194) from the control group was not significant (125 [62%] of 203; RD 3·4%, 95% CI -6 to 13). Adjusting for minimisation factors or doing treatment-received analyses did not change these results in either trial. No adverse effects were reported. In both trials, the intervention resulted in higher mean costs per patient (£180 and £209 respectively) but we did not identify evidence of an economically important difference in QALYs (0·002 [95% CI -0·027 to 0·023] and -0·00003 [-0·026 to 0·026]).

INTERPRETATION

In settings where information about pelvic-floor exercise is widely available, one-to-one conservative physical therapy for men who are incontinent after prostate surgery is unlikely to be effective or cost effective. The high rates of persisting incontinence after 12 months suggest a substantial unrecognised and unmet need for management in these men.

FUNDING

National Institute of Health Research, Health Technology Assessment (NIHR HTA) Programme.

Perioperative management of transurethral surgery for benign prostatic hyperplasia: a nationwide survey in Japan

OBJECTIVES

Various types of minimally invasive surgical treatments, including transurethral resection of prostate (TURP), are being carried out in Japan for patients with benign prostatic hyperplasia (BPH). The aim of the present study was to elucidate the current status of perioperative care for these treatments by carrying out a nationwide survey.

METHODS

Assisted by the Japanese Endourology and ESWL Association, perioperative data from 157 institutions participating in this survey were collected and analyzed.

RESULTS

This survey included 3918 patients undergoing TURP, 242 TUR in saline (TURis), 638 holmium laser enucleation of the prostate (HoLEP), 90 holmium laser ablation (HoLAP) and 241 photoselective vaporization (PVP). Mean operative time was shorter in TURP (71 min) and longer in HoLEP (127). Although no transfusions were required in cases undergoing HoLAP or PVP, blood was frequently transfused in those undergoing TURis (25.6%), TURP (10.2%) and HoLEP (7.8%), and the difference was significant. During the hospital stay, the incidence of TUR-syndrome, postoperative bleeding requiring bladder irrigation, acute urinary retention/difficulty on micturition and pad use at discharge was highest in TURP (2.3%), TURis (7.9%), HoLAP (16.7%) and HoLEP (15.1%), respectively. Two patients undergoing TURP died (0.05%). The shortest mean postoperative hospital stay was for PVP (1.6 days, even if the readmission rate within 90 days was the highest in this same group; 6.2%). Perioperative care during hospital stay varied among the five types of procedures.

CONCLUSIONS

This survey provides useful documentation on the current status of minimally invasive treatments for BPH in Japan. Complication rates for TURP are not significantly higher as compared with other procedures. Thus, TURP can still be considered as the gold standard for BPH treatment.

The fate of conference abstracts: systematic review and meta-analysis of surgical treatments for men with benign prostatic enlargement

OBJECTIVE

From the literature search for a government-commissioned systematic review on surgical treatments for benign prostatic enlargement (BPE), we identified the relevant conference abstracts of randomised controlled trials (RCTs) which failed to reach full publication and their data were not utilised. We aimed to ascertain, first, the reasons of failure to reach full publication and second, to estimate the impact of including the abstracts' data.

DESIGN

A two-part study, consisting of a questionnaire survey and a sensitivity analysis of the above said review.

METHODS

An ad hoc questionnaire was sent to each author of the relevant abstracts, as to determine the reasons of failure to reach full publication. The data from the abstracts were then extracted and incorporated into sensitivity analysis of the review.

RESULTS

Forty-seven questionnaires were completed for 47 abstracts. Of these abstracts, 32 of them were claimed to have reached full publication. A number of reasons of failure to reach full publication were identified, for example: 'being written up' and 'lack of time'. Utilizable, relevant data were obtained from eight of the 47 abstracts, and put into sensitivity analysis. There were small changes in effect sizes and directions for three of 14 reviews' secondary outcomes.

CONCLUSION

Common reasons of failure to reach full publication were also identified in the context for the BPE review. Inclusion of abstract data did not affect primary outcome defined in the original review. Identification, summarisation of conference abstracts and other grey literature should form an essential exercise for any systematic review.

Prostate histotripsy in an anticoagulated model

OBJECTIVES

To further explore the phenomenon of minimal bleeding after histotripsy by performing extensive prostate histotripsy treatments in anticoagulated canines. Histotripsy is a noninvasive ultrasound technology which induces microbubble formation (cavitation) within tissues producing mechanical tissue fractionation. During initial in vivo feasibility canine studies of prostate ablation, minimal hematuria was observed.

METHODS

Histotripsy was performed on 9 canine subjects pretreated with 6 mg of oral warfarin for 3-5 days using an extracorporeal 750 kHz therapeutic ultrasound transducer delivering acoustic pulses to the prostatic urethra and periurethral parenchyma. After 7-28 days, the subjects were euthanized, transrectal prostate ultrasound was performed, and the prostate was harvested. Serum hemoglobin and International Normalization Ratio were measured immediately before histotripsy treatment and at euthanasia.

RESULTS

Mean treatment International Normalization Ratio was 4.6 (median, 2.4; range, 1.2-11.3). There was no clinically significant change in hemoglobin concentration at euthanasia compared with baseline. At harvest, histologic sections of the prostate revealed a large cavity corresponding to the planned treatment volume incorporating the prostatic urethra and parenchyma in all subjects. Urine was clear within 2 days of treatment, and no blood clots were seen.

CONCLUSIONS

Despite therapeutic and supratherapeutic anticoagulation, histotripsy resulted in minimal bleeding despite significant fractionation and tissue debulking of the prostate. These results have prompted further studies to understand the mechanism of nonthermal hemostasis underlying histotripsy.

Surgical treatments for men with benign prostatic enlargement: cost effectiveness study

OBJECTIVE

To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective.

DESIGN

Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation.

DATA SOURCES

Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources.

METHODS

The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25,000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10,000 iterations.

RESULTS

A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of pound20,000 (euro21,595, $28,686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses.

CONCLUSION

The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.

Endoscopic ablation for benign enlargement of the prostate

Newer techniques are no better than transurethral resection, but the evidence base is poor