1
|
Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JP. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses. BMJ Open 2024; 14:e076675. [PMID: 38195174 PMCID: PMC10810041 DOI: 10.1136/bmjopen-2023-076675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVES This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured. DESIGN Systematic review of systematic reviews (umbrella review). DATA SOURCES Cochrane Database of Systematic Reviews. ELIGIBILITY CRITERIA Systematic reviews attempt to compare surgical to drug interventions. DATA EXTRACTION We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review. SYNTHESIS The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed. RESULTS Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance. CONCLUSIONS Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.
Collapse
Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Denmark, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John P Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| |
Collapse
|
2
|
Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JPA. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.30.23285207. [PMID: 36778340 PMCID: PMC9915830 DOI: 10.1101/2023.01.30.23285207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored. Design Systematic review of systematic reviews (umbrella review). Data sources Cochrane Database of Systematic Reviews (CDSR). Eligibility criteria and synthesis of results Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses. Results Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs. Conclusions Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed. Protocol registration https://osf.io/p9x3j.
Collapse
Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherland, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
3
|
Carilli M, Asimakopoulos AD, Pastore S, Germani S, Orecchia L, Agrò EF, Miano R. Can circumcision be avoided in adult male with phimosis? Results of the PhimoStop TM prospective trial. Transl Androl Urol 2022; 10:4152-4160. [PMID: 34984181 PMCID: PMC8661253 DOI: 10.21037/tau-21-673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background Circumcision as surgical treatment of adult phimosis is not devoid of complications. Efficacy of alternative non-surgical options is unclear. PhimoStopTM is a therapeutic protocol which involves the use of appropriately shaped silicone tuboids of increasing size to obtain a non-forced dilation of the prepuce. The aim of the study was to evaluate the efficacy and durability of results of PhimoStopTM device for the treatment of adult male phimosis. Methods A prospective trial was conducted between 2018 and 2020 on 85 consecutive adult male patients affected by phimosis and with an indication for circumcision. Patients were treated with PhimoStopTM protocol and they were evaluated at baseline and after treatment through a subjective (patient self-reported information on various domains of his sexual function) and an objective assessment (evaluation of phimosis severity grade according to the Kikiros scale pre- and post-treatment, re-assessment of indication for circumcision post-treatment and validated questionnaires scores). Primary endpoint was to avoid the scheduled circumcision in 33% of the patients enrolled. Results Seventy-one patients (84%) completed the device usage phase as per study protocol. Median duration of tuboid application was 60 days. Thirty-seven patients (52.1%) had no indication for circumcision after treatment. Even considering patients lost to follow-up as failures, primary endpoint was reached in 43.5% of cases. There was a significant reduction of the grade of phimosis after treatment (P<0.001). Moreover IIEF-5 showed a statistically significant improvement after treatment (P<0.001). Thirty/37 patients who met the primary endpoint (81%) still have a successful resolution of their phimosis avoiding circumcision at a median follow-up of 24 months. Conclusions PhimoStopTM device is effective for the treatment of adult male phimosis of Kikiros grade ≤2. The results seem to be durable in most patients at a median follow-up of 24 months. Randomized clinical trials are necessary in order to confirm our results and assess cost-efficacy.
Collapse
Affiliation(s)
- Marco Carilli
- Division of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | | | - Serena Pastore
- Division of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Stefano Germani
- Division of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Luca Orecchia
- Division of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Enrico Finazzi Agrò
- Department of Surgical Sciences, Division of Urology, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Miano
- Department of Surgical Sciences, Division of Urology, University of Rome Tor Vergata, Rome, Italy
| |
Collapse
|
4
|
Sridharan K, Sivaramakrishnan G. Topical corticosteroids for phimosis in children: a network meta-analysis of randomized clinical trials. Pediatr Surg Int 2021; 37:1117-1125. [PMID: 33991205 DOI: 10.1007/s00383-021-04906-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Corticosteroids and hyaluronidase are trialed for treating phimosis in children. We carried out the present network meta-analysis to compare the therapeutic effect of these drugs. METHODS Electronic databases were searched for appropriate randomized clinical trials. Odds ratio (OR) with 95% confidence intervals (95% CI) was used as the effect estimate. A random-effects model was used for generating the pooled estimates. Rankogram plot was used for ranking the drugs. MAIN OUTCOME MEASURES Proportions of patients with remission (partial/complete) and with complete remission. RESULTS Mometasone (OR 6.53, 95% CI 2.85, 14.96), betamethasone/hyaluronidase (OR 12.1, 95% CI 4.27, 34.49), triamcinolone (OR 19.15, 95% CI 4.47, 81.96), dexamethasone (OR 21.38, 95% CI 5.71, 79.98), betamethasone (OR 23.02, 95% CI 6.92, 79.54), hydrocortisone (OR 23.2, 95% CI 5.91, 91.02) and methylprednisolone (OR 50.47, 95% CI 4.45, 572.72) were observed with significantly higher proportions of patients with remission (partial/complete) compared to placebo. Dexamethasone, triamcinolone, betamethasone, betamethasone/hyaluronidase, clobetasol, mometasone, and hydrocortisone were observed with significantly higher proportions of patients with complete remission compared to placebo. Beclomethasone was not observed to be superior to either placebo or other drugs. Rankogram plot revealed methylprednisolone followed by hydrocortisone had the maximum statistical probability of being 'the best' in the pool for remission and betamethasone followed by hydrocortisone for complete remission. CONCLUSION Topical methylprednisolone, hydrocortisone, and betamethasone were observed with better clinical resolution of phimosis compared to other corticosteroids. Very high potent corticosteroids like beclomethasone and clobetasol were not observed with superior benefits compared to other corticosteroids. Considering low-potency, hydrocortisone shall be preferred until further evidence emerges.
Collapse
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | | |
Collapse
|
5
|
Leung AKC, Wong AHC, Leung AAM, Hon KL. Urinary Tract Infection in Children. ACTA ACUST UNITED AC 2020; 13:2-18. [PMID: 30592257 PMCID: PMC6751349 DOI: 10.2174/1872213x13666181228154940] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition. OBJECTIVE To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children. METHODS A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com. RESULTS Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed. CONCLUSION Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.
Collapse
Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
| | - Amy A M Leung
- Department of Family Medicine, The University of Alberta, Edmonton, Alberta, Canada
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong
| |
Collapse
|
6
|
Nguyen ATM, Holland AJA. Balanitis xerotica obliterans: an update for clinicians. Eur J Pediatr 2020; 179:9-16. [PMID: 31760506 DOI: 10.1007/s00431-019-03516-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/05/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022]
Abstract
Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1-16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:• Surgical circumcision is considered the definitive management of BXO• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.What is New:• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts.
Collapse
Affiliation(s)
- Alexander T M Nguyen
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew J A Holland
- Douglas Cohen Department of Paediatric Surgery, The University of Sydney School of Medicine, The Children's Hospital at Westmead Clinical School, The Faculty of Medicine and Health, Sydney, New South Wales, Australia.
| |
Collapse
|
7
|
Chen CJ, Satyanarayan A, Schlomer BJ. The use of steroid cream for physiologic phimosis in male infants with a history of UTI and normal renal ultrasound is associated with decreased risk of recurrent UTI. J Pediatr Urol 2019; 15:472.e1-472.e6. [PMID: 31345734 DOI: 10.1016/j.jpurol.2019.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 06/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND An uncircumcised male infant with a history of urinary tract infection (UTI), physiologic phimosis, and a normal renal ultrasound is a common patient referred to pediatric urology clinics. Topical steroid creams have been shown to effectively release physiologic phimosis. OBJECTIVE The objective of this study was to test the hypothesis that use of steroid cream for physiologic phimosis is associated with a lower UTI recurrence in uncircumcised male infants with normal renal ultrasounds. STUDY DESIGN Uncircumcised males younger than 12 months referred for a UTI with a normal renal ultrasound were included. A longitudinal data set was created, and recurrent UTIs were identified. The proportion with a recurrent UTI was compared between those who received a prescription for a steroid cream for phimosis and those who did not. The morbidity of the initial and recurrent UTIs was also described. The association of recurrent UTI with vesicoureteral reflux (VUR) was also evaluated. RESULTS A total of 192 uncircumcised males with a median age of 5.8 months (interquartile range [IQR]: 3.5-7.9 months) were included. Twenty-seven patients were treated with a course of betamethasone valerate 0.1% cream, and 165 were not (Summary Table). There were no significant differences between groups in the frequency of voiding cystourethrogram (VCUG), diagnosis of VUR, or use of continuous prophylactic antibiotics (CAP). During a median follow-up of 8.7 months (IQR: 3.1-17.5 months), none of the patients treated with steroid cream had a recurrent UTI compared with 27 of 165 (16%) patients not treated (P = 0.02). Among the 173 patients whose initial UTI was febrile, recurrent febrile UTIs occurred in no treated patients and 23 of 150 (15%) untreated patients (P = 0.047). DISCUSSION The results of this study are consistent with those of a previous randomized trial of steroid cream for physiologic phimosis which found lower recurrent UTI in those whose foreskins became retractable. In addition, the results are consistent with the declining incidence of UTIs in uncircumcised males mirroring the natural history of physiologic phimosis resolving. This study is limited by its retrospective nature and non-standardized follow-up. CONCLUSION The use of steroid cream for physiologic phimosis is associated with a decreased risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound. In this group, steroid cream for physiologic phimosis is a well-tolerated and simple alternative to circumcision to potentially decrease risk of recurrent UTI.
Collapse
Affiliation(s)
- C J Chen
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Satyanarayan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - B J Schlomer
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
8
|
Abstract
The circumcision of newborn males in Canada has become a less frequent practice over the past few decades. This change has been significantly influenced by past recommendations from the Canadian Paediatric Society and the American Academy of Pediatrics, who both affirmed that the procedure was not medically indicated. Recent evidence suggesting the potential benefit of circumcision in preventing urinary tract infection and some sexually transmitted infections, including HIV, has prompted the Canadian Paediatric Society to review the current medical literature in this regard. While there may be a benefit for some boys in high-risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male.
Collapse
|