Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis

Complication rate across the minimally invasive surgical treatments (MISTs): where do we stand? A systematic review of the literature

BACKGROUND

Over the past decade, the range of surgical options to benign prostatic obstruction (BPO) has expanded significantly with the advent of minimally invasive surgical therapies (MISTs). Nevertheless, the available evidence in the field is heterogeneous. Efficacy and safety thresholds are yet to be determined.

OBJECTIVE

To evaluate perioperative and long-term complications after MISTs - including Aquablation, steam injection (Rezūm), Transperineal laser ablation of the prostate (TPLA), implantation of a prostatic urethral lift (PUL) and temporary implantable nitinol device (iTIND) - in patients with lower urinary tract symptoms due to BPO.

EVIDENCE ACQUISITION

A systematic literature search was conducted in January 2024 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria (Patients, Interventions, Comparisons, Outcomes) [1], focusing specifically on patients with BPH-associated LUTS who underwent MIST or other comparative treatments, aiming to assess both perioperative and long-term safety outcomes. Article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest.

EVIDENCE SYNTHESIS

The initial electronic search identified 3660 records, of which 24 ultimately met the inclusion criteria and were included in the analysis. Overall, Aquablation was associated with a higher major complications rate of 14% (IQR 6-22), particularly in the case of patients with prostates <70 ml. PUL showed a higher early postoperative acute urinary retention rate (10.9%, IQR 9.2-12.3%), while 1.4% of patients treated with iTIND experienced major perioperative complications. Urinary tract infections were mostly reported in series assessing TPLA and Rezūm.

CONCLUSIONS

The adoption of MISTs for LUTS due to BPH is associated with a varied spectrum of perioperative and long-term complications. Our findings showed an acceptable safety profile with specific complications dependent on the type of MIST performed, highlighting the importance of individualized patient selection and procedure-specific considerations.

Safety and efficacy of transurethral holmium laser enucleation of the prostate versus bipolar transurethral resection of the prostate in the treatment of benign prostatic hyperplasia: a prospective randomized controlled trial

PURPOSE

To evaluate the safety and efficacy of transurethral holmium laser enucleation of the prostate (HoLEP) compared to bipolar transurethral resection of the prostate (bTUR-P) in the treatment of benign prostatic hyperplasia (BPH).

METHODS

A total of 220 BPH patients hospitalized from January 2022 to September 2023 were included in this study. These patients were randomly assigned to HoLEP and bTUR-P groups, with 110 participants in each group. We collected preoperative general information, perioperative data, complications, and postoperative follow-up indicators from both groups of patients.

RESULTS

The baseline characteristics of patients in both groups were similar, with no statistical significance (P > 0.05). Compared to the bTUR-P group, the HoLEP group exhibited significantly less intraoperative bleeding (P < 0.001), shorter bladder irrigation time (P = 0.002), shorter catheter retention time (P < 0.001), and reduced postoperative hospitalization (P = 0.002). Additionally, the pain score during urination after catheter removal was significantly lower in the HoLEP group (P < 0.001). Postoperative complications occurred in both groups; however, they were less frequent in the HoLEP group (4 cases), primarily consisting of urinary retention and postoperative bleeding. The bTUR-P group experienced more complications (9 cases). Significant reductions in postoperative residual urine volume (RUV) were observed in both groups (P < 0.001). Both groups also showed significant improvements in Quality of Life (QoL) scores and International Prostate Symptom Scores (IPSS), with the HoLEP group demonstrating a more significant decrease in IPSS (P < 0.001).

CONCLUSION

After comprehensive evaluation, HoLEP was superior to bTUR-P in terms of safety and efficacy. Therefore, HoLEP may be a preferable choice for the treatment of BPH.

Association between caffeine intake and erectile dysfunction: a meta-analysis of cohort studies

BACKGROUND

Erectile dysfunction (ED) is a common condition with various contributing factors, including lifestyle and dietary habits. Caffeine, a widely consumed stimulant, has been linked to multiple physiological effects on vascular function and hormonal balance that might influence sexual function. This meta-analysis aims to evaluate the association between caffeine intake and the risk of ED by analyzing data from cohort studies.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase databases, and a manual search was conducted on Google Scholar for studies on the relationship between caffeine intake and ED in adult men. The search included observational studies published up to April 1, 2024. Four cohort studies were included, and their data were extracted and analyzed by STATA version 18.

RESULTS

Four included cohort studies comprised 51,665 cohort members. The study population included adult males, on average, aged 18 to 80. The results indicate that there was no significant relationship between coffee consumption and the risk of ED (relative risk [RR] = 0.94, 95% CI: 0.86-1.03; p = 0.999).

CONCLUSIONS

The current evidence suggests no significant relationship between caffeine intake and ED, but limited studies limit conclusions. Future research should focus on larger sample sizes, standardized outcome assessments, and different dosages and forms of caffeine consumption.

Non-inferiority, randomised, open-label clinical trial on the effectiveness of transurethral microwave thermotherapy compared to prostatic artery embolisation in reducing severe lower urinary tract symptoms in men with benign prostatic hyperplasia: study protocol for the TUMT-PAE-1 trial

BACKGROUND

One-fourth of men older than 70 years have lower urinary tract symptoms (LUTS) that impair their quality of life. Transurethral resection of the prostate (TURP) is considered the gold standard for surgical treatment of LUTS caused by benign prostatic hyperplasia (BPH) that cannot be managed conservatively or pharmacologically. However, TURP is only an option for patients fit for surgery and can result in complications. Transurethral microwave thermotherapy (TUMT) and prostatic artery embolisation (PAE) are alternative minimally invasive surgical therapies (MISTs) performed in an outpatient setting. Both treatments have shown to reduce LUTS with a similar post-procedure outcome in mean International Prostate Symptom Score (IPSS). It is however still unknown if TUMT and PAE perform equally well as they have never been directly compared in a randomised clinical trial. The objective of this clinical trial is to assess if PAE is non-inferior to TUMT in reducing LUTS secondary to BPH.

METHODS

This study is designed as a multicentre, non-inferiority, open-label randomised clinical trial. Patients will be randomised with a 1:1 allocation ratio between treatments. The primary outcome is the IPSS of the two arms after 6 months. The primary outcome will be evaluated using a 95% confidence interval against the predefined non-inferiority margin of + 3 points in IPSS. Secondary objectives include the comparison of patient-reported and functional outcomes at short- and long-term follow-up. We will follow the patients for 5 years to track long-term effect. Assuming a difference in mean IPSS after treatment of 1 point with an SD of 5 and a non-inferiority margin set at the threshold for a clinically non-meaningful difference of + 3 points, the calculated sample size was 100 patients per arm. To compensate for 10% dropout, the study will include 223 patients.

DISCUSSION

In this first randomised clinical trial to compare two MISTs, we expect non-inferiority of PAE to TUMT. The most prominent problems with MIST BPH treatments are the unknown long-term effect and the lack of proper selection of candidates for a specific procedure. With analysis of the secondary outcomes, we aspire to contribute to a better understanding of durability and provide knowledge to guide treatment decisions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05686525. Registered on January 17, 2023, https://clinicaltrials.gov/study/NCT05686525 .

Cost Comparison of Prostatic Artery Embolization Between In-Hospital and Outpatient-Based Lab Settings

Purpose This study aimed to determine the costs associated with prostatic artery embolization (PAE) performed in hospital and outpatient-based lab (OBL) settings. Methods Procedures were performed in similarly equipped procedure suites located within a tertiary hospital or OBL. Time-driven activity-based costing (TDABC) was utilized to calculate procedural costs incurred by the institution. Process maps were created describing personnel, space, equipment, and materials. The time duration of each procedural step was recorded independently by a nurse caring for the patient at the time of the procedure, and mean values were included in our model. Using institutional and publicly available financial data, costs, and capacity cost rates were determined. Results Thirty-seven PAE procedures met inclusion criteria with a mean patient age of 70.4 (+/- 6.7) years and a mean prostate gland size of 129.7 (+/-56.4) cc. Twenty-six procedures were performed within the hospital setting, and 11 procedures were performed within the OBL. Reduction in International Prostate Symptom Score (IPSS) was not significantly different following hospital and OBL procedures (57.2% vs. 82.4%, P = 0.0796). Mean procedural time was not significantly different between the hospital and OBL settings (136.6 vs. 147.3 minutes, P = 0.1893). However, the duration between admission and discharge was significantly longer for procedures performed in a hospital (468.8 vs. 325.4 minutes, P <0.0001). Total costs for hospital-based procedures were marginally higher ($3,858.28 vs. $3,642.67). Conclusion Total PAE cost was similar between the hospital and OBL settings. However, longer periprocedural times for hospital-based procedures and differences in reimbursement may favor the performance of PAE in an OBL setting.

The Assessment of Patient-Reported Outcomes in the Medical Management of Patients With Benign Prostatic Hyperplasia

Background Benign prostatic hyperplasia (BPH) is a prevalent condition that a large portion of the male population develops with aging, in which the prostate gland enlarges and results in urinary symptoms. Objective The objective of this article is to assess patient-reported outcomes (PRO) of medical management of benign prostate hyperplasia in terms of international prostate symptoms score (IPSS), BPH impact index (BPHII), and treatment satisfaction score (TSS). Methods This descriptive study included 114 patients who received medical management for BPH during the period 5th May 2021 till 30th December 2023, at the Department of Urology, Institute of Kidney Disease Peshawar. Patient-reported outcomes were measured in terms of IPSS, BPHII, and TSS. Readings were recorded at the start of treatment and at three months of treatment and then compared. Data was analyzed using SPSS v.25 (IBM Inc., Armonk, New York). Results The mean age of the patients was 64.33 ± 6.12 years. The mean prostate size was 77.35 ± 12.83 ml. Overall mean pre-treatment and post-treatment IPSS was 24.82 ± 4.90 versus 15.57 ± 5.15, respectively (p-value 0.00). Mean pre-treatment and post-treatment BPHII were 11.98 ± 1.02 and 7.12 ± 2.46, respectively (p-value 0.000). The overall mean treatment satisfaction score was 6.89 ± 1.44. Conclusion Medical management improved symptomatology in BPH patients. This study is a step in the direction of the development of larger and longer-term PRO studies in BPH management.

Transurethral resection and other minimally invasive treatment options for BPH: would we treat ourselves as we treat our patients? Results from EAU Section of Uro-Technology (ESUT) decision-making survey among urologists

Introduction

With the introduction of novel treatment options for benign prostatic hyperplasia (BPH), decision making regarding surgical management has become ever more complex. Factors such as clinical exposure, equipment availability, patient characteristics and hospital setting may affect what treatment is offered and an informed patient choice. The aim of this study was to investigate how urologists help patients make decisions regarding BPH management and whether their practice would differ if they were the patient themselves.

Material and methods

A 52-question survey presenting hypothetical clinical scenarios was distributed to European urologists and trainees/residents online and in person. In each scenario, regarding treatment options for BPH, the participant considered themselves firstly as the treating clinician and secondly as the patient themselves. Details regarding the participants' clinical experience, awareness of treatment options and exposure to these options were obtained.

Results

There were 139 participants; 69.8% of whom were consultants, with 82.1% of participants having practiced urology for more than 5 years. A total of 59.7% of urologists consider themselves BPH specialists. Furthermore, 93.5% of those surveyed had performed transurethral resection of the prostate (TURP), whilst procedures performed the least by participants were minimally invasive surgical therapy (MIST) options. Only 17.3% had seen and 1.4% had performed all of the treatment options. When considering themselves as a patient within standard practice, there was a preference for HoLEP amongst participants.

Conclusions

The majority of urologists surveyed had minimal experience to newer BPH techniques and MIST, suggesting that more exposure is required. A higher rate of HoLEP was chosen as a treatment option for urologists themselves as a patient than what they would choose as an option for their patients.

Prostatic Arterial Embolization for Treatment of Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement

PURPOSE OF REVIEW

Prostatic artery embolization (PAE) is an emerging minimally invasive technique for lower urinary tract symptom reduction from benign prostatic hypertrophy (BPH). While the technique is becoming increasingly popular with patients and interventional radiologists, most urologists remain skeptical of the PAE's long-term efficacy and comparative success to the gold standard transurethral resection of the prostate.

RECENT FINDINGS

PAE has been found in multiple meta-analyses to perform similarly to the gold standard transurethral resection of the prostate (TURP) with regard to patient-driven measures like IPSS and IPSS-QoL, while also performing favorably in objective measurements including Qmax and PVR out to at least 12 months post intervention. Furthermore, PAE has a demonstrated shorter hospital length of stay and fewer adverse events when compared to TURP. PAE provides patients with an alternative to transurethral options for the management of LUTS in the setting of bladder outlet obstruction. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. Patients deserve to be counseled on PAE as an alternative to surgery and made aware that while the overall treatment effect may not be as robust or durable, the procedure carries a favorable adverse event profile that is attractive to patients wishing to avoid a trans-urethral approach.

Novel minimally invasive treatments for lower urinary tract symptoms: a systematic review and network meta-analysis

PURPOSE

To review and compare the effectivity of novel minimally invasive treatments (MITs) to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) in men.

METHODS

Medline, Embase, and Cochrane databases were searched from January 2010 to December 2022 for randomized controlled trials (RCTs) evaluating MITs, compared to TURP or sham, in men with LUTS. Studies were assessed by risk of bias tool, and evidence by GRADE. Functional outcomes by means of uroflowmetry and IPSS were the primary outcomes, safety and sexual function were secondary outcomes. As part of this review, a network meta-analysis (NMA) was conducted. MITs were ranked based on functional outcome improvement probability.

RESULTS

In total, 10 RCTs were included, evaluating aquablation, prostatic urethral lift, prostatic artery embolization (PAE), convective water vapor thermal treatment or temporary implantable nitinol device. All MITs showed a better safety profile compared to TURP. Functional outcome improvement following aquablation were comparable to TURP. In the NMA, aquablation was ranked highest, PAE followed with the second highest probability to improve functional outcomes. Other novel MITs resulted in worse functional outcomes compared to TURP. Level of evidence was low to very low.

CONCLUSIONS

Five MITs for treatment of LUTS were identified. Aquablation is likely to result in functional outcomes most comparable to TURP. Second in ranking was PAE, a technique that does not require general or spinal anesthesia. MITs have a better safety profile compared to TURP. However, due to high study heterogeneity, results should be interpreted with caution.

The role of tranexamic acid in reducing bleeding during transurethral resection of the prostate: An updated systematic review and meta-analysis of randomized controlled trials

Introduction

Transurethral resection of the prostate (TURP) is regarded as the current gold standard surgical intervention for benign prostatic hyperplasia (BPH). However, this procedure is associated with significant chances of intraoperative and postoperative bleeding. Several studies have reported the role of tranexamic acid in prostatic surgeries, but, its role in TURP is still unclear. This review aims to evaluate the role of tranexamic acid in reducing the blood loss during TURP.

Materials and Methods

A systematic search was performed on Medline, Scopus, Embase, and Cochrane, up to December 2021. Relevant randomized controlled trials (RCTs) evaluating the role of tranexamic acid in TURP were screened using our predefined eligibility criteria. Data were expressed as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs). All analyses were performed using RevMan 5.4 (Cochrane Collaboration, UK).

Results

Six trials were included in this meta-analysis, comprising of 582 patients with BPH who underwent TURP. The meta-analysis revealed an insignificant difference in the rate of blood transfusion (OR 0.68, 95% CI 0.34, 1.34, P = 0.27) but, a significantly lower amount of blood loss and a lower reduction in the hemoglobin (Hb) levels in the patients receiving tranexamic acid as compared to the control group (MD - 127.03, 95% CI - 233.11, -20.95, P = 0.02; MD - 0.53, 95% CI - 0.84, -0.22, P < 0.01; respectively). Also, the operative time (P = 0.12) and the length of hospitalization (P = 0.59) were similar between the two groups.

Conclusion

The administration of tranexamic acid was not found to be effective in reducing the need for blood transfusion, the operative time, and the length of hospitalization during the TURP. However, it could reduce the amount of blood loss and the fall in the Hb levels.

Efficacy and Safety of Prostatic Artery Embolization in the Treatment of High Risk Benign Prostatic Hyperplasia and its Influence on Postoperative Life Quality of Patients

Objective

To evaluate the efficacy, safety and postoperative quality of life of high risk benign prostatic hyperplasia (BPH) patients treated with prostatic artery embolization.

Methods

34 patients with high-risk BPH were selectedfrom January 2020 to June 2021 in our hospital. All patients were treated with prostatic artery embolization. The changes of international prostate symptom score (IPSS), prostate volume (PV), remaining urine (RU), maximum urine flow rate (Qmax), quality of life scale -74(GQOLI-74), time to sleep without disturbance (HUS) judgment, self-rating anxiety scale (SAS) score and self-rating depression scale (SDS) were compared before operation, 1 month and 6 months after operation.

Results

Prostatic artery embolization was successful in all 34 patients, including unilateral embolization in 15 patients and bilateral embolization in 19 patients. No severe complications occurred in the postoperative patients. The IPSS, PV and RU levels of the patient one month and six months after surgery were lower than those before surgery, while the Qmax level was higher than that before surgery. Besides, the IPSS, PV and RU levels six months after surgery were significantly lower than those one month after surgery, and the Qmax level was significantly higher than that one month after surgery (p < 0.05). The GQOLI-74 score six months after surgery was significantly higher than that before surgery (p < 0.05). The HUS of the patient six months after surgery was significantly increased, and the SAS and SDS scores were significantly decreased as compared with those before surgery (p < 0.05).

Conclusion

For high-risk patients with BPH, prostate embolization is an effective and safe method, which can significantly improve the quality of life of patients after surgery and has good application prospects.