madman
Super Moderator
An Indirect Comparison of Newer Minimally Invasive Treatments for Benign Prostatic Hyperplasia: A Network Meta-Analysis Model
Abstract
Objective This study was designed to provide an indirect comparison of the urinary and sexual domain outcomes and complications following newer minimally invasive surgical therapy (MIST) of Aquablation, Rezum, and UroLift for benign prostatic hyperplasia (BPH) to transurethral resection of the prostate (TURP).
Methods We searched Embase, Medline, and Cochrane in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA), in December 2019. Only randomized clinical trials (RCTs) that reported outcomes following treatment of BPH for prostate less than 80g with Aquablation, Rezum, or UroLift, were included in the analysis.
Results A total of 4 RCTs reporting the outcomes after treatment with newer MIST for BPH were identified. Patients undergoing the respective procedures i.e. TURP and Aquablation had greater improvement in urinary domain outcomes: International Prostate Symptom Score, Quality of Life, peak flow rate, and Post Voiding Residual compared to patients undergoing non-respective procedures: UroLift and Rezum. Patients in the UroLift group maintained a higher sexual function domain score compared to TURP but not Aquablation. Our multiple comparison analysis did not reveal a significant difference in urinary and sexual domain scores between patients undergoing UroLift and Rezum at 24 months of follow-up.
Conclusions Aquablation and TURP necessitate general or regional anesthesia, both produced significantly better urinary domain scores compared to Rezum and UroLift. On the other hand, UroLift demonstrated better sexual function domain scores compared to TURP but not Aquablation. There was no significant difference in urinary domain scores between UroLift and Rezum at 24 months follow up.
INTRODUCTION
Benign prostatic hyperplasia (BPH) is a chronic condition associated with the development of lower urinary tract symptoms (LUTS). BPH is the most common diagnosis for men between 45-74 years of age diagnosed with urological problems. Since 20% of the population in the United States (US) is estimated to reach 65 years of age by 2030, a corresponding increase in the proportion of patients with BPH will lead to a significant increase in health care costs.1, 2 Although many men are initially managed with medical therapy, 25-70 % will become non-compliant or discontinue medication due to inadequate relief or side effects.3, 4 Until recently, treatment options for those who fail or discontinue medical management included surgical management with open or minimally invasive simple prostatectomy or minimally invasive treatments including transurethral resection of the prostate (TURP), laser enucleation, photo vaporization, transurethral needle ablation (TUNA), and transurethral microwave therapy (TUMT). TURP remains the gold standard for the treatment of BPH in prostates with a gland size of 30-80g.5 Although TURP causes a significant improvement in International Prostate Symptoms Score (IPSS), peak flow rate (Qmax), quality of life (QoL), and reduction of post voiding residual (PVR) volume, it may be associated with early complications including bleeding, capsular perforation, and need for blood product transfusion; as well as delayed postoperative complications including incontinence, erectile dysfunction, and/or retrograde ejaculation.6 Sexual function remains an important component of overall QoL regardless of age in the majority of men7 and especially the preservation of antegrade ejaculation remains a challenge. However, in recent years newer minimally invasive surgical therapies (MIST) options have emerged which provide effective urinary domain score improvement along with favorable ejaculatory sexual domain scores. More recent choices of intervention are prostatic urethral lift (PUL) (UroLift; Neotract Inc., Pleasanton, California, USA), convective water vapor energy (WAVE) (Rezum; NxThera Inc., Maple Grove, Minnesota, USA) and water jet dissection, AquaBeam System (Aquablation, PROCEPT BioRobotics, Redwood Shores, CA, USA.8,9,10 A desirable gold standard for these procedures include the ability to perform the procedure in an office setting under local anesthesia, provide rapid and durable relief of LUTS with minimal complications and preservation of sexual function and early return to the normal activity of patients. While none of the currently available MIST for BPH meets the gold standard criteria, several of the newer MIST preserve the ejaculatory sexual domain score while maintaining efficacy in the urinary domain scores.
In spite of the newer MIST being compared to gold standard TURP, there is a lack of RCT reporting a head to head comparison of each of these MIST, which makes the selection of the procedure based on comparative efficacy and side effect profile a challenge. Therefore, we carried out an indirect comparison using a network meta-analysis framework (NMA) on urinary and ejaculatory domain scores using the existing randomized controlled trials (RCTs) in the literature.
CONCLUSION
Patients undergoing Aquablation had greater improvement in IPSS, QOL, Qmax, and PVR compared to patients undergoing Rezum and UroLift. Patients in Aquablation had similar outcomes to patients receiving TURP in all domains. Patients in the UroLift group performed better in the sexual function domain compared to patients in the TURP group but not to patients in the Aquablation group. There was no significant difference between Rezum and UroLift at 24 months of follow-up.
Abstract
Objective This study was designed to provide an indirect comparison of the urinary and sexual domain outcomes and complications following newer minimally invasive surgical therapy (MIST) of Aquablation, Rezum, and UroLift for benign prostatic hyperplasia (BPH) to transurethral resection of the prostate (TURP).
Methods We searched Embase, Medline, and Cochrane in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA), in December 2019. Only randomized clinical trials (RCTs) that reported outcomes following treatment of BPH for prostate less than 80g with Aquablation, Rezum, or UroLift, were included in the analysis.
Results A total of 4 RCTs reporting the outcomes after treatment with newer MIST for BPH were identified. Patients undergoing the respective procedures i.e. TURP and Aquablation had greater improvement in urinary domain outcomes: International Prostate Symptom Score, Quality of Life, peak flow rate, and Post Voiding Residual compared to patients undergoing non-respective procedures: UroLift and Rezum. Patients in the UroLift group maintained a higher sexual function domain score compared to TURP but not Aquablation. Our multiple comparison analysis did not reveal a significant difference in urinary and sexual domain scores between patients undergoing UroLift and Rezum at 24 months of follow-up.
Conclusions Aquablation and TURP necessitate general or regional anesthesia, both produced significantly better urinary domain scores compared to Rezum and UroLift. On the other hand, UroLift demonstrated better sexual function domain scores compared to TURP but not Aquablation. There was no significant difference in urinary domain scores between UroLift and Rezum at 24 months follow up.
INTRODUCTION
Benign prostatic hyperplasia (BPH) is a chronic condition associated with the development of lower urinary tract symptoms (LUTS). BPH is the most common diagnosis for men between 45-74 years of age diagnosed with urological problems. Since 20% of the population in the United States (US) is estimated to reach 65 years of age by 2030, a corresponding increase in the proportion of patients with BPH will lead to a significant increase in health care costs.1, 2 Although many men are initially managed with medical therapy, 25-70 % will become non-compliant or discontinue medication due to inadequate relief or side effects.3, 4 Until recently, treatment options for those who fail or discontinue medical management included surgical management with open or minimally invasive simple prostatectomy or minimally invasive treatments including transurethral resection of the prostate (TURP), laser enucleation, photo vaporization, transurethral needle ablation (TUNA), and transurethral microwave therapy (TUMT). TURP remains the gold standard for the treatment of BPH in prostates with a gland size of 30-80g.5 Although TURP causes a significant improvement in International Prostate Symptoms Score (IPSS), peak flow rate (Qmax), quality of life (QoL), and reduction of post voiding residual (PVR) volume, it may be associated with early complications including bleeding, capsular perforation, and need for blood product transfusion; as well as delayed postoperative complications including incontinence, erectile dysfunction, and/or retrograde ejaculation.6 Sexual function remains an important component of overall QoL regardless of age in the majority of men7 and especially the preservation of antegrade ejaculation remains a challenge. However, in recent years newer minimally invasive surgical therapies (MIST) options have emerged which provide effective urinary domain score improvement along with favorable ejaculatory sexual domain scores. More recent choices of intervention are prostatic urethral lift (PUL) (UroLift; Neotract Inc., Pleasanton, California, USA), convective water vapor energy (WAVE) (Rezum; NxThera Inc., Maple Grove, Minnesota, USA) and water jet dissection, AquaBeam System (Aquablation, PROCEPT BioRobotics, Redwood Shores, CA, USA.8,9,10 A desirable gold standard for these procedures include the ability to perform the procedure in an office setting under local anesthesia, provide rapid and durable relief of LUTS with minimal complications and preservation of sexual function and early return to the normal activity of patients. While none of the currently available MIST for BPH meets the gold standard criteria, several of the newer MIST preserve the ejaculatory sexual domain score while maintaining efficacy in the urinary domain scores.
In spite of the newer MIST being compared to gold standard TURP, there is a lack of RCT reporting a head to head comparison of each of these MIST, which makes the selection of the procedure based on comparative efficacy and side effect profile a challenge. Therefore, we carried out an indirect comparison using a network meta-analysis framework (NMA) on urinary and ejaculatory domain scores using the existing randomized controlled trials (RCTs) in the literature.
CONCLUSION
Patients undergoing Aquablation had greater improvement in IPSS, QOL, Qmax, and PVR compared to patients undergoing Rezum and UroLift. Patients in Aquablation had similar outcomes to patients receiving TURP in all domains. Patients in the UroLift group performed better in the sexual function domain compared to patients in the TURP group but not to patients in the Aquablation group. There was no significant difference between Rezum and UroLift at 24 months of follow-up.
