Holmium Laser Enucleation versus Transurethral Resection in Patients with Benign Prostate Hyperplasia: An Updated Systematic Review with Meta-Analysis and Trial Sequential Analysis

<div><p>Background</p><p>Holmium laser enucleation (HoLEP) in surgical treatment of benign prostate hyperplasia (BPH) potentially offers advantages over transurethral resection of the prostate (TURP).</p><p>Methods</p><p>Published randomized controlled trials (RCTs) were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Library up to October 10, 2013 (updated on February 5, 2014). After methodological quality assessment and data extraction, meta-analysis was performed using STATA 12.0 and Trial Sequential Analysis (TSA) 0.9 software.</p><p>Results</p><p>Fifteen studies including 8 RCTs involving 855 patients met the criteria. The results of meta-analysis showed that: a) efficacy indicators: there was no significant difference in quality of life between the two groups (P>0.05), but compared with the TURP group, Qmax was better at 3 months and 12 months, PVR was less at 6, 12 months, and IPSS was lower at 12 months in the HoLEP, b) safety indicators: compared with the TURP, HoLEP had less blood transfusion (RR 0.17, 95% CI 0.06 to 0.47), but there was no significant difference in early and late postoperative complications (P>0.05), and c) perioperative indicators: HoLEP was associated with longer operation time (WMD 14.19 min, 95% CI 6.30 to 22.08 min), shorter catheterization time (WMD −19.97 h, 95% CI −24.24 to −15.70 h) and hospital stay (WMD −25.25 h, 95% CI −29.81 to −20.68 h).</p><p>Conclusions</p><p>In conventional meta-analyses, there is no clinically relevant difference in early and late postoperative complications between the two techniques, but HoLEP is preferable due to advantage in the curative effect, less blood transfusion rate, shorter catheterization duration time and hospital stay. However, trial sequential analysis does not allow us to draw any solid conclusion in overall clinical benefit comparison between the two approaches. Further large, well-designed, multicentre/international RCTs with long-term data and the comparison between the two approaches remain open.</p></div

Forest plot for intraoperative complications.

<p>RR = relative risk; CI = confidence interval.</p

Forest plot for early postoperative complications.

<p>RR = relative risk; CI = confidence interval.</p

Forest plot for late postoperative complications.

<p>RR = relative risk; CI = confidence interval.</p

Characteristics of the included randomized controlled trials (RCTs).

<p>IPSS = International Prostate Symptom Score; QoL = quality of life; Qmax = maximum flow rate; PVR = postvoid residual volume; IIEF = International Index of Erectile Function; NA = not available.</p

Trial sequential analysis of operation time.

<p>The required information size for operation time was calculated based on a two side α = 5%, β = 20% (power 80%), a minimal relevant difference of 5.0 min, a standard deviation of 29.2 min, and D² = 63% as estimated in a random effects model.</p

Identification of eligible studies.

<p>Identification of eligible studies.</p

Forest plot for perioperative indicators.

<p>WMD = weight mean difference; CI = confidence interval.</p

Forest plot for postvoid residual volume (PVR) at 6 months and 12 months based on a random effects model.

<p>WMD = weight mean difference; CI = confidence interval.</p

Trial sequential analysis of catheterization time.

<p>The required information size for operation time was calculated based on a two side α = 5%, β = 20% (power 80%), a minimal relevant difference of 5.0 min, a standard deviation of 26.8 min, and D² = 60% as estimated in a random effects model.</p