NEW YORK (Reuters Health) – The optimal choice of transurethral procedure for benign prostatic hyperplasia is not made much easier by a new meta-analysis, published online June 11 in European Urology. It suggests the procedures have similar efficacy and overall morbidity.
Still, the authors note, the number and type of complications vary with each technique, meaning that patient characteristics should inform the choice.
“We feel that after considering the patient’s performance status, medication, prostate size, and personal expectations, the selection of the most appropriate transurethral technique for the individual patient must be of the utmost importance,” lead author Dr. Sascha A. Ahyai, of University Medical Centre Hamburg-Eppendorf in Germany, and colleagues write.
After reviewing the literature published since 1997, the researchers included 23 randomized controlled trials in their analysis. This allowed them to compare standard monopolar transurethral resection of the prostate (TURP) to the most common minimally invasive surgical therapies — bipolar TURP, bipolar transurethral vaporisation of the prostate (bipolar TUVP), holmium laser enucleation of the prostate (HoLEP), and potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate.
Compared to standard TURP, only HoLEP did better in terms of International Prostate Symptoms Score (mean difference, 1.31; p=0.005) and peak urinary flow rate (mean difference, 1.69 mL/s; p=0.012). However, there was no difference in quality of life or post-void residual volume.
Overall, there were no significant differences in the number of complications for each newer method compared with standard TURP, and the same was true for late complications such urethral strictures and persistent urgency.
The KTP procedure had significantly fewer intraoperative complications (odds ratio, 0.22; p=0.002), including bleeding, capsular perforation, and hyponatremia (TUR syndrome).
Perioperatively, bipolar TURP (OR, 0.65, p=0.029) and bipolar TUVP (OR, 0.53, p=0.022) both had significantly fewer complications, such as acute urinary retention, clot retention, and tract infections.
“How do you make your choice?” said Dr. Petrisor Geavlete, an expert in urologic surgery at Saint John Emergency Clinical Hospital in Bucharest, Romania, who was not involved in the new analysis. “That’s a very good question.”
“I suppose it’s also a subjective matter — which technique you feel more comfortable which,” he added.
Although he has used many of the different procedures, his own choice is clear.
“For the average prostate of 30 to 80 ml, plasma vaporization using the bipolar (transurethral resection in saline) is a good as it gets,” Dr. Geavlete said, adding that this procedure is cost-effective, easier to learn than HoLEP, and achieves better coagulation than laser surgery.
Dr. Vinod Malhotra, professor of anesthesiology in clinical urology at Weill Cornell Medical College in New York, said lasers were becoming increasingly popular in the U.S.
From his perspective, which he said was mostly intraoperative, the absence of blood loss “is a major plus for all of these techniques.”
He said bipolar plasma vaporization was also a good technique, but less widespread. With more studies and increased production of the surgical instruments, he predicted the procedure would gain a stronger foothold.
Reference:
http://www.europeanurology.com/article/S0302-2838%2810%2900537-3/fulltext
Eur Urol 2010.
