Emerging technologies for the surgical management of lower urinary tract symptoms secondary to benign prostatic obstruction. A systematic review

Context: Surgical management of lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) aims at ablating prostate adenoma by resection, enucleation, or vaporisation. Apart from established ablation modes according to the European Association of Urology guidelines, various technologies have emerged as safe/effective alternatives but remain under investigation. Objective: To explore short-term benefits/harms of emerging technologies for surgical management of LUTS/BPO. Evidence acquisition: A systematic literature search was conducted using MEDLINE, EMBASE, and CENTRAL via Ovid up to June 18, 2022. We included randomised controlled trials (RCTs) exploring aquablation, prostatic arterial embolisation (PAE), Rezum, prostatic urethral lift (PUL), and temporary implantable nitinol device (iTIND) versus sham/transurethral resection of the prostate (TURP). Evidence synthesis: We included ten RCTs (1108 men). Aquablation versus TURP: insignificant change in International Prostate Symptoms Score (IPSS; mean difference [MD] 0.0, 95% confidence interval [CI] –2.44 to 2.44), quality of life (QoL; MD 0.30, 95% CI –0.81 to 0.21), maximum urinary flow rate (Qmax; MD –0.30, 95% CI –3.71 to 3.11), retreatment (risk ratio [RR] 0.18, 95% CI 0.02–1.66), and urinary incontinence (UI; RR 0.71, 95% CI 0.26–1.95). PAE versus monopolar TURP (M-TURP): insignificant change in IPSS (MD 3.33, 95% CI –28.39 to 35.05), QoL (MD 0.12, 95% CI –0.30 to 0.54), International Index of Erectile Function (IIEF-5; MD 3.07, 95% CI –1.78 to 7.92), and UI (RR 0.15, 95% CI 0.01–2.86), and significant change in Qmax (MD –9.52, 95% CI –14.04 to –5.0), favouring M-TURP. PAE versus bipolar TURP: insignificant change in IPSS (MD –2.80, 95% CI –6.61 to 1.01), QoL (MD –0.69, 95% CI –1.46 to 0.08), Qmax (MD –3.51, 95% CI –8.08 to 1.06), UI (RR 0.14, 95% CI 0.01–2.51), and retreatment (RR 1.91, 95% CI 0.19–19.63). PUL versus TURP: insignificant change in QoL (MD 0.40, 95% CI –0.29 to 1.09), UI (RR 0.13, 95% CI 0.02–1.05), and retreatment (RR 0.48, 95% CI 0.12–1.86), and significant change in IPSS (MD 3.40, 95% CI 0.22–6.58), and IIEF-5 (MD 3.00, 95% CI 0.41–5.59) and Qmax (MD –9.60, 95% CI –13.44 to –5.76), favouring PUL and TURP, respectively. Rezum and iTIND have not been evaluated in RCTs against TURP to date. Conclusions: Supporting evidence for clinical use of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits/harms should be investigated further in high-quality RCTs. Patient summary: This review summarises the evidence for the clinical use of aquablation, prostatic arterial embolisation (PAE), prostatic urethral lift (PUL), Rezum, and temporary implantable nitinol device (iTIND) to manage lower urinary tract symptoms secondary to benign prostatic obstruction. The supporting evidence for the clinical usage of aquablation, PAE, PUL, Rezum, and iTIND is very limited. Benefits and harms should be investigated further in high-quality randomised controlled trials.