Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta‐analysis (Review)

BackgroundA variety of minimally invasive treatments are available as an alternative to transurethral resection of the prostate (TURP) for managementof lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). However, it is unclear which treatments providebetter results.ObjectivesOur primary objective was to assess the comparative effectiveness of minimally invasive treatments for lower urinary tract symptoms inmen with BPH through a network meta-analysis. Our secondary objective was to obtain an estimate of relative ranking of these minimallyinvasive treatments, according to their effects.Search methodsWe performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science and LILACS), trialsregistries, other sources of grey literature, and conference proceedings, up to 24 February 2021. We had no restrictions on language ofpublication or publication status.Selection criteriaWe included parallel-group randomized controlled trials assessing the effects of the following minimally invasive treatments, comparedto TURP or sham treatment, on men with moderate to severe LUTS due to BPH: convective radiofrequency water vapor therapy(CRFWVT); prostatic arterial embolization (PAE); prostatic urethral liK (PUL); temporary implantable nitinol device (TIND); and transurethralmicrowave thermotherapy (TUMT).
Data collection and analysisTwo review authors independently screened the literature, extracted data, and assessed risk of bias. We performed statistical analysesusing a random-effects model for pair-wise comparisons and a frequentist network meta-analysis for combined estimates. We interpretedthem according to Cochrane methods. We considered a minimally important difference of three points for the International ProstateSymptoms Score[IPSS]. We used the GRADE approach to rate the certainty of evidence.Main resultsWe included 27 trials involving 3017 men, mostly over age 50, with severe LUTS due to BPH. The overall certainty of evidence was low to verylow due to concerns regarding bias, imprecision, inconsistency (heterogeneity), and incoherence. Based on the network meta-analysis,results for our main outcomes were as follows.Urologic symptoms (19 studies, 1847 participants): PUL and PAE may result in little to no difference in urologic symptoms scores comparedto TURP (3 to 12 months; MD of IPSS range 0 to 35; higher scores indicate worse symptoms; PUL: 1.47, 95% CI -4.00 to 6.93; PAE: 1.55, 95%CI -1.23 to 4.33; low-certainty evidence). CRFWVT, TUMT, and TIND may result in worse urologic symptoms scores compared to TURP atshort-term follow-up, but the CIs include little to no difference (CRFWVT: 3.6, 95% CI -4.25 to 11.46; TUMT: 3.98, 95% CI 0.85 to 7.10; TIND:7.5, 95% CI -0.68 to 15.69; low-certainty evidence).Quality of life (QoL) (13 studies, 1459 participants): All interventions may result in little to no difference in the QoL scores, compared toTURP (3 to 12 months; MD of IPSS-QoL score; MD range 0 to 6; higher scores indicate worse symptoms; PUL: 0.06, 95% CI -1.17 to 1.30;PAE: 0.09, 95% CI -0.57 to 0.75; CRFWVT: 0.37, 95% CI -1.45 to 2.20; TUMT: 0.65, 95% CI -0.48 to 1.78; TIND: 0.87, 95% CI -1.04 to 2.79; low-certainty evidence).Major adverse events (15 studies, 1573 participants): TUMT probably results in a large reduction of major adverse events compared toTURP (RR 0.20, 95% CI 0.09 to 0.43; moderate-certainty evidence). PUL, CRFWVT, TIND and PAE may also result in a large reduction in majoradverse events, but CIs include substantial benefits and harms at three months to 36 months; PUL: RR 0.30, 95% CI 0.04 to 2.22; CRFWVT:RR 0.37, 95% CI 0.01 to 18.62; TIND: RR 0.52, 95% CI 0.01 to 24.46; PAE: RR 0.65, 95% CI 0.25 to 1.68; low-certainty evidence).Retreatment (10 studies, 799 participants): We are uncertain about the effects of PAE and PUL on retreatment compared to TURP (12 to60 months; PUL: RR 2.39, 95% CI 0.51 to 11.1; PAE: RR 4.39, 95% CI 1.25 to 15.44; very low-certainty evidence). TUMT may result in higherretreatment rates (RR 9.71, 95% CI 2.35 to 40.13; low-certainty evidence). There was insufficient data to include data on CRFWVT and TINDin this analysis.Erectile function (six studies, 640 participants): We are very uncertain of the effects of minimally invasive treatments on erectile function(MD of International Index of Erectile Function [IIEF-5]; range 5 to 25; higher scores indicates better function; CRFWVT: 6.49, 95% CI -8.13 to21.12; TIND: 5.19, 95% CI -9.36 to 19.74; PUL: 3.00, 95% CI -5.45 to 11.44; PAE: -0.03, 95% CI -6.38, 6.32; very low-certainty evidence).Ejaculatory dysfunction (eight studies, 461 participants): We are uncertain of the effects of PUL, PAE and TUMT on ejaculatory dysfunctioncompared to TURP (3 to 12 months; PUL: RR 0.05, 95 % CI 0.00 to 1.06; PAE: RR 0.35, 95% CI 0.13 to 0.92; TUMT: RR 0.34, 95% CI 0.17 to 0.68;low-certainty evidence). There was insufficient data to include data on CRFWVT and TIND in this analysis.TURP is the reference treatment with the highest likelihood of being the most efficacious for urinary symptoms, QoL and retreatment, butthe least favorable in terms of major adverse events, erectile function and ejaculatory function. Among minimally invasive procedures withsufficient data for analysis, PUL and PAE have the highest likelihood of being the most efficacious for urinary symptoms and QoL, TUMTfor major adverse events, PUL for retreatment, CRFWVT and TIND for erectile function and PUL for ejaculatory function.Authors' conclusionsMinimally invasive treatments may result in similar or worse effects concerning urinary symptoms and QoL compared to TURP at short-termfollow-up. They may also result in fewer major adverse events. PUL and PAE resulted in better rankings for symptoms scores and PUL mayresult in fewer retreatments, especially compared to TUMT, which had the highest retreatment rates. We are very uncertain about the effectsof these interventions on erectile and ejaculatory function. There was limited long-term data, especially for CRFWVT and TIND. Future high-quality studies with more extended follow-up, comparing different, active treatment modalities, and adequately reporting critical outcomes relevant to patients, including those related to sexual function, could provide more information on the relative effectiveness of these interventions.