Efficacy And Safety Of Transurethral Enucleation Of The Prostate For Treating Benign Prostate Hyperplasia: A Network Meta-Analysis

Objective: Network meta-analysis is applied to compare the safety and effectiveness of seven different types of surgery including transurethral resection of the prostate(TURP),plasmakinetic enucleation of the prostate(PKEP),monopolar resectoscope enucleation of the prostate(mTUEP),holmium laser enucleation of the prostate(HoLEP),thulium laser enucleation of the prostate(ThuLEP),diode laser enucleation of the prostate(DiLEP),Photoselective Vapo-Enucleation of the prostate(PVEP).Materials and Methods: We searched for reports of RCTs about TURP and different types of enucleation surgery published up to October 25,2017,using Pubmed,EMBASE and the Cochrane Library,and manual searched relevant reports.IPSS of 12 mouths,Qmax of 12 mouths,operation time,cathedral removal time,hematuria rates,incontinence rates,urethral stricture rates were set to be the outcome indicators.Data were extracted by two researchers after screening and evaluating the quality of the RCTs according to the inclusion criteria and exclusion criteria standard.Gemtc software based on the Bayesian theory was used to perform the network meta-analysis.Results were expressed as standard mean difference(SMD)for continuous outcomes with 95% confidence intervals(CI)and odds ratio(OR)for binary outcomes with 95% confidence intervals(CI).Results: 29 RCTs including 3188 patients were enrolled in this study,referring to 7 types of surgery.Result of network meta-analysis showed that HoLEP had the longer operation time compared to TURP [TURP vs HoLEP:SMD=-11.13,95%CI(-20.76,-1.78)].In terms of cathedral removal time,four types of surgery(PKEP?HoLEP?mTUEP?ThuLEP)showed shorter than TURP[TURP vs PKEP: SMD=0.85,95%CI(0.25,1.47);TURP vs HoLEP: SMD=0.98,95%CI(0.53,1.45);TURP vs DiLEP: SMD=1.29,95%CI(0.39,2.21);TURP vs ThuLEP: SMD=1.20,95%CI(0.61,1.84)].For the urethral stricture rates,HoLEP had the lower rates than TURP[TURP vs HoLEP: OR=4.20,95%CI(1.19,23.99)].There was no statistically signification difference of IPSS of 12 mouths,Qmax of 12 mouths,the hematuriarates and the incontinence rates.Basing on the Bayesian theory,we performed the network meta-analysis and ranked for all these outcome indicators.For IPSS at 12 months,the order was Di LEP<HoLEP<mTUEP<ThuLEP <PKEP<TURP.For Qmax at 12 months,the order was DiLEP>ThuLEP>PKEP > mTUEP>HoLEP>TURP.The order of operation time was TURP<PVEP<DiLEP<PKEP<HoLEP<mTUEP<ThuLEP.In terms of cathedral removal time,the order was DiLEP<ThuLEP<HoLEP<PKEP<PVEP<TURP.For the hematuria rates,the order was PKEP<HoLEP<TURP<PVEP.For the incontinence rates,the order was TURP< PVEP<HoLEP<PKEP<mTUEP<ThuLEP<DiLEP.The order of the urethral stricture rates was HoLEP<PKEP<DiLEP<mTUEP<ThuLEP <TURP.Conclusion: 1?Operation time was longer and urethral stricture rates were lower for HoLEP than TURP.2?In terms of cathedral removal time,TURP was longer than four types of surgery(PKEP?HoLEP?DiLEP?ThuLEP).3?No clinically relevant differences in the efficacy and safety among enucleation surgeries we had analysed.4?There were no clinically relevant differences in IPSS of 12 mouths,Qmax of 12 mouths,the hematuria rates,the incontinence rates among surgeries.5?From the result of SUCRA we can learn that these types of enucleation surgery showed advantages than TURP in addition to operation time,incontinence rates.Based on the result of this study,DiLEP might be the best choice for the BPH.Because of the limitation of the present study,data from big sample well-designed multicentric RCTs are welcomed to verify our result.