Laser prostatectomy for benign prostatic obstruction

Bothersome lower urinary tract symptoms (LUTS) associated with benign prostatic obstruction (BPO) is a common problem for older men.  LUTS can be both irritative (urgency, frequency, frequent nighttime urinations) and obstructive (weak stream, hesitancy, intermittency, and feeling the bladder is not emptied).  Transurethral resection of the prostate (TURP) is considered the gold standard treatment for symptomatic BPO.  TURP improves urinary symptoms and urinary flow by surgically removing prostatic tissue through the urethra.  However, side effects occurring in approximately 20% of all TURPs include blood loss requiring transfusion, infections, strictures, sexual dysfunction, urinary incontinence, and urinary retention.  Laser prostatectomy, which uses a laser to destroy the enlarged prostate tissue that leads to LUTS, is a minimally invasive procedure currently used as an alternative to TURP.  This review of 20 studies involving 1898 subjects found laser techniques to be useful and relatively safe alternatives to TURP.  The small number of enrolled subjects and differences in study design limit any definitive conclusions regarding which type of laser technique is the most effective.  Improvements in LUTS and urine flow slightly favored TURP, though laser procedures had fewer side effects and shorter hospitalization times.  The follow-up durations of these studies ranged from 6 to 36 months and men with extremely large prostates were generally excluded from the trials. The risk of needing a reoperation for recurrent LUTS was higher following laser procedures. Study results were insufficient to adequately compare laser techniques with other minimally invasive procedures. More studies, using randomized treatment assignment, enrolling larger numbers of subjects, and comprehensive measures of treatment effectiveness and side events, are needed to better define the long-term safety and durability of laser techniques for treating LUTS associated BPO.

Authors' conclusions: 

Laser techniques are a useful alternative to TURP for treating BPO. Small sample sizes and differences in study design limit any definitive conclusions regarding the preferred type of laser technique. Data were insufficient to compare laser techniques with other minimally invasive procedures.

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Background: 

Symptomatic benign prostatic obstruction is a common problem for older men. The gold standard treatment, transurethral resection of the prostate (TURP), significantly improves urinary symptoms and urinary flow. However, TURP has up to a 20% morbidity. Currently, there are a number of minimally invasive procedures that may be safe, effective alternatives to TURP. One promising surgical technique is laser prostatectomy.

Objectives: 

To assess the therapeutic efficacy and safety of laser prostatectomy techniques for treating men with symptomatic benign prostatic obstruction.

Search strategy: 

Randomized controlled trials were identified from the Cochrane Collaboration Library, MEDLINE, EMBASE, bibliographies of retrieved articles and reviews, and contacting expert relevant trialists and laser manufacturers.

Selection criteria: 

All randomized controlled trials evaluating laser prostatectomy treatment for men with symptomatic BPH. Trials were eligible if they (1) were randomized comparisons of a laser technique with TURP, (2) included at least 10 men with BPO in each treatment arm, (3) provided at least 6-months follow-up, and (4) included clinical outcomes such as urologic symptom scales or urodynamic measurements.

Data collection and analysis: 

Data extraction and assessment of methodologic quality was performed independently by two reviewers. Information on study design, subject and treatment characteristics, adverse events, urinary symptoms, and urinary flow were extracted using a standard form.

Main results: 

Twenty studies involving 1898 subjects were evaluated, including 4 studies with multiple comparisons. We found eight comparisons of TURP with contact lasers, eight with non-contact lasers, four with hybrid techniques, and one with interstitial laser coagulation (ILC). Two studies compared transurethral electrovaporization (TUVP) with contact lasers, one study compared interstitial laser coagulation with transurethral microwave thermotherapy (TUMT), and one study compared holmium contact lasers (HoLRP) with open prostatectomy. Among the studies comparing laser prostatectomy with TURP, follow-up duration ranged from 6 to 36 months. Mean age (67.2 yrs), mean baseline symptom score (20.2), and mean baseline peak urinary flow (9.2 mL/s) did not differ by treatment group. The pooled percentage improvements for mean urinary symptoms ranged from 59% to 68% with lasers and 63% to 77% with TURP. The improvements for mean peak urinary flow ranged from 56% to 119% with lasers and 96% to 127% with TURP. Overall, laser subjects were less likely to receive transfusions or develop strictures and their hospitalizations were shorter. Non-contact laser subjects were more likely to have dysuria, urinary tract infection, and retention. Re-operation occurred more often following laser procedures.

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