An Indirect Comparison of Newer Minimally Invasive Treatments for Benign Prostatic Hyperplasia: A Network Meta-Analysis Model - Beyond the Abstract

Nearly 70% of men between 60 and 69 years have benign prostatic hyperplasia (BPH). Prevalence and severity of lower urinary tract symptoms (LUTS) in men also increase with age and approaches 80% in men over 80 years. A significant percentage of these patients on medical management will require surgical management due to inadequate improvement in symptoms, noncompliance with medications due to associated costs or side effects. Transurethral resection of the prostate (TURP) is the most commonly performed procedure for surgical management of BPH and is considered the gold standard treatment of BPH. Although TURP causes a significant improvement in the urinary domain (IPSS, IPSS-QoL, Qmax), it is associated with postoperative complications, of which retrograde ejaculation has a significant effect on the quality of life (QoL). TURP has other disadvantages like the need for general/regional anesthesia, need for a hospital stay, and delayed return to normal activity.


Newer minimally invasive surgical treatments (MIST) like UroLift®, Rezūm™, and Aquablation have shown to be effective in improving urinary symptoms with the advantage of preserving sexual function. UroLift® and Rezūm™ have the added advantage of being offered as office-based procedures under local anesthesia, enabling an early return to normal activity.

Despite the advantages of MIST, many physicians across the world are apprehensive to choose these procedures due to lack of comparison with the gold standard TURP and head to head comparison of the newer MIST. To overcome this challenge, we used a network meta-analysis framework to indirectly compare the outcomes between these procedures. We limited our study to a prostate size of less than 80 grams and a follow-up period of two years as the data for the comparator TURP arm is not available beyond two years in the available literature.

The findings from our study can be used to develop index patients and facilitate easy discussion by the clinicians with their patients.

  • TURP and Aquablation require general/regional anesthesia whereas UroLift® and Rezūm™ can be performed under local anesthesia/sedation in the office setting
  • TURP and Aquablation have superior outcomes in the urinary domain scores compared to UroLift® and Rezūm™
  • For patients who prefer office-based procedures and want better preservation of sexual function, UroLift® or Rezūm™ can be offered as an alternative to TURP
  • For patients who want greater improvement in urinary domain scores, Aquablation can be offered as an alternative to TURP
One of the other concerns about these MIST is regarding the durability of the results. Two-year follow-up data does exist for UroLift®, Rezūm™, and Aquablation and show a durable response with a retreatment rate of 7.5%, 4%, and 4 %, respectively.2,3 Of note, UroLift® and Rezūm™ have been shown to have durable results at five years with a retreatment rate of 13.6% and 4.4%, respectively in other studies.4,5 Nevertheless, until more time passes and more long-term data is obtained, some of the questions about long-term efficacy of MIST in BPH will remain unanswered.

Written by: Karthik Tanneru, MD, Jatinder Kumar, MD, Seyed Behzad Jazayeri, MD, Joseph Costa, MD, Department of Urology, University of Florida, Jacksonville, Florida

References:

  1. Tanneru, Karthik, Seyedbehzad Jazayeri, Alam Muhammad, Jatinder Kumar, Soroush Bazargani, Gretchen Kuntz, Hariharan PalayapalayamGanapathi et al. "An Indirect Comparison of Newer Minimally Invasive Treatments for Benign Prostatic Hyperplasia: A Network Meta-Analysis Model." Journal of Endourology ja (2020).
  2. Tanneru, Karthik, Shiva Gautam, Daniel Norez, Jatinder Kumar, Muhammad Umar Alam, Shahriar Koocheckpour, K. C. Balaji, and Costa Joseph. "Meta-analysis and systematic review of intermediate-term follow-up of prostatic urethral lift for benign prostatic hyperplasia." International Urology and Nephrology (2020): 1-10.
  3. Gilling, Peter, Neil Barber, Mohamed Bidair, Paul Anderson, Mark Sutton, Tev Aho, Eugene Kramolowsky et al. "Two-year outcomes after aquablation compared to TURP: efficacy and ejaculatory improvements sustained." Advances in therapy 36, no. 6 (2019): 1326-1336.
  4. Roehrborn, Claus, Jack Barkin, Steven N. Gange, Neal D. Shore, Jonathan L. Giddens, Damien M. Bolton, Barrett E. Cowan et al. "Five year results of the prospective randomized controlled prostatic urethral LIFT study." Canadian Journal of Urology 24, no. 3 (2017): 8802-8813.
  5. “Five-Year Rezūm Outcomes Demonstrate Effective Long-Term BPH Treatment.” Accessed December 23, 2020.  https://www.urotoday.com/recent-abstracts/men-s-health/bph-benign-prostatic-enlargement/120618-rezum-water-vapor-therapy-five-year-outcomes-demonstrate-effective-long-term-treatment-of-benign-prostatic-hyperplasia.html.
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