- What is the clinical effectiveness of select minimally-invasive treatments for the management of lower urinary tract symptoms in people with benign prostatic hyperplasia?
Four recent systematic reviews, two randomized controlled trials, and one retrospective comparative study were identified that addressed the clinical effectiveness and safety of minimally invasive surgical techniques in treating lower urinary tract symptoms in patients with benign prostatic hyperplasia. The systematic reviews were well-conducted and comprehensive, reporting on numerous outcome measures evaluating prostatic artery embolization, prostatic urethral lift, and transurethral resection of the prostate. However, there was substantial overlap in the populations that were included and bias in some of the primary studies was apparent. One randomized controlled trial on aquablation was covered by four articles. There was some evidence of patient selection bias and discrepancy in the reporting of results among these studies. While the authors of the systematic reviews may have had no conflicts of interest, authors of the randomized controlled trials were sponsored by the manufacturer of a technology that was under evaluation. For these and other reasons, considerable caution must be taken in making inferences from the results presented in this report. Treatment effect was assessed with numerous outcomes ranging from symptom relief, quality of recovery, quality of life, and safety. Overall, based on findings from four studies that covered one randomized controlled trial, there was no difference in the changes in symptom relief between aquablation and transurethral resection at six and 12 months, except for men with prostates that were 50 mL or larger. In this sub-population, the difference in the change in maximum urinary flow from baseline to six months favoured aquablation over transurethral resection. Findings on prostatic artery embolization and prostatic urethral lift were mixed. Based on results from one meta-analysis, the difference in maximum urinary flow at post-treatment and the difference in the change of ejaculatory function scores favoured embolization over transurethral resection. Conversely, the difference in post-treatment quality of life scores and prostate volume, as well as the difference in symptom relief favoured transurethral resection and prostatectomy over embolization. Similarly, while changes in ejaculatory function at 12 months and quality of recovery at 12 and 24 months favoured prostate urethral lift over transurethral resection, improvement in symptom relief at 12 months and 24 months favoured transurethral resection over prostatic urethral lift. Overall, safety outcomes favoured minimally invasive surgical techniques over transurethral resection. Evidence from three primary studies reporting on the same randomized controlled trial suggested that for up to six months, men who were treated with aquablation had a lower mean incidence of complications compared to those who had transurethral resection. One primary study involving the same randomized controlled trial reported similar findings at 12 months. Evidence from two systematic reviews favoured both prostatic artery embolization and prostatic urethral lift over transurethral resection up to 12 months after treatment. Additionally, one randomized controlled trial favoured prostatic urethral lift over transurethral resection up to 24 months after treatment.No comparative evidence on recovery time following surgery was found, nor was there comparative evidence on water vapour thermal therapy. None of the studies compared minimally invasive surgical techniques with lifestyle changes, watchful waiting, or medical management, and none were conducted in Canada