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Tur Vs TVP
Tur Vs TVP
Tur Vs TVP
DOI 10.1007/s00345-015-1735-9
INVITED REVIEW
Abstract time and resected prostate weight favored OP. There was
Purpose To evaluate the efficacy and safety of transure- significantly less blood transfusion with TUEP, but no sig-
thral enucleation of the prostate (TUEP) versus transvesi- nificant differences were found in other complications such
cal open prostatectomy (OP) for the management of large as recatheterization, urinary tract infection, reintervention
benign prostatic hyperplasia (BPH). for clots and bleeding control, incidence of pneumonia and
Methods Randomized controlled trials (RCTs) comparing infarction, transient incontinence, bladder neck contracture,
TUEP and OP were identified from PubMed, Embase and urethral stricture and recurrent adenoma.
Web of Science up to February 28, 2015. A meta-analysis Conclusions TUEP can be performed effectively and
was conducted with the STATA 12.0 software. safely with functional outcomes and complications similar
Results Nine RCTs including 758 patients were enrolled to OP for large BPH, whereas it has the advantages of a
in our meta-analysis. There were no significant differ- shorter catheter period, shorter hospital stays and less blood
ences between the two groups in the maximum urinary transfusion. These findings seem to support TUEP as the
flow rate at 1, 3, 6months, 1 and 2years: postvoiding next-generation gold standard of surgery for large BPH.
residual urinary volume, prostate-specific antigen, interna-
tional prostate symptom score and quality of life score at Keywords Transurethral enucleation Open
1, 3, 6months and 1year; or international index of erectile prostatectomy Large benign prostatic hyperplasia
function at 3, 6months and 1year. Perioperative outcomes Meta-analysis Bipolar enucleation PKEP International
including hemoglobin level drop, catheter period, irriga- Consultation in Bipolar Enucleation of the Prostate
tion length and hospital stay favored TUEP, while operative ICBEP
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Chen etal. 2014 PKEP Gyrus 80 >100g 64.73.7 4 (36) 240 (160 4 (45) 25.63.3 110 (102130) g 72 3
[10] generator 390)
OP 80 63.74.5 4 (2.255) 249 (180 5 (46) 25.73.3 114.5 (104128) g
400)
Geavlete 2015 PKEP SurgMaster 80 >80mL 68.58.5 6.61.6 134.186.8 4.11.1 24.73.3 122.630.7mL 12 2
etal. [16] UES-40
generator
OP 80 68.78.6 6.51.7 142.193.1 4.01.2 24.93.0 128.732.7mL
Kuntz etal. 2008 HoLEP VersaPulse 60 >100mL 69.28.4 3.83.6 280273 NA NA 114.621.6mL 60 3
[14] PowerSuite
OP 60 71.28.3 3.63.8 292191 NA NA 113.019.2mL
Kuntz etal. 2004 HoLEP VersaPulse 60 >100g 69.28.4 3.83.6 280273 NA NA 114.621.6mL 18 3
[18] PowerSuite
OP 60 71.28.3 3.63.8 292191 NA NA 113.019.2mL
Kuntz etal. 2002 HoLEP VersaPulse 60 >100g 69.28.4 3.83.6 280273 NA NA 114.621.6mL 6 3
[17] PowerSuite
OP 60 71.28.3 3.63.8 292191 NA NA 113.019.2mL
Naspro etal. 2006 HoLEP VersaPulse 41 >70g 66.266.55 7.833.42 NA 4.070.93 20.115.84 113.2735.33g 24 2
[19] PowerSuite
OP 39 67.276.72 8.322.37 NA 4.440.96 21.603.24 124.2138.52g
Ou etal. 2013 PKEP Gyrus 47 >80mL 69.810.2 5.92.1 89.652.7 4.10.4 23.25.7 132.236.9mL 12 2
[20] generator
OP 45 71.59.5 5.12.3 81.348.6 4.30.5 25.15.4 139.536.2mL
Rao etal. 2013 PKEP Gyrus 43 >80mL NA 5.82.0 83.411.8 5.20.7 24.83.1 116.232.4mL 12 2
[21] generator
OP 40 NA 5.92.3 81.415.7 5.10.9 24.53.6 110.232.1mL
Salonia 2006 HoLEP VersaPulse 34 70220g 67.46.7 8.94.2 87.483.5 4.61.0 19.67.0 113.837.0mL NA 2
etal. [22] PowerSuite
OP 29 68.06.4 8.42.4 106.371.8 4.41.0 21.63.5 121.034.9mL
PKEP plasmakinetic enucleation of the prostate, OP open prostatectomy, HoLEP holmium laser enucleation of the prostate, TUEP transurethral enucleation of the prostate, Qmax maximum
flow rate, PVR postvoid residual, QoL quality of life, IPSS international prostate symptom score, NA not available
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Statistical analysis month [11, 21, 23, 30, 31], five at 3months [2123, 30,
31], four at 6months [11, 21, 23, 30], six at 1year [11, 15,
A meta-analysis was performed to generate summary sta- 2123, 31] and three at 2years [11, 15, 31]. There were
tistics when two or more RCTs adequate for pooling were no significant differences in Qmax between TUEP and OP
available for any outcome including perioperative data, effi- during the postoperative 1, 3, 6, 12months and 2years, and
cacy and complications. We also conducted subgroup meta- no significant differences were observed in subgroup analy-
analyses on the type of enucleation technology: PKEP and sis (all p>0.05, Table2).
HoLEP. Continuous data were expressed as weighted mean
difference (WMD) with a 95% confidence interval (CI) PVR
and dichotomous data as an odds ratio (OR) with a 95%
CI. The Chi-square test was used to test statistical hetero- The PVR data were obtained from four trials [2123, 30].
geneity. In the case of statistically significant heterogeneity Three trials reported PVR at 1 and 6months [21, 23, 30],
(p<0.10), the random effects model was used for the meta- and four trials reported PVR at 3months and 1year [21
analyses. Otherwise, the fixed effects model was used. 23, 30]. TUEP and OP showed no significant differences in
Forest plots and funnel plots were produced to reflect the PVR during the postoperative 1, 3, 6months and 1year (all
pooled indicators and publication bias. Statistical tests were p>0.05, Table2).
performed using STATA version 12.0 (StataCorp, College
Station, TX, USA). IPSS
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PubMed Embase Web of Science Irrigation length, catheterization time andhospital stay
(n = 105) (n = 222) (n = 177)
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Outcome of interest No. of studies No. of patients, TUEP/OP WMD (95% CI) p value Favors Heterogeneity p value
Qmax (mL/s)
1month
TUEP 5 304/302 0.05 [0.710, 0.611] 0.883 None 0.662
PKEP 3 203/203 0.175 [0.873, 0.523] 0.624 None 0.823
HoLEP 2 101/99 1.008 [1.022, 3.038] 0.331 None 0.356
3months
TUEP 5 271/264 0.815 [2.410, 0.779] 0.316 None 0.002
PKEP 3 170/165 0.735 [2.768, 1.298] 0.479 None 0.001
HoLEP 2 101/99 1.059 [4.480, 2.361] 0.544 None 0.145
6months
TUEP 4 263/160 0.705 [0.124, 1.534] 0.095 None 0.211
PKEP 3 203/200 0.353 [0.540, 1.246] 0.438 None 0.904
1year
TUEP 6 351/344 0.228 [0.975, 0.518] 0.549 None 0.330
PKEP 4 250/245 0.018 [0.796, 0.832] 0.965 None 0.347
HoLEP 2 101/99 1.53 [3.401, 0.341] 0.109 None 0.618
2years
TUEP 3 181/179 0.344 [1.839, 1.152] 0.652 None 0.840
HoLEP 2 101/99 0.787 [2.900, 1.327] 0.466 None 0.921
PVR (mL)
1month
TUEP 3 183/180 2.946 [9.753, 3.860] 0.396 None 0.001
PKEP 2 123/120 5.688 [16.255, 4.878] 0.291 None 0.001
3months
TUEP 4 230/225 1.72 [6.472, 3.033] 0.478 None 0.001
PKEP 3 170/165 3.533 [9.105, 2.038] 0.214 None 0.003
6months
TUEP 3 183/180 2.373 [8.140, 3.394] 0.420 None 0.000
PKEP 2 123/120 4.681 [13.498, 4.136] 0.298 None 0.000
1year
TUEP 4 230/225 0.748 [1.824, 0.328] 0.173 None 0.037
PKEP 3 170/165 0.754 [1.854, 0.345] 0.179 None 0.014
IPSS
1month
TUEP 3 164/159 0.528 [0.023, 1.078] 0.060 None 0.049
PKEP 2 123/120 0.243 [0.353, 0.839] 0.424 None 0.871
3months
TUEP 4 211/204 0.323 [0.112, 0.758] 0.146 None 0.607
PKEP 3 170/165 0.222 [0.245, 0.688] 0.352 None 0.801
6months
TUEP 2 164/159 0.2 [0.267, 0.667] 0.401 None 1.000
PKEP 2 164/159 0.2 [0.267, 0.667] 0.401 None 1.000
1year
TUEP 4 211/204 0.006 [0.310, 0.322] 0.970 None 0.549
PKEP 3 170/165 0.005 [0.313, 0.324] 0.973 None 0.347
QoL
1month
TUEP 3 164/159 0.08 [0.268, 0.109] 0.407 None 0.694
PKEP 2 123/120 0.112 [0.317, 0.093] 0.283 None 0.753
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Table2continued
Outcome of interest No. of studies No. of patients, TUEP/OP WMD (95% CI) p value Favors Heterogeneity p value
3months
TUEP 4 211/204 0.005 [0.304, 0.314] 0.976 None 0.002
PKEP 3 170/165 0.168 [0.309,0.027] 0.020 OP 0.811
6months
TUEP 2 164/159 0.054 [0.177, 0.069] 0.392 None 0.835
PKEP 2 164/159 0.054 [0.177, 0.069] 0.392 None 0.835
1year
TUEP 4 211/204 0.748 [1.824, 0.328] 0.173 None 0.037
PKEP 3 170/165 0.754 [1.854, 0.345] 0.179 None 0.014
PSA (ng/dl)
1month
TUEP 3 203/200 0.156 [0.050, 0.361] 0.138 None 0.497
PKEP 3 203/200 0.156 [0.050, 0.361] 0.138 None 0.497
3months
TUEP 2 123/120 0.06 [0.232, 0.112] 0.494 None 1.000
PKEP 2 123/120 0.06 [0.232, 0.112] 0.494 None 1.000
6months
TUEP 3 203/200 0.011 [0.079, 0.057] 0.749 None 0.270
PKEP 3 203/200 0.011 [0.079, 0.057] 0.749 None 0.270
1year
TUEP 3 203/200 0.007 [0.060, 0.073] 0.845 None 0.561
PKEP 3 203/200 0.007 [0.060, 0.073] 0.845 None 0.561
IIEF
3months
TUEP 2 84/79 0.473 [0.644, 1.589] 0.407 None 0.677
6months
TUEP 2 84/79 0.954 [1.981, 0.073] 0.069 None 0.086
1year
TUEP 2 84/79 0.97 [0.066, 2.005] 0.066 None 0.031
TUEP transurethral enucleation of the prostate, WMD weighted mean difference; other abbreviations as in Table1
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Fig.2continued d
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a Study % e
ID OR (95% CI) Weight Study %
.0033 2 1 301
.0133 1 75.1
Favors TUEP Favors OP
Favors TUEP Favors OP
b Study % f Study %
ID OR (95% CI) Weight
ID OR (95% CI) Weight
PKEP
Geavlete (2015) 1.00 (0.06, 16.27) 10.20 PKEP
Ou (2013) 1.91 (0.17, 21.86) 10.22 Chen (2014) 0.64 (0.23, 1.72) 34.34
Rao (2013) 0.31 (0.03, 3.10) 30.62 Geavlete (2015) 0.33 (0.01, 8.31) 5.15
Chen (2014) (Excluded) 0.00 Ou (2013) 0.96 (0.06, 15.77) 3.47
Subtotal (Isquared = 0.0%, p = 0.557) 0.77 (0.20, 2.92) 51.03 Rao (2013) 0.47 (0.08, 2.68) 13.42
.
Subtotal (Isquared = 0.0%, p = 0.954) 0.59 (0.26, 1.30) 56.38
HoLEP
.
Kuntz (2002) 1.00 (0.19, 5.15) 29.50
HoLEP
Naspro (2006) 2.38 (0.44, 12.98) 19.46
Subtotal (Isquared = 0.0%, p = 0.471) 1.55 (0.49, 4.91) 48.97
Naspro (2006) 0.78 (0.34, 1.80) 43.62
.031 1 32.3
Favors TUEP Favors OP
.0134 1 74.7
Favors TUEP Favors OP
c Study %
g Study %
ID OR (95% CI) Weight
ID OR (95% CI) Weight
PKEP PKEP
Chen (2014) 0.56 (0.18, 1.73) 36.84 Chen (2014) 0.25 (0.03, 2.29) 27.32
Geavlete (2015) 0.33 (0.03, 3.27) 20.62
Geavlete (2015) 0.43 (0.11, 1.72) 29.32
Ou (2013) 2.87 (0.11, 72.38)
72.38 3.52
Ou (2013) 0.96 (0.18, 4.99) 12.81
Rao (2013) 0.19 (0.01, 4.00) 17.61
Rao (2013) 0.56 (0.13, 2.49) 21.03 Subtotal (Isquared = 0.0%, p = 0.600) 0.39 (0.12, 1.27) 69.07
Subtotal (Isquared = 0.0%, p = 0.909) 0.57 (0.29, 1.13) 100.00 .
HoLEP
.
Kuntz (2002) 0.20 (0.01, 4.25) 17.18
Overall (Isquared = 0.0%, p = 0.909) 0.57 (0.29, 1.13) 100.00
Naspro (2006) 0.95 (0.13, 7.09) 13.75
Subtotal (Isquared = 0.0%, p = 0.398) 0.53 (0.11, 2.59) 30.93
.
.107 1 9.35 Overall (Isquared = 0.0%, p = 0.741) 0.44 (0.17, 1.12) 100.00
Favors TUEP Favors OP
d Study %
.00868 1
Favors TUEP Favors OP
115
Subtotal (Isquared = 0.0%, p = 0.983) 0.33 (0.05, 2.12) 56.87 Chen (2014) 3.00 (0.31, 29.46) 16.49
Geavlete (2015) 2.00 (0.18, 22.50) 16.60
.
Ou (2013) 2.87 (0.11, 72.38) 8.45
HoLEP
Rao (2013) 0.31 (0.03, 3.10) 50.14
Kuntz (2002) 1.00 (0.19, 5.15) 36.71
Subtotal (Isquared = 0.0%, p = 0.503) 1.34 (0.44, 4.07) 91.68
Naspro (2006) 2.86 (0.11, 72.19) 6.42
.
Subtotal (Isquared = 0.0%, p = 0.569) 1.28 (0.31, 5.33) 43.13 HoLEP
. Kuntz (2002) 3.00 (0.12, 75.11) 8.32
Overall (Isquared = 0.0%, p = 0.675) 0.74 (0.25, 2.17) 100.00 Subtotal (Isquared = .%, p = .) 3.00 (0.12, 75.11) 8.32
.
Overall (Isquared = 0.0%, p = 0.637) 1.47 (0.52, 4.19) 100.00
.0127 1 78.9
Favors TUEP Favors OP
.0133 1 75.1
Favors TUEP Favors OP
Fig.3Forest plot and meta-analysis of complications between TUEP Incidence of pneumonia and infarction. f Transient incontinence. g
and OP. a Blood transfusion. b Recatheterization. c Urinary tract Bladder neck contracture. h Urethral stricture
infection (UTI). d Reintervention for clots and bleeding control. e
resected prostate weight in TUEP was less than that in OP. Length of catheterization, irrigation and hospital stay
This result might be explained by the fact that some of the was markedly shorter in the TUEP group. Reduced length
tissue retrieved by TUEP is vaporized in the enucleation of catheterization, irrigation and hospital stay may reduce
procedure [36]. the costs of postoperative care. However, the economic
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0 Funnel plot with pseudo 95% confidence limits We should admit that there are certain intrinsic limita-
tions that cannot be ignored when analyzing our data.
Though we regarded TUEP as a modality of ablation of
prostatic tissue and innovatively included both PKEP and
2
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Advisory Board; LISA Laser OHG AG Honoraria, Financial support trial with long-term results at 6 years. Eur Urol 66(2):284291.
for attending Symposia, financial support for educational programs; doi:10.1016/j.eururo.2014.01.010
Ipsen Pharma Honoraria, Financial support for attending Symposia, 12. Iacono F, Prezioso D, Di Lauro G, Romeo G, Ruffo A, Illiano
Advisory Board. All other authors declare that they have no conflict E, Amato B (2012) Efficacy and safety profile of a novel
of interest. technique, ThuLEP (Thulium laser enucleation of the pros-
tate) for the treatment of benign prostate hypertrophy. Our
Ethical standard As the present study is a meta-analysis and struc- experience on 148 patients. BMC Surg 12(Suppl 1):S21.
tured review, this manuscript is in line with the Declaration of Helsinki. doi:10.1186/1471-2482-12-S1-S21
13. Wang L, Liu B, Yang Q, Wu Z, Yang B, Xu Z, Cai C, Xiao L,
Chen W, Sun Y (2012) Preperitoneal single-port transvesical
enucleation of the prostate (STEP) for large-volume BPH: one-
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