A meta-analysis comparing treatment of benign prostatic hyperplasia with holmium laser enucleation and photoselective greenlight vaporization

Abstract

Background: We compared the safety and efficacy of treating benign prostatic hyperplasia with photoselective greenlight vaporization (PVP) versus holmium laser enucleation of the prostate (HoLEP).

Methods: Databases (PubMed, Embase, Cochrane Library, Chinese CBM, and CNKI) were searched for eligible studies evaluating HoLEP or PVP outcomes, published until May 2022. We analyzed the incidence of relative complications and postoperative outcomes, including the international prostate symptom score, maximum flow rate (Qmax), postvoid residual urine volume, quality of life index, and prostate-specific antigen levels.

Results: Eleven studies involving 4763 patients were included in this meta-analysis. The significant differences in postoperative Qmax at 1 month (mean difference [MD], 3.31, 95% confidence interval [CI], 0.45-6.16, p = 0.02, I², 92%), 3 months (MD, 2.78, 95% CI, 0.53-5.02, p = 0.02, I², 89%), 6 months (MD, 2.13, 95% CI, 1.11-3.15, p < 0.0001, I², 87%), and 12 months (MD, 3.98, 95% CI, 2.06-5.89, p < 0.0001, I², 58%) further confirmed unique advantage of HoLEP over PVP. We used forest plots to determine significant differences in the severe complication rates among patients in the PVP and HoLEP groups (odds ratio, 0.05, 95% CI, 0.01 to 0.28, p = 0.0005).

Conclusions: Holmium laser enucleation of the prostate and PVP showed comparable international prostate symptom scores, quality of life index, postvoid residual urine volumes, prostate-specific antigen levels, perioperative factors, and total complication rates. Compared with PVP, HoLEP had a greater Qmax 1 year postoperatively, decreased energy expenditure, and fewer high-grade complications. These results need to be verified in long-term follow-up studies with well-structured randomized controlled trials.

Keywords

Benign prostatic hyperplasia / Holmium laser enucleation / Meta-analysis / Photoselective greenlight vaporization / Reintervention

Acknowledgments

None.

Statement of ethics

The study followed the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guideline and the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023433139).

Conflict of interest statement

The authors have completed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting checklist. No conflict of interest has been declared by the author.

Funding source

None.

Author contributions

LZ, WZ: Conception and design;

LZ: Administrative support;

ZT, MQ: Provision of study materials or patients, collection and assembly of data;

ZW, ZT: Data analysis and interpretation;

All authors: Manuscript writing and final approval of manuscript.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

References

[1] Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: Benign prostatic hyperplasia. J Urol 2008;179:S75-S80.

[2] Cornu JN. Bipolar, monopolar, photovaporization of the prostate, or holmium laser enucleation of the prostate: How to choose what’s best? Urol Clin North Am 2016;43:377-384.

[3] Fwu CW, Eggers PW, Kaplan SA, et al. Long-term effects of doxazosin, finasteride and combination therapy on quality of life in men with benign prostatic hyperplasia. J Urol 2013;190:187-193.

[4] DerSarkissian M, Xiao YL, Duh MS, et al. Comparing clinical and economic outcomes associated with early initiation of combination therapy of an alpha blocker and dutasteride or finasteride in men with benign prostatic hyperplasia in the United States. J Manag Care Spec Pharm 2016;22:1204-1214.

[5] Foster HE, Barry MJ, Dahm P, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. J Urol 2018;200:612-619.

[6] Reich O, Gratzke C, Stief CG. Techniques and long-term results of surgical procedures for BPH. Eur Urol 2006;49:970-978.

[7] Rassweiler J, Teber D, Kuntz R, et al. Complications of transurethral resection of the prostate (TURP)—Incidence, management, and prevention. Eur Urol 2006;50:969-980.

[8] Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: A prospective multicenter evaluation of 10,654 patients. J Urol 2008;180:246-249.

[9] Cornu J-N, Ahyai S, Bachmann A, et al. A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: An update. Eur Urol 2015;67:1066-1096.

[10] Brassetti A, De Nunzio C, Delongchamps NB, et al. Green light vaporization of the prostate: Is it an adult technique? Minerva Urol Nefrol 2017;69:109-118.

[11] Woo HH. Photoselective vaporization of the prostate using the 120-W lithium triborate laser in enlarged prostates (>120 cc). BJU Int 2011;108:860-863.

[12] Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 2009;151:264-269.

[13] Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187-196.

[14] Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.

[15] Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603-605.

[16] DerSimonian R, Kacker R. Random-effects model for meta-analysis of clinical trials: An update. Contemp Clin Trials 2007;28:105-114.

[17] Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-560.

[18] Sun IY, Yoo SJ, Park J, et al. Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes. Sci Rep 2019;9:8261.

[19] Elkoushy MA, Elshal AM, Elhilali MM. Postoperative lower urinary tract storage symptoms: Does prostate enucleation differ from prostate vaporization for treatment of symptomatic benign prostatic hyperplasia? J Endourol 2015;29:1159-1165.

[20] Cho MC, Ha SB, Oh SJ, et al. Change in storage symptoms following laser prostatectomy: Comparison between photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). World J Urol 2015;33:1173-1180.

[21] Cho MC, Song WH, Park J, et al. Long-term outcomes of laser prostatectomy for storage symptoms: Comparison of serial 5-year followup data between high performance system photoselective vaporization and holmium laser enucleation of the prostate. J Urol 2018;199:1591-1599.

[22] Jaeger CD, Mitchell CR, Mynderse LA, et al. Holmium laser enucleation (HoLEP) and photoselective vaporisation of the prostate (PVP) for patients with benign prostatic hyperplasia (BPH) and chronic urinary retention. BJU Int 2015;115:295-299.

[23] Kim KS, Choi JB, Bae WJ, et al. Comparison of photoselective vaporization versus holmium laser enucleation for treatment of benign prostate hyperplasia in a small prostate volume. PloS One 2016;11:e0156133.

[24] Cho MC, Park J, Kim JK, et al. Can preoperative detrusor underactivity influence surgical outcomes of 120 W HPS vaporization of the prostate (PVP) or holmium laser enucleation of the prostate (HoLEP)? A serial 3-year follow-up study. Neurourol Urodyn 2018;37:407-416.

[25] Elmansy H, Baazeem A, Kotb A, et al. Holmium laser enucleation versus photoselective vaporization for prostatic adenoma greater than 60 mL: Preliminary results of a prospective, randomized clinical trial. J Urol 2012;188:216-221.

[26] Lu TZ, Li XX, Zhu J, et al. Evaluation of the effectiveness and patient satisfaction of HoLEP and PVP in the treatment of prostate hyperplasia of different volumes. Int J Urol Nephrol 2021;41:584-588.

[27] Zhu J, Li XX, Xie LZ. Comparative analysis of transurethral green laser photoselective vaporization vs. holmium laser enucleation of the prostate in the treatment of benign prostatic hyperplasia. J Minim Invasive Urol 2018;7:342-345.

[28] Mi L, Chang F, Sun Y, et al. Effects of green laser vaporization resection and holmium laser enucleation in the treatment of benign prostatic hyperplasia on blood routine and urethral function. J Hunan Normal Univ (Med Sci) 2022;19:170-173.

[29] Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol 2010;58:384-397.

[30] Peng L, Zheng XN, Wu JP, et al. Holmium laser technologies versus photoselective greenlight vaporization for patients with benign prostatichyperplasia: A meta-analysis. Lasers Med Sci 2020;35:1441-1450.

[31] Socarrás MR, del Álamo JF, Espósito F, et al. En bloc enucleation with early apical release technique using MOSES (en bloc MoLEP) vs. classic en bloc HoLEP: A single arm study comparing intra- and postoperative outcomes. World J Urol 2023;41:159-165.

[32] Elmansy HM, Elzayat E, Elhilali MM. Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: Long-term results of a randomized trial. J Urol 2010;184:2023-2028.

[33] Son H, Song SH, Paick JS. Current laser treatments for benign prostatic hyperplasia. Korean J Urol 2010;51:737-744.

[34] Aladesuru O, Punyala A, Stoddard M, et al. Review of the economics of surgical treatment options for benign prostatic hyperplasia. Curr Urol Rep 2022;23:11-18.

[35] Elmansy HM, Kotb A, Elhilali MM. Holmium laser enucleation of the prostate: Long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol 2011;186:1972-1976.

[36] Fonseca RC, Gomes CM, Meireles EB, et al. Prostate specific antigen levels following transurethral resection of the prostate. Int Braz J Urol 2008;34:41-48.

[37] Herrmann TRW. Enucleation is enucleation is enucleation is enucleation. World J Urol 2016;34:1353-1355.

[38] Stamey TA, Yang N, Hay AR, et al. Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med 1987;317:909-916.

[39] Horasanli K, Silay MS, Altay B, et al. Photoselective potassium titanyl phosphate (KTP) laser vaporization versus transurethral resection of the prostate for prostates larger than 70 mL: A short-term prospective randomized trial. Urology 2008;71:247-251.

[40] Vincent MW, Gilling PJ. HoLEP has come of age. World J Urol 2015;33:487-493.

[41] Capogrosso P, Fallara G, Pozzi E, et al. Rates and predictors of postoperative complications after holmium laser enucleation of the prostate (HoLEP) at a high-volume center. Minerva Urol Nephrol 2022;74:461-466.

[42] Li Z, Chen P, Wang J, et al. The impact of surgical treatments for lower urinary tract symptoms/benign prostatic hyperplasia on male erectile function: A systematic review and network meta-analysis. Medicine (Baltimore) 2016;95:e3862.