Transurethral enucleation is superior to resection for the management of LUTS secondary to BPH
Reviewed by Mithun Kailavasan

This meta-analysis (Level 1b evidence) examined the efficacy and safety of two primary transurethral therapies used in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), enucleation (HoLEP – holmium laser enucleation of prostate, ThuLEP, and PKEP) and resection of prostate (TURP). Inclusion criteria included patients with lower urinary tract symptoms caused by BPH, with International Prostate Symptom Score (IPSS) ≥8, Qmax ≤15mls/s. Twenty-six randomised controlled trials (RCTs) were included, but due to the different surgical techniques used, seven types of comparable studies were assessed, with their main comparator HoLEP vs. TURP (650/646, n=12). In summary, enucleation was associated with significantly lower IPSS scores (-1.32, -0.35), and higher Qmax (0.26, 1.40mls/s) at 12 months (although of minimal effect size), however no differences in quality of life (n=11) or IIEF-5 (n=7) scores were noted. Safety outcomes demonstrated higher mean operative times (5.51, 16.78 minutes), shorter length of stay (-28.87, -15.36 hours), lower haemoglobin and serum sodium loss in the enucleation subgroup. For early complications, better results were seen for enucleation subgroup with lower rates of urinary retention (p=0.03) and need for blood transfusion (p<0.001). For late complications, urethral stricture (p=0.009) occurred less often in the enucleation subgroup. No significant differences were noted in other complication rates such as urge / stress incontinence, dysuria, haematuria, and bladder neck contracture. The study highlights the need for a core outcome set for bladder outlet obstruction (BOO), especially with the emergence of novel minimally invasive treatments, in order for fair and standardised assessments to be made in the future. One of the notable limitations included the lack of long-term follow up with most studies reporting 12-month data. Despite this, enucleation has shown to have a favourable profile for efficacy and safety compared with resection.

Efficacy and safety of enucleation vs. resection of prostate for treatment of benign prostatic hyperplasia : a meta-analysis of randomized controlled trials.
Zhang Y, Yuan P, Ma D, et al.
PROSTATE CANCER AND PROSTATIC DISEASES
2019;22:493-508.