Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis

Objective: To compare and evaluate the safety and efficacy of holmium laser enucleation of the prostate (HoLEP) and simple prostatectomy for large prostate burdens, as discussion and debate continue about the optimal surgical intervention for this common pathology.

Materials and methods: A systematic search was conducted for studies comparing HoLEP with simple prostatectomy [open (OP), robot-assisted, laparoscopic] using a sensitive strategy and in accordance with Cochrane collaboration guidelines. Primary parameters of interest were objective measurements including maximum urinary flow rate (Qmax) and post-void residual urine volume (PVR), and subjective outcomes including International Prostate Symptom Score (IPSS) and quality of life (QoL). Secondary outcomes of interest included volume of tissue retrieved, catheterisation time, hospital stay, blood loss and serum sodium decrease. Data on baseline characteristics and complications were also collected. Where possible, comparable data were combined and meta-analysis was conducted.

Results: In all, 310 articles were identified and after screening abstracts (114) and full manuscripts (14), three randomised studies (263 patients) were included, which met our pre-defined inclusion criteria. All these compared HoLEP with OP. The mean transrectal ultrasonography (TRUS) volume was 113.9 mL in the HoLEP group and 119.4 mL in the OP group. There was no statistically significant difference in Qmax, PVR, IPSS and QoL at 12 and 24 months between the two interventions. OP was associated with a significantly shorter operative time (P = 0.01) and greater tissue retrieved (P < 0.001). However, with HoLEP there was significantly less blood loss (P < 0.001), patients had a shorter hospital stay (P = 0.03), and were catheterised for significantly fewer hours (P = 0.01). There were no significant differences in the total number of complications recorded amongst HoLEP and OP (P = 0.80).

Conclusion: The results of the meta-analysis have shown that HoLEP and OP possess similar overall efficacy profiles for both objective and subjective disease status outcome measures. This review shows these improvements persist to at least the 24 month follow-up point. Further randomised studies are warranted to fully determine the optimal surgical intervention for large prostate burdens.