Authors' objectives:

The objective of this review was to assess the safety and efficacy of holmium laser prostatectomy, both holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), in comparison with transurethral resection of the prostate (TURP) - the current standard treatment for benign prostatic hyperplasia (BPH).

Authors' results and conclusions: Studies that compared the use of HoLRP or HoLEP with TURP in the treatment of BPH were limited in number. Three randomised controlled trials comparing HoLRP and TURP and two comparing HoLEP and TURP were identified. There was also one uncontrolled comparative study comparing each of the holmium techniques with TURP. The remainder of the evidence was in the form of case series (Level IV evidence). There were 13 HoLRP case series and 10 HoLEP case series. The available evidence-base was relatively weak with only one of the five RCTs considered to be of good quality. The other RCTs identified were hampered by poor reporting of methodological details particularly methods of randomisation, allocation concealment and blinding. In general the evidence-base was weakened by significant losses to follow-up and short follow-up periods. In terms of the primary safety issue from a clinical perspective blood loss both of the holmium laser procedures (HoLRP and HoLEP) were found to be superior to TURP in terms of a number of key indicators (transfusion rates, postoperative bladder irrigation, and duration of catheterisation and length of hospital stay), although blood loss itself was not often reported due to measurement difficulties. There did not appear to be a difference between the holmium laser procedures and TURP for rates of stricture or urinary tract infection. However, for other safety outcomes, such as mortality and rates of perforation, it was difficult to make any firm conclusions due to a lack of high quality data. In terms of efficacy, the holmium laser procedures appear to be equivalent to TURP for symptom relief. TURP was found to be superior to the holmium laser procedures in terms of operative times and retrieved more tissue than HoLRP. The addition of the mechanical morcellator in the HoLEP technique appeared to result in more tissue being retreived than in TURP. Both the holmium laser techniques and TURP were found to retrieve adequate tissue for postoperative histology to detect undiagnosed prostate cancer. The lack of long-term follow-up in the majority of holmium laser studies meant that no conclusion could be drawn about the long-term durability of the procedures in comparison to TURP. Cost-effectiveness was addressed in one RCT comparing HoLRP and TURP, which suggested that HoLRP may be more cost-effective than TURP. However, longer term follow-up and studies in other settings would be required to determine whether this finding can be generalised.

Authors' recommendations: Evidence rating: On balance, the evidence-base was rated as average. However, for some outcomes the evidence base was poor and as a result no conclusive findings could be determined for these outcomes. Safety: The holmium laser procedures are considered at least as safe as TURP in terms of blood loss, rates of stricture and urinary tract infection. In terms of other safety indicators, such as mortality, rates of perforation, and other complications, the relative safety of the holmium laser procedures could not be determined. Efficacy: The holmium laser procedures appear to be at least as efficacious as TURP in the short term but long-term efficacy could not be determined. Recommendations: Additional high-quality randomised controlled trials would strengthen the evidence base for the holmium laser procedures. However, at this stage, the priority for research should probably focus on providing long-term follow-up and addressing problems with losses to follow-up which threatened the validity of many of the included studies. Centres considering introducing the holmium laser procedures should ensure that surgeons have adequate experience in transurethral resection techniques and preferably previous experience in laparoscopic and laser surgery. An appropriate program of supervised training could best be developed by the Urological Society of Australasia.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.surgeons.org/asernip-s/

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Australia

Organisation Name: Australian Safety and Efficacy Register of New Interventional Procedures-Surgical

Contact Address: ASERNIP-S 24 King William Street, Kent Town SA 5067 Australia Tel: +61 8 8219 0900

Contact Name: racs.asernip@surgeons.org

Contact Email: racs.asernip@surgeons.org

Copyright: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical