Comment on : “Network Meta-Analysis of the Treatment Safety and Efficacy of Different Lasers in Prostate Enucleation” by Y. Ma et al.

Dear Editor:

We read with great interest the current article published by Ma et al in the Journal of Endourology. ¹ They conducted a network meta-analysis to compare different laser systems for the enucleation of benign prostate hyperplasia (BPH). The authors conclude that thulium laser may be the recommended laser system since it can bring less complication risk with comparable efficacy. This finding will guide clinicians in clinical decision making for evidence-based treatment of BPH. We are indebted to the authors for their great work. However, we would like to make some comments on this topic.

Although the meta-analysis provides better evidence for further clinical application, some issues regarding the details of the inclusion process are worth considering. According to the inclusion criteria of the study proposed by the authors, there were no restrictions on prostate size. The baseline characteristics of the prostate volume were not relatively equal in the included studies (the mean prostate volume >80 in four studies), but no analysis was performed to explore the possible consequences of this difference.

Recently, Sun et al conducted a paired meta-analysis to evaluate the efficacy and safety of different endoscopic enucleation in the treatment of BPH with large volume (≥80 mL). They reported that the holmium laser could improve maximum urine flow rate (Qmax) compared with thulium laser (weighted mean difference [MD], 2.73; 95% confidence interval [CI] [1.06–4.40]; p = 0.001). There is no statistical significance in postoperative complications between holmium laser and thulium laser. The thulium laser had less operative time (MD, 7.19; 95% CI, [4.61–9.77]; p < 0.00001). ² Therefore, the analysis of perioperative outcomes may be biased.

In addition, the quality of life (QoL) is an important indicator of surgical quality. ³ Furthermore, most of included studies have reported the postoperative QoL. We believe that the outcomes about QoL should be included in the analysis. Adding some outcomes to the literature can help many readers better understand this article.

There was another potential concern about the systematic review. This meta-analysis should be conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ⁴ The PRISMA statement requires that publication bias should be evaluated. Although some studies reported that publication bias cannot be carried out in 10 or fewer studies, ⁵ the authors should explain in their study. The authors performed a commendable analysis on available evidence; however, we believe that solving the mentioned problems will make the authors' findings clearer.