Reoperation Rate for Residual/Regrowth Adenoma Following Transurethral Interventions for Benign Prostatic Enlargement: Results from a Systematic Review and Meta-Analysis of Comparative Randomized Studies

Abstract

Objective:

To perform a systematic review to assess the incidence of reoperation rate for residual/regrowth adenoma after transurethral surgeries for benign prostatic enlargement.

Materials and Methods:

A systematic literature search was performed on November 12, 2023, using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of reoperation was assessed using the Cochran-Mantel-Haenszel Method and reported as risk ratio (RR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05.

Evidence synthesis:

Forty-eight studies were included. Six studies compared enucleation vs TURP, 41 ablation vs TURP, and 1 study enucleation vs ablation vs TURP, encompassing 457 patients in enucleation, 2259 in ablation, and 2517 in the TURP group. The pooled incidence of reoperation was 6.2%, 0.7%, 2.3%, and 4.3% after ablation, enucleation, M-TURP, and B-TURP, respectively. Meta-analysis showed that the incidence of reoperation was significantly lower in the enucleation group (RR 0.28, 95% CI 0.10–0.81, p = 0.02), but the difference accounted only in studies with follow-up between 1 and 3 years (RR 0.18, 95% CI 0.04–0.85, p = 0.03). The incidence of reoperation was significantly lower in the enucleation compared with the B-TURP group (RR 0.14, 95% CI 0.03–0.77, p = 0.02). Meta-analysis showed that the incidence of reoperation was significantly higher in the ablation group (RR 1.81, 95% CI 1.33–2.47, p = 0.0002), but there was no difference in studies with follow-up up to 1 year (odds ratio 1.78 95% CI 0.97–3.29, p = 0.06) longer than 5 years (RR 2.02, 95% CI 0.71–5.79, p = 0.19). The incidence of reoperation was significantly higher in the ablation compared with the M-TURP group (RR 1.91, 95% CI 1.44–2.54, p < 0.0001).

Conclusions:

In mid-term follow-up, reoperation rate for residual/regrowth adenoma was significantly lower after enucleation, although was significantly higher after ablation compared with TURP.

Introduction

Benign prostatic enlargement (BPE) is the leading cause of lower urinary tract symptoms (LUTS) in middle-aged and elderly men. Surgery is advised when pharmaceutical treatments prove ineffective or complications related to bladder outlet obstruction arise.¹ Since its introduction in the late 1930s, monopolar transurethral resection of the prostate (M-TURP) has remained for many decades the primary surgical choice for patients with a prostate volume ranging between 30 and 80 mL.² Over the past 30 years, new transurethral enucleation and ablation techniques showed equal or even superior effectiveness, coupled with reduced morbidity, even in cases of large prostate volume.^3,4

Patient satisfaction after BPE surgery not only relies upon improvement of symptoms, micturition parameters, and quality of life in the early postoperative period but also on the long-term durability of the same. As life expectancy among patients increases, this arises a greater likelihood of requiring reoperation for recurrent LUTS owing to regrowth adenoma after initial BPE surgery. Yet, a recent analysis of patients' perspectives on attributes, although choosing minimally invasive BPE surgery, demonstrated that 97% of respondents considered the ability to avoid further treatments as either “very important” or “extremely important” when selecting a procedure.⁵ This scenario frequently poses challenges to the long-term outcomes of any BPE intervention, underwhelming the outcomes of the original surgery. The need for reoperation not only has social but also financial effects.

This review aims to systematically assess the incidence of surgical retreatment for residual/regrowth adenoma after BPE transurethral treatment in studies comparing TURP vs ablation vs enucleation procedures.

Evidence Acquisition

Aim of the review

The main outcome of this study was to assess differences in the incidence of surgical retreatment among different transurethral procedures, namely ablation, enucleation, and TURP. The secondary outcome was to assess the difference in retreatment rate according to the study follow-up period and the use of monopolar vs bipolar (B) electrocautery in resection.

Literature search

This study adhered to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. A comprehensive literature search was performed on November 12, 2023, using Cochrane Central Register of Controlled Trials, PUBMED, and Scopus. Medical Subject Heading terms and keywords were used as follows: (prostatic hyperplasia OR BPH OR benign prostatic enlargement OR benign prostatic obstruction) AND (Prostate resection OR Prostate enucleation OR Prostate vaporization OR ablation OR monopolar transurethral OR bipolar transurethral OR MTURP OR BTURP OR plasmakinetic OR PKRP OR PKEP OR PKERP OR TURis OR photovaporization or PVP OR PVEP OR holmium OR HoLEP OR thulium OR ThuLEP OR ThuVEP OR ThuFLEP diode OR DiLEP OR BTUEP OR MTUEP OR TUNA OR Aquablation OR Rezum OR Water vapor thermal therapy). There was no date restriction. Animal and pediatric studies were excluded. This review was registered in PROSPERO (Receipt No. 482741).

Selection criteria

The Patient Intervention Comparison Outcome Study (PICOS) type model was used to frame and answer the clinical question. Population: Men who underwent a surgical procedure for BPE; intervention: Transurethral procedures; comparison: M-TURP/B-TURP; outcome: Incidence reoperation for residual/regrowth adenoma after initial surgery; and study type: Prospective randomized studies. Transurethral procedures were categorized into two groups based on the technique used (enucleation and ablation), without regard to the energy applied. The enucleation group included the use of any laser and bipolar and monopolar electrocautery. The ablation group included bipolar/monopolar vaporization and any laser vaporization technique. The transurethral resection group consisted of M and B resection procedures. The incidence of reoperation was categorized according to the time between the reoperation and original surgical procedure in early (up to 1 year), medium (1–5 years), and long-term (>5 years) outcomes.

Study screening and selection

Two separate authors screened all gathered records through Covidence Systematic Review Management^®. A third senior author solved discrepancies. Studies were included based on PICOS eligibility criteria. Only prospective randomized studies were accepted. Studies with no data on reoperation rate or with no patient in each group who required reoperation were excluded. Reviews, meeting abstracts, letters to the editor, case reports, editorials, and retrospective and prospective nonrandomized studies were also excluded. The full text of the screened articles was selected if deemed relevant to the aim of this study.

Statistical analysis

Incidence of reoperation was assessed using the Cochran-Mantel-Haenszel method with the random-effect model and reported as risk ratio (RR), 95% confidence interval (CI), and p-values. Analyses were two tailed and the significance was set at p < 0.05 and a 95% CI. RR <1 indicates that the intervention decreases the risk of reoperation. A subanalysis was conducted to investigate potential differences in the incidence of reoperation after monopolar and bipolar TURP procedures. Another subanalysis was performed to evaluate how the duration of study follow-up impacted the incidence of reoperation. Study heterogeneity was assessed utilizing the I ² value. Substantial heterogeneity was defined as an I ² value >50%. Meta-analysis was conducted using Review Manager (RevMan) 5.4 software by Cochrane Collaboration. Pooled analysis was performed using OpenMeta[Analyst] software (www.cebm.brown.edu/openmeta/#). The quality assessment of included studies was performed using the Cochrane Risk of Bias tool (i.e., RoB 2).

Evidence Synthesis

The initial literature search yielded 11,648 articles. Upon removing 933 duplicated studies, 10,715 studies remained for screening. Another 10,465 articles were further excluded after the title and abstract screening owing to their lack of relevance to the study's purpose. The full texts of the remaining 250 studies were assessed and 202 articles were further excluded. Finally, 48 studies were accepted and included in the review. Six studies compared Enucleation vs TURP (Table 1). Forty-one studies compared ablation vs TURP (Table 2). One study compared enucleation vs ablation vs TURP (Tables 1 and 2). The complete list of studies included is available in Supplementary Appendix S1. Figure 1 shows the 2020 PRISMA flow diagram.

FIG. 1.

PRISMA flow diagram of the study. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1.

Characteristics of Included Studies Comparing Transurethral Resection of the Prostate vs Enucleation

Author (year of publication)	Interventions	Inclusion criteria	Exclusion criteria	Randomized patients	Mean age (±SD) or median (interquartile range)	Mean PV (±SD) or median (interquartile range), mL	Length of follow-up, months
Ahyai (2007)	HoLEP vs M-TURP	IPSS of ≥12, Qmax of ≤12 mL/s, PVR ≥50 mL, Schafer grade of 2 or more in pressure flow studies, and a total PV <100 mL at TRUS.	Previous prostate or urethral surgery and voiding disorders not related to BPH. Also, prostate carcinoma was excluded by biopsy.	200 patients 100 HoLEP 100 M-TURP	68.0 (56–88) HoLEP 68.7 (52–86) M-TURP	53.5 (20–95) HoLEP 49.9 (20–99) M-TURP	36
Elshal (2020)	B-TURP vs GLPVP vs HoLEP	Patients with refractory LUTS secondary to benign prostatic obstruction or patients with AUR secondary to BPO, who failed medical treatment. TRUS-estimated prostate volumes of 80–150 mL	Neurological disorder, bleeding tendency, ongoing anticoagulants, or antiplatelet medications. Patients with history of previous prostate surgery and patients diagnosed with PCa	182 patients 60 GLPVP 60 HoLEP 62 B-TURP	64.5 (±6) GL-PVEP 66.2 (±7) HoLEP 66.1 (±7) B-TURP	103 (±25) GLPVP 107 (±21) HoLEP 106 (±23) B-TURP	36
Gilling (2012)	HoLEP vs M-TURP	TRUS volume of 40–200 mL, Qmax ≤15 mL/s or less, AUA symptom score ≥8, PVR <400 mL, and Schafer grade ≥2	Patients who had undergone previous prostatic or urethral surgery, who had carcinoma of the prostate, or who were in urinary retention	31 patients 14 HoLEP 17 M-TURP	71.70 (±1.10) HoLEP 70.30 (±1.00) M-TURP	77.68 (±32.13) HoLEP 70.00 (±27.78) M-TURP	12
Gu (2018)	HoLEP vs B-TURP	PSS ≥9, Qmax ≤15 mL/s, QoL ≥3, or urine PVR ≥50 mL	Severe pulmonary disease, heart disease, bladder calculus, neurogenic bladder dysfunction, bladder cancer, previous prostate surgery, prostate cancer, urethral stricture, or coagulopathy. Or treatment with antiplatelets or anticoagulants during the procedure.	241 patients 122 HoLEP 119 B-TURP	Not reported	56.70 (±28.41) HoLEP 60.31 (±22.41) B-TURP	72
Świniarski (2012)	ThuLEP vs M-TURP	IPPS >7, Qmax <5 mL/s, and the clinically confirmed BPH	Previous surgical treatment for BPH, prostate cancer, and LUTS resulting from conditions other than BPH	54 ThuLEP 52 M-TURP	68.3 (±6.8) ThuLEP 69.3 (±7.2) M-TURP	62.03 ± 23.7 ThuLEP 66.5 (±22) M-TURP	3
Zhao (2010)	Plasmakinetic enucleation vs TURP	Age >45 years, Qmax <15 mL/s, IPSS >12, medication failure, prostate volume on TRUS >20 mL, urodynamically proven obstruction.	Neurovesical dysfunction, a diagnosis of prostate carcinoma, and a previous history of prostatic or urethral surgery	204 patients 102 ThuLEP 102 M-TURP	67.3 (±6.6) BEP 67.8 (±6.4) M-TURP	69.2 (±13.5) BEP 67.5 (±11.8) M-TURP	36
Zhu (2013)	BEP vs B-TURP	Urodynamically proven obstruction, Qmax <10 mL per second, IPSS >19, age 50–70 years, PV 70–200 mL on TRUS, PSA <4 ng/mL and failure of medical therapy (adrenoreceptor blocker and 5-reductase inhibitor for at least 6 months)	Neurogenic bladder, urethral stricture, bladder tumor, prostate cancer, or previous prostate, bladder neck, or urethral surgery, PSA >4 ng/mL or greater, or prostate biopsy within 3 months	80 patients 40 BEP 40 B-TURP	64.1 (±4.8) BEP 64.8 (±3.9) B-TURP:	113.8 (±32.0) BEP 109.4 (±32.4) B-TURP	60

AUR = acute urinary retention; BEP = bipolar enucleation of the prostate; BPH = benign prostatic hyperplasia; GLL-PVP = green light laser photovaporization; HoLEP = holmium laser enucleation of the prostate; IPSS = international prostate symptoms score; LUTS = lower urinary tract symptoms; NA = not available; PCa = prostate cancer; PSA = prostate-specific antigen; PV = prostate volume; PVR = postvoiding residual; Qmax = maximum flow rate; QoL = quality of life; SD = standard deviation; ThuLEP = thulium laser enucleation of the prostate.

Table 2.

Characteristics of Included Studies Comparing Transurethral Resection of the Prostate vs Ablation

Author (year of publication)	Interventions	Inclusion criteria	Exclusion criteria	Randomized patients, ablation vs TURP	Mean age (±SD) or median (interquartile range)	Mean PV (±SD) or median (interquartile range), mL	Length of follow-up
Al-Ansari (2010)	TURP vs 120 W GLL-PVP	Patients with moderate/severe LUTS (IPSS >16), failure of previous medical treatment with a washout period of at least 2 weeks, Qmax <15 mL/s, PVR <100 mL, PV <100 mL on TRUS, and ability to give fully informed consent	Patients on permanent anticoagulants, urethral strictures, bladder stone, neurogenic bladder, or PCa.	120 patients 60 TURP 60 GLL-PVP	67.1 (±8) M-TURP 66.3 (±9.4) GLL-PVP	60.3 (±20) M-TURP 61.8 (±22) GLL-PVP	36 months
Bouchier-Hayes (2010)	TURP vs 80 W GLL-PVP	Age >50 years with LUTS; Qmax <15 mL/s; IPSS >11; PV on TRUS 15–85 mL; Obstructed on urodynamics; able to fill questionnaires; Able to give fully informed consent	Patients with neurogenic bladder; PCa; chronic retention; on α-blockers; or permanent anticoagulation	119 patients 59 M-TURP 60 GLL-PVP	66.36 (55–80) M-TURP 65.06 (51–81) GLL-PVP	33.36 (15.3–67.54) M-TURP 38.78 (15.02–82.6) GLL-PVP	12 months
Capitán (2011)	120 W GLL-PVP vs TURP	IPSS >15 after failed medical therapy, PV <80 cm³ on TRUS, Qmax <15 mL/s, and patient understanding and signed written informed consent.	Patients with detrusor overactivity or hypocontractility on urodynamic study; urethral stricture; PCa; previous prostate, bladder neck, or urethral surgery	100 patients 50 GLL-PVP 50 M-TURP	69.8 (±8.44) GLL-PVP 67.7 (±6.7) M-TURP	51.29 (±14.72) GLL-PVP 53.10 (±13.75) M-TURP	24 months
Carter (1999)	Hybrid KTP/Nd:YAG laser vs M-TURP	Symptomatic BPH who matched the inclusion criteria of BLUES protocol.	Patients with PCa, history of urinary retention, PV on TRUS ⪰100 mL, or suspected neurogenic bladder dysfunction	204 patients 101 Hybrid KTP/Nd:YAG laser 103 M-TURP	67.9 (±7.8) Hybrid KTP/Nd:YAG laser 67 (±7.5) M-TURP	41.6 (±17.3) Hybrid KTP/Nd:YAG lser 41.7 (±19.4) M-TURP	12 months
Cetinkaya (2015)	980 nm diode laser PVP vs M-TURP	BPH refractory to medical treatment, recurrent urinary retention, prostate volume <80 mL, Qmax ≤15 mL/s (under medical treatment), IPSS ≥15, or IPSS-QoL ≥3.	Patients with prostate or bladder cancer, neurogenic bladder dysfunction, bladder stones, urethral structures, or previous bladder, urethral, or prostate surgery were excluded	72 patients 36 PVP 36 TURP	63.1 (±9.1) PVP 64.7 (±10.2) TURP	50.6 (±16) PVP 54.8 (±22.7) TURP	13 months
Cimentepe (2003)	TUNA vs M-TURP	LUTS owing to BPH, age >40 years, Qmax <15 mL/sec, IPSS >13, prostate weight 20–70 g No suspicion of prostate malignancy	Urethral stricture, bladder neck contracture, previous prostate surgery, bladder stones or tumors, neurogenic bladder, prominent median lobe	59 patients 26 TUNA 33 TURP	60.1 ± 7.3 TUNA 63.3 (±5.9) TURP	67.4 (±29.4) TUNA 76.1 (±50.1) TURP	18 months
Elsakka (2016)	B-TUVP vs M-TURP	Patients with LUTS secondary to bladder outlet obstruction with an IPSS ≥8, Qmax <15 m/s, not responding to medical treatment, and/or BPH complications such as refractory retention or recurrent hematuria, and prostate size <80 mL	Patients unfit for surgery and those suspected of prostatic carcinoma	82 patients 40 B-TUVP 42 M-TURP	56.9 (±1.2) B-TUVP 55.6 (±3.1) M-TURP	50.9 (±5.3) B-TUVP 53.8 (±8.1) M-TURP	6 months
Elshal (2020)	B-TURP vs GL-PVP vs HoLEP	Patients with refractory LUTS secondary to BPO or patients with acute urine retention secondary to BPO, who failed medical treatment. TRUS-estimated prostate volumes of 80–150 mL were included	Neurological disorder, bleeding tendency, ongoing anticoagulants or antiplatelet medications. Patients with history of previous prostate surgery and patients diagnosed with PCa	182 patients 60 GL-PVP, 60 HoLEP 62 B-TURP	64.5 (±6) GL-PVEP 66.2 (±7) HoLEP 66.1 (±7) B-TURP	103 (±25) GL-PVP 107 (±21) HoLEP 106 (±23) B-TURP	36 months
Falahatkar (2014)	B-TUVP vs B-TURP	Age >50 years, prostate volume of 30–80 mL, serum PSA <4 ng/mL, IPSS ≥20, Qmax ≤10 mL/s, and failed medical therapy	Abnormal DRE or ultrasonography with suspicion of PCa, history of PCa, serum PSA ≥4 ng/mL, previous urethral or prostate surgery, urethral stricture, neurogenic bladder, bladder calculi, BPH-related hydronephrosis, anticoagulant therapy, coagulation disorders, renal insufficiency and severe comorbidities or co-existing diseases	88 patients 39 B-TUVP 49 B-TURP	70.97 (±3.79) B-TUVP 69.14 (±4.09) B-TURP	46.92 (±4.67) B-TUVP 47.14 (±4.44) B-TURP	3 months
Gallucci (1998)	M-TUVP vs M-TURP	Diagnosis of symptomatic BPH with urodynamically assessed obstruction.	Complete urinary retention, bladder calculi, neurogenic bladder, prostate weight >170 g, bladder cancer, mental or psychological illness, and PCa	150 patients 80 M-TURP 70 M-TUVP	Not reported	36.59 (±1.37) M-TURP 36.61 (±1.52) M-TUVP	12 months
Geavlete (2011)	B-TUVP vs B-TURP vs M-TURP	Qmax <10 mL/s, IPSS >19, and prostate volume between 30 and 80 mL	Severe comorbidities, previous prostate surgery, history of PCa, abnormal DRE, and/or increased PSA	510 patients 170 each group	Not reported	54.1 (31–78) B-TUVP 53.7 (30–79) B-TURP 54.8 (32–80) M-TURP	18 months
Gilling (2022)²¹	M-TURP vs Aquabeam Robotic System (Aquablation)	Men 45–80 years old, with LUTS secondary to BPH, prostate size 30–80 mL, IPSS ≥12, and Qmax <15 mL/s	History of PCa or bladder cancer, neurogenic bladder, bladder calculus or significant bladder diverticulum, active UTI, treatment for chronic prostatitis, diagnosis of urethral stricture, meatal stenosis or bladder neck contracture, damaged external urinary sphincter, stress urinary incontinence, postvoid residual >300 mL or AUR, use of self-catheterization, or prior prostate surgery. Use of anticoagulants or bladder anticholinergics, or severe cardiovascular disease.	181 patients 116 Aquablation 65 M-TURP	66.0 (±7.3) Aquablation 65.8 (±7.2) M-TURP	54.1 (±16.2) Aquablation 51.8 (±13.8) M-TURP	60 months
Gujral (2000)	M-TURP vs ND:YAG laser ablation	LUTS related to BPH with IPSS ≥8, Qmax ≤15 mL/s on two occasions, or AUR with PVR >300 mL	PCa, previous prostatic surgery, life expectancy <6 months, proved neuropathic bladder dysfunction, serum creatinine >250 mmol, abnormal upper tracts on renal tract USS or a prostate of >120 mL on TRUS; long-term active medication for the lower urinary tract	82 patients 38 laser 44 M-TURP	70.6 (±5.8) M-TURP 70.2 (±6.8) laser ablation	49.7 (±21.8) TURP 40.7 (±19.9) laser ablation	7.5 months
Hammadeh (2003)	M-TUVP vs M-TURP	Man with LUTS and BOO owing to BPH, with IPSS 13 or greater, QoL index of 3 or greater, and Qmax <15 mL/s	Neurogenic bladder, PCa, previous prostatic or urethral surgery, bladder stone, or receiving anticoagulant therapy	104 patients 52 M-TUVP 52 M-TURP	70.2 (±7.2) M-TURP 67.5 (±6.7) M-TUVP	27 (±12.2) M-TURP 32 (±9.1) M-TUVP	5 years
Hill (2004)	TUNA vs M-TURP	LUTS secondary to BPH a minimum of 3 months in duration. IPSS >13, a Qmax ≤12 mL/s with a minimum voided volume of at least 125 mL and a prostate size of between 20 and 75 mL, as determined by TRUS.	Active UTI, AUR, or PVR >350 mL, abnormal renal function, PSA >10 ng/mL, biopsy-proven PCa, an enlarged median lobe, neurogenic bladder and/or sphincter abnormalities, previous nonpharmacological prostate treatment, a prostate gland of <34 or >64 mm in transverse diameter, current therapy affecting prostate physiology, or another medical condition that would pose an unacceptable patient risk.	121 patients 65 TUNA 56 M-TURP	66 (±1.0) TUNA 66 (±1.0) M-TURP	Not reported	5 years
Hoekstra (2010)	M-TURP vs CLP vs M-TUVP	Men >45 years of age with LUTS suggestive of BPH, with a prostate volume of 20–65 mL and a Schäfer obstruction grade of ≥2.	Those listed by the International Consensus Committee on BPH	150 patients 53 M-TURP 49 CLP 48 M-TUVP	66 (49–82) overall population	M-TURP 36 (29–45) CLP 35 (29–43) M-TUVP 28 (20–35)	10 years
Horasanli (2008)	Potassium titanyl phosphate PVP vs TURP	LUTS owing to BPH, with a prostate volume of 70 to 100 mL, Qmax = <15 mL/s, or PVR >150 mL in conjunction with IPSS >7.	Neurogenic bladder disorder, urethral strictures, PVR >400 mL, history of PCa or any previous prostatic, bladder neck, or urethral surgery; presence of an indwelling catheter	76 patients 37 TURP 39 PVP	68.3 (±6.7) M-TURP 69.2 (±7.1) PVP	88 (±9.2) M-TURP 86.1 (±8.8) PVP	6 months
Kabalin (1993)	M-TURP vs ND:YAG laser ablation (Urolaser)	Men >50 years of age, with Qmax = <15 mL/s and significant voiding symptoms secondary to BPH leading the patient to request surgical therapy	ASA IV or V, patients with coagulation disorders or requiring anticoagulant medications. Known PCa, or induration/nodularity on DRE that was judged suspicious for PCa.	25 patients 12 M-TURP 13 laser ablation	69 TURP 65 laser ablation	17 (10–30) M-TURP 24 (15–45) laser ablation	6 months
Karadag (2014)	B-TUVP vs B-TURP	Moderate to severe LUTS (based on IPSS) requiring surgery, recurrent urinary retention, failed medical therapy (at least 21 days), and obstructive pressure flow study or Qmax <10 mL/s.	Suspicion of prostatic adenocarcinoma, abnormal DRE or elevated PSA, known urethral stricture or neurogenic bladder, and a history of prostate surgery.	183 patients 87 B-TUVP 96 B-TURP	67.98 (±6.069) B-TUVP 66.72 (±6.04) B-TURé	50.9 (±16.5) B-TUVP 50.6 (±16.9) B-TURP	12 months
Kaya (2007)	B-TUVP vs M-TURP	Qmax of <10 mL/s or obstructive pressure flow study, severe LUTS requiring surgical treatment, based on the IPSS, and a prostate volume of <60 mL.	Known neurogenic bladder, PCa, urethral stricture, and previous prostate surgery	40 patients 25 B-TUVP 15 M-TURP	67.2 B-TUVP 66 M-TURP	50 B-TUVP 51 M-TURP	36 months
Keoghane (2000)	Contact laser vaporization Nd:YAG vs M-TURP	All patients presenting for TURP between January 1993 and January 1995	Previous surgery or instrumentation for BPE, know PCa, unable to understand English to complete the questionnaires, unable to give informed consent	148 patients 72 contact laser 76 M-TURP	70 (51–95) contact laser 71 (47–84) M-TURP	45.7 (20–70) overall population	36 months
Koca (2014)	B-TUVP vs M-TURP	Qmax <15, IPSS >20 and prostate <60 ML. PSA >4 and abnormal DRE were included after ruling out cancer with a prostate biopsy	Known PCa	36 patients 22 B-TUVP 14 M-TURP	67.2 (±19.8) B-TUVP 66.1 (±21.2) M-TURP	50.1 (±8.8) B-TUVP 51.2 (±9.8) M-TURP	72 months
Küpeli (1998)	M-TUVP vs M-TURP	IPSS of 7 or more and a Qmax 15 or less.	Histopathologic diagnosis of adenocarcinoma, prostate volume >60	66 patients: 30 M-TUVP 36 M-TURP	65.7 M-TVP 62.4 M-TURP	43.57 M-TUVP 41.46 M-TURP	12 months
Kursh (2003)	ILC vs M-TURP	American Urological Association Symptom Index of 13 or greater; Qmax <15 mL/s for 2 seconds with an adequately filled bladder; a PVR volume of between 30 and 300 mL; a prostatic length of 1.5 cm or more; and a prostatic volume of not more than 75 cm	Angina, creatinine >1.8 mg/dL poorly controlled diabetes mellitus. PCa AUR, chronic or active prostatitis, cystolithiasis, neurogenic bladder, bladder neck contracture, or UTI. Patients taking terazosin, doxazosin, or tamsulosin within 14 days of enrolment; finasteride or phytotherapy within 30 days of enrolment; and anticholinergic medications within 1 month of enrolment	72 patients 35 M-TURP 37 ILC	69.3 M-TURP 67.6 ILC	40 M-TURP 41.4 ILC	24 months
Lukacs (2012)	120 W GLL-PVP vs M-TURP	IPSS 12 and bother score 3 (according to IPSS question 8) Qmax <12 mL/s (associated with a >125-mL void) Prostate volume between 25 and 80 mL Postvoid residual volume <300 mL Normal DRE PSA <4 ng/mL or negative prostate biopsy if PSA between 4 and 10 ng/mL for patients <75 years of age or with life expectancy >10 years	Patients with urinary catheter before intervention UTI Impaired renal function Unstable cardiac or pulmonary disease Bladder disease or neurologic disease affecting bladder function Altered urinary sphincter function, urethral stricture, bladder neck stenosis, active hematuria, or bladder stones History of prostate or urethral surgery Anorectal disease Anticoagulation therapy that cannot be stopped or replaced without risk for the patient Antiaggregant therapy that cannot be stopped without risk for the patient Severe coagulopathy ASA score >3 Patient unable to complete questionnaires or having no medical insurance	139 patients 70 M-TURP 69 GLL-PVP	67.6 (±7.6) M-TURP 66.9 (±7.8) GLL-PVP	50.11 (±14.73) M-TURP 50.54 (±16.53) GLL-PVP	12 months
Martenson (1999)	ILC vs M-TURP	PV >25 cm³ Age >45 years Duration of symptoms >3 months IPSS >12 Qmax <15 mL/s	PCa Bacterial prostatitis Urethral stricture Neurogenic bladder dysfunction UTI Use of drugs influencing bladder function History of TURP Diabetes mellitus Bladder residual urine >350 mL	44 patients ILC vs M-TURP 2:1	Not reported	50 (±16) M-TURP 46 (±20) ILC	24 months
McAllister (2000)	ELAP vs M-TURP	Suitable candidate for TURP Age over 50 years ASA grade 1 to 3 Urinary flow rates consistent with outflow obstruction Prostatic urethral length exceeding 2.4 cm	ASA grade <3 Inability to provide informed consent PCa Renal impairment Life expectancy <6 months Medication that would preclude them from the study (such as anticoagulants, which might preclude the patient from the TURP arm of the study)	151 patients 76 ELAP 75 M-TURP	68.3 (66.5–70.1) M-TURP 67.9 (66.3–69.5) ELAP	Not reported	60 months
McAllister (2003)	M-TUVP vs M-TURP	All patients who had been evaluated and assessed as being suitable for bladder outlet surgery were considered	PCa History of previous bladder outlet surgery, any neurological condition affecting bladder function, ASA grade >3, a clinically significant acute illness, taking medication, which might influence the trial outcome	235 patients 120 TURP 115 M-TUVP	69.7 M-TURP 70.2 M-TUVP	51.1 TURP 54.3 TUVP	6 months
Mohanty (2012)	80 W GLL-PVP vs M-TURP	Age >50 years, IPSS >7 PV (TRUS): >20 and <80 cc, Qmax <15 mL/s	History of prostate, bladder, or urethral surgery. History of spinal surgery or spinal trauma. Neurological disease. PVRU >300 cc. Indwelling Foley's catheter where indication for catheterization was chronic retention (PVR >300). PCa, carcinoma bladder, stricture urethra Alpha blocker/5 alpha reductase inhibitor drugs/herbal medications believed to be active in prostate. Patients on antiplatelet drugs where drugs could not be safely stopped perioperatively. Patients who did not give written informed consent.	117 patients 57 M-TURP 60 GLL-PVP	65.74 (±9.09) M-TURP 66.68 (±8.62) GLL-PVP	49.02 (±15.93) M-TURP 44.77 (±14.09) GLL-PVP	12 months
Mordasini (2018)	80 W GLL-PVP vs M-TURP	IPSS >12 PV on TRUS, 20–60 mL Able to give fully informed consent	Suspicion of PCa (based on DRE and PSA) Mandatory anticoagulant and/or antiaggregant treatment Previous prostate surgery Chronic kidney failure, heart failure	238 patients 112 GLL-PVP 126 TURP	68.4 (±8.7) GLL-PVP 67.6 (±8.4) M-TURP	36.1 (±11.5) GLL-PVP 37.9 (±14.3) M-TURP	60 months
Mottet (1999)	Holmium:YAG Laser Vaporization vs M-TURP	Nondiabetic patients older than 45 years, with a Qmax <12 mL/sec and a residual volume <250 mL, an AUA score >13, a prostate <60 g, and PSA <10 ng/mL	Not reported	36 patients 23 Holmium:YAG Laser Vaporization 13 M-TURP	67 Holmium YAG Laser Vaporization 64 M-TURP	39 Holmium YAG Laser vaporization 34 M-TURP	12 months
Nuhoğlu (2005)	M-TUVP vs M-TURP	Men with lower urinary tract symptoms associated with BPH	History of prostate or urethral surgery, suspected carcinoma of the prostate, and neurogenic bladder.	77 patients 35 TUVP 38 M-TURP	64.5 (±8.7) M-TUVP vs 65.1 (±9.4) M-TURP	39 (±8.1) M-TUVP 39 (±7.7) M-TURP	60 months
Peng (2016)	80 W GLL-PVP vs B-TURP	Age range from 50 to 80 years, IPSS >7, Qmax <15 mL/s, transrectal ultrasound volume >30 and <150 cc	A diagnosis of or suspected PCa, neurogenic bladder, urethral stricture, bladder stone, and PVR urine volume of >300 mL	120 patients 61 80 W GLL-PVP 59 B-TURP	69.3 (±6.4) 80 W GLL-PVP 68.7 (±5.8) B-TURP	63.7 (±26.5) 80 W GLL-PVP 64.7 (±25.5) B-TURP	12 months
Purkait (2017)	120 W GLL-PVP vs B-TURP	BPH leading to refractory urinary retention, recurrent urinary tract infections, LUTS refractory to medical treatment, renal insufficiency, bladder stones, and recurrent hematuria	History of prostate, bladder, urethral, spinal surgery or spinal trauma, hypocontractile bladder on UDS, diagnoses prostate carcinoma, carcinoma of the bladder, urethral stricture, and patients who did not give consent for the study.	117 patients 60 GLL-PVP 57 B-TURP	63.6 (±8.12) GLL-PVP 65.3 (±7.86) B-TURP	70.3 (±15.5) GLL-PVP 69.6 (±16.3) B-TURP	48 months
Razzaghi (2014)	980 nm diode laser vaporization vs M-TURP	BPH with LUTS, despite maximal medical therapy, frequent urinary tract infections, hematuria unresponsive to medical therapy, high serum creatinine that decreased with urethral catheter placement, and urinary retention, despite medical therapy.	History of neurogenic bladder, previous prostate surgery, anticoagulant medication, urethral stricture, bladder stone, diagnosis of PCa, prostate volume >100 mL on TRUS, and disability or refusal to give a fully informed consent	102 patients 50 Diode Laser Vaporization 52 M-TURP	68.5 (±8.8) diode laser vaporization 68.2 (±7.8) M-TURP	61.1 (±16.1) diode laser vaporization 59.6 (±14.1) M-TURP	24 months
Telli (2015)	120 W GLL-PVP vs M-TURP	Qmax <15 mL/s or PVR <150 cc; IPSS >7 PV <80 mL	Neurogenic bladder disorder, urethral strictures, history of PCa or any previous prostatic, bladder neck, or urethral surgery	101 patients 62 M-TURP 39 GLL-PVP	69 (56–87) M-TURP 67 (51–87) GLL-PVP	55 (40–72) M-TURP 60 (41–75) GLL-PVP	24 months
Thomas (2016)	180 GLL-PVP vs M or B-TURP	Consent and agrees to attend all study visits. LUTS subject able to complete self-administered questionnaires. Subject is a surgical candidate for either the XPS or the TURP procedure and may be randomized into either arm. 40–80 years of age. IPSS score 12 measured at the baseline visit. Qmax <15 mL/s. Prostate volume <100 mL by TRUS. ASA I, II, or III. Normal serum creatinine	Life expectancy <2 year. Subject has an active infection (e.g., urinary tract infection or prostatitis). Chronic prostatitis or chronic pelvic pain syndrome (e.g., nonbacterial chronic prostatitis). Urethral stricture or bladder neck contracture within the last 180 days. Two or more urethral strictures and/or bladder neck contractures within 5 years. Lichen sclerosus. Neurogenic bladder or other neurologic disorder. Polyneuropathy (e.g., diabetic). Lower urinary tract surgery. Stress urinary incontinence that requires treatment or daily pad or device use. Intermittent self-catheterization. PVR >400 mL in the 14 days before the surgical procedure. Bladder stones. PCa. CIS, TaG2, TaG3, or any T1 stage bladder cancer. Damage to external urinary sphincter. Disorder of the coagulation cascade or disorders that affect platelet count or function. Acute myocardial infarction, open heart surgery, or cardiac arrest <180 days . Immunocompromised	281 patients 139 GLL-PVP 142 TURP	65.9 (±6.8) GLL-PVP 65.4 (±6.6) TURP	48.6 (±19.2) GLL-PVP 46.2 (±19.1) TURP	24 months
Tuhkanen (2001)	Hybrid Laser ablation vs M-TURP	Infravesical obstruction confirmed by the pressure outl-flow study and benign prostates 40–100 mL measured with TRUS	PCa, urethral stricture, neurogenic bladder dysfunction, previous prostate operation, or PVR >350 mL	46 patients 21 Hybrid laser treatment 25 M-TURP	67 (55–78) Hybrid laser 67 (46–77) M-TURP	55 (42–83) Hybrid laser 55 (40–94) M-TURP	24 months
Tuhkanen (2003)	CLP vs M-TURP	LUTS suggestive of BPH and willingness of patients to undergo operative treatment. All accepted patients had to have BOO confirmed by pressure–flow studies and prostate volume <40 mL	PCa, urethral stricture, neurogenic bladder dysfunction, previous prostate operation, or PVR >350 mL	52 patients CLV (n = 26) TURP (n = 26)	68 (56–82) CLP 67 (55–77) M-TURP	30 (15–37) CLP 28 (15–38) M-TURP	48 months
vanMelick (2003)	M-TURP vs CLP vs M-TUVP	Men older than 45 years with LUTS associated with BPH. All patients underwent DRE, TRUS, urodynamic evaluation, free flowmetry, postvoid residual urine volume estimation, urinalysis, and blood analysis. Patients had to be urodynamically equivocal or obstructed. Volume had to be between 20 and 65 cm		141 patients50 M-TURP45 CLP46 M-TUVP	Not reported	37 (±11) M-TURP38 (±9) CLP35 (±12) M-TUVP	84 months
Xue (2013)	120 W GLL-PVP vs M-TURP	IPSS >15, failure of previous medical treatment, Qmax <15 mL/s, prostate volume <100 mL on TRUS, and patient willingness to sign a written informed consent form	Detrusor overactivity or hypocontractility on urodynamic study, urethral stricture, PCa, and previous prostate, bladder neck, or urethral surgery. Patients presenting with a serum PSA >4 ng/mL, abnormal DRE, and suspicious TRUS undergoing biopsy	200 patients100 M-TURP100 GLL-PVP	71.0 (±10.8) M-TURP72.1 (±11.3) GLL-PVP	67.3 (±24.7) M-TURP65.8 (±23.6) GLL-PVP	36 months
Zhang (2011)	Channel M-TURP and ILC vs M-TURP vs ILC	Age >65 years; Q max <10 mL/s, and moderate or severe LUTS; IPSS >10. Urodynamics were performed for all patients	Bladder calculus, bladder diverticulum, neurogenic bladder, or diabetes with abnormal cystometry, severe peripheral arterial insufficiency, PVR >350 mL, prostatic urethra <25 mm, urethral stricture, a history of any previous prostatic, bladder neck, or urethral surgery, and the presence of an indwelling catheter were excluded	150 patients50 ILC+M-TURP50 ILC50 M-TURP	72.4 (±5.6)71.2 (±5.8) ILC70.5 (±5.4) M-TURP	53.1 (±4.8)ILC+M-TURP52.0 (±5.1)ILC54.2 (±5.7)M-TURP	48 months

ASA = American Society of Anesthesiologists; B = bipolar; BLUES = British Laser Urological Evaluation Society; BOO = bladder outflow obstruction; BPE = benign prostatic enlargement; BPO = benign prostatic obstruction; CLP = contact laser prostatectomy; DRE = digital rectal examination; ELAP = endoscopic laser ablation of the prostate; GLL-PVP = green light laser photovaporization of the prostate; ILC = interstitial laser coagulation; M = monopolar; ND-YAG = neodymium-yttrium-aluminum-garnet; PVRU = ; TRUS = transurectal ultrasound; TUNA = transurethral needle ablation; TUVP = transurethral vaporization; UDS = urodynamic study; UTI = urinary tract infection.

Study quality assessment

There were 457 patients in enucleation, 2259 in ablation, and 2517 in the TURP group.

Supplementary Figure S1 shows the details of quality assessment for studies comparing enucleation vs TURP. Four studies showed some concerns about the overall risk of bias. One study showed a high overall risk of bias and the remaining two studies had a low overall risk of bias. The most frequent reason for bias was attributable to deviation from intended interventions, followed by bias arising from the randomization process. Supplementary Figure S2 demonstrates the details of quality assessment for studies comparing ablation vs TURP. Seventeen studies showed a low overall risk of bias. Twenty-one studies showed some concerns regarding the overall risk of bias and the remaining ones had a high overall risk of bias. The most frequent reason for bias was bias from the randomized process, followed by bias attributable to deviation from intended interventions.

Incidence of reoperation after M-TURP

The pooled incidence of reoperation in patients who underwent M-TURP ranged from 1.5% to 3.0%, with a pooled rate of 2.3% (Supplementary Fig. S3).

Incidence of reoperation after B-TURP

The pooled incidence of reoperation in patients who underwent B-TURP ranged from 0.9% to 7.8%, with a pooled rate of 4.3% (Supplementary Fig. S4).

Incidence of reoperation after ablation

The pooled incidence of reoperation in patients who underwent ablation ranged from 4.7% to 7.8%, with a pooled rate of 6.2% (Supplementary Fig. S5).

Incidence of reoperation after enucleation

The pooled incidence of reoperation in patients who underwent enucleation ranged from 0% to 1.5%, with a pooled rate of 0.7% (Supplementary Fig. S6).

Reoperation rate: Enucleation vs TURP

Meta-analysis for 7 studies (457 enucleation and 444 TURP cases) showed that the incidence of reoperation was significantly lower in the enucleation group (RR 0.28, 95% CI 0.10–0.81, p = 0.02) (Fig. 2). There was no significant heterogeneity among the studies (I ² 0%). Subanalysis demonstrated that the difference in reoperation rate was significantly lower in the enucleation group only in studies with follow-up between 1 and 3 years (RR 0.18, 95% CI 0.04–0.85, p = 0.03).

FIG. 2.

Forrest plot of reoperation in studies comparing enucleation vs TURP according to follow-up period. TURP = transurethral resection of the prostate.

A further subanalysis showed that the incidence of reoperation was similar between M-TURP and enucleation (RR 0.43, 95% CI 0.10–1.80, p = 0.25) and significantly lower in the enucleation compared with the B-TURP group (RR 0.14, 95% CI 0.03–0.77, p = 0.02) (Fig. 3).

FIG. 3.

Forrest plot of reoperation in studies comparing enucleation vs TURP, subgroup analysis for monopolar and bipolar TURP.

Reoperation rate: Ablation vs TURP

Meta-analysis for 43 studies (2596 ablation and 2499 TURP cases) showed that the incidence of reoperation was significantly higher in the ablation group (RR 1.81, 95% CI 1.33–2.47, p = 0.0002) (Fig. 4). Study heterogeneity was low (I ² 17%). Subanalysis demonstrated that the difference in reoperation rate was significantly higher in the ablation group in studies with mid-term follow-up (1–3 years, odds ratio (OR) 2.20 95% CI 1.1–4.37, p = 0.02; 3–5 years, OR 1.84 95% CI 1.18–2.88, p = 0.008), but not in studies with short and longer than 5 years of follow-up. A further subanalysis showed that the incidence of reoperation was similar between B-TURP and ablation (RR 0.68, 95% CI 0.34–1.37, p = 0.28) and significantly higher in the ablation compared with the M-TURP group (RR 1.91, 95% CI 1.44–2.54, p < 0.0001) (Fig. 5).

FIG. 4.

Forrest plot of reoperation in studies comparing ablation vs TURP according to follow-up period.

FIG. 5.

Forrest plot of reoperation in studies comparing ablation vs TURP, subgroup analysis for monopolar and bipolar TURP.

Discussion

From patients' and surgeons' perspective in the modern era, any BPE intervention should have minimal morbidity, improve symptoms and quality of life, and withstand the test of time, which is ideal to provide a lifetime solution. Despite data showing that improvements of LUTS and micturition parameters are sustained for over 10 years,⁶ a second prostatic operation after TURP has been reported at a constant annual rate of ∼1% to 2%, with a reoperation rate for BPE of between 8.3%⁷ and 12.0%⁸ at 8 years after primary TURP.

Holmium laser enucleation of the prostate (HoLEP), Thulium laser enucleation of the prostate (ThuLEP), green light laser photovaporization of the prostate (GLL-PVP), and B-TURP demonstrated a shorter hospital stay and fewer early complications compared to M-TURP.^4,6,9 However, to replace traditional TURP as the new gold standard surgical treatment, these new procedures should also demonstrate durable outcomes in terms of the need for reoperation. This is clearly demonstrated by Eredics and colleagues who showed that 85% of their cohort survived for 8 years after TURP and even within the 70 to 79 year cohort, the 8-year survival was nearly 75%.⁷

To the best of our knowledge, our review is the first study that assessed and compared the reoperation rate for BPE intervention in randomized trials comparing TURP vis a vis enucleation and ablation.

Although enucleation techniques may have a steep learning curve varying from 30 cases for ThuLEP¹⁰ to 50 for HoLEP¹¹ and bipolar enucleation,¹² in our study, enucleation had the lowest rate of reoperation, despite the learning curve being able to very well influence the data for reoperation. Indeed, the learning curve may partially explain why reoperation is possible despite enucleation should be, in theory, a better anatomically designed procedure by dissecting and separating adenoma from the peripheral zone. Once the learning curve is mounted, enucleation could offer a more “radical” and complete adenoma removal vis a vis TURP, and hence this could account for the better results compared to TURP in our study.

This hypothesis is supported by Elzayat and Elhilali who showed that the reoperation rate in their HoLEP series of 118 patients with a mean follow-up of 49.4 months was 4.2%, but the retreatment rate in the first 50 cases was higher compared with the following 68 cases (8% vs 1.4%, respectively).¹³ Another reason for the persistence or recurrence of adenoma after enucleation might be attributed to the multinodular nature of benign prostatic hyperplasia. This involves the potential regrowth of a few subcapsular nodules not completely enucleated, subsequently leading to regrowth and recurrent obstruction. The latter can occur also in small-volume prostates where a less distinct or clear plane of enucleation might not always be as apparent as in larger glands.¹⁴

It is common evidence that sometimes, urologists need to stop TURP, particularly in patients with large volume prostate. This is frequently associated with intraoperative bleeding-related poor vision or prolonged surgery with the fear of transurethral resection syndrome. Actually, during enucleation, major vessels are accessed only once at the level of the surgical capsule, which is reached early and then followed through. In contrast, these same vessels are opened and reopened multiple times until reaching the surgical capsule in TURP. At this juncture, final coagulation can be completed. Theoretically, this disparity could result in more significant bleeding and a greater amount of tissue left behind if vision is compromised, particularly in larger glands.⁹

As a consequence, obstructing adenoma can be left inside, leading to early reoperation. In a study of more than 3500 single-surgeon M-TURP, Tasc et al. performed early re-TURP in almost 1% of their patients because of recurrent postoperative recatheterization.¹⁵ The persistence of obstructing residual adenoma can explain our results of a significantly lower rate of reoperation between 1 and 3 years after enucleation compared with TURP.

However, there was no difference in reoperation rate behind 3 years of follow-up and this might be related to fewer studies and patients. Another important argument in favor of the role of residual obstructing adenoma after inadequate resection is demonstrated in the study by Aagaard et al.¹⁶ They found that the reoperation rate at an 8-year follow-up after minimal prostate resection was 23%, whereas for “radical” resection, it stood at 7%. Therefore, this difference could be linked to the extent of resection performed and an incomplete resection should be suspected when patients require restarting medical therapy in the early postoperative period since this has been recognized as a risk factor for secondary TURP.¹⁷ As a consequence, urologists performing TURP should always pursue a complete adenoma removal, whenever feasible, to avoid reoperation.

Another important finding of our study was the significantly higher reoperation rate after Ablation procedures compared with M-TURP. In a recent meta-analysis, TURP demonstrated a more substantial improvement in micturition parameters compared to GLL-PVP over a 5-year period.⁴ These findings indicate that, although GLL-PVP is highly effective initially, its efficacy probably diminishes over time. The relatively lower reduction of prostatic adenoma by GLL-PVP might elucidate its declining effectiveness in micturition over the long term. Furthermore, this evidence converts to a higher incidence of reoperation owing to the persistence or regrowth of prostatic adenoma (RR 0.64, 95% CI 0.41–0.99).⁴

Therefore, this difference in reoperation rate could potentially be linked to inadequate energy delivery during the procedure, leading to incomplete tissue removal, possibly attributable to the surgeon's early learning curve, or ineffective tissue ablation by low-performance lasers employed in the late 1990s and early 2000s. In fact, the reoperation rate over 30 months of follow-up after 80 W PVP was high at 6.8%, but the authors of this study argued that redo surgery was also related to their learning curve since the reoperation rate decreased from 10% to 0%–5% after each surgeon's initial and subsequent 30 cases,¹⁸ thus indicating once again the important role of experience in minimizing subsequent reintervention for adenoma regrowth owing to residual tissue. The hypothesis of incomplete tissue ablation is also supported by our results of a pooled rate of reoperation after ablation of 6.2%, much higher than enucleation and both M-TURP and B-TURP.

Moreover, reoperation after GLL-PVP is also influenced by prostate volume, as demonstrated by Kim et al.¹⁹ The authors showed that even using a high-performance laser (i.e., 120 W), patients requiring reoperation had a significantly larger prostate volume (74.2 g vs 53.0 g), longer lasing time (45.8 minutes vs 36.5 minutes), and greater mean total energy use (219.3 kJ vs 153.6 kJ). However, when a “radical” tissue ablation is performed, such as in Aquablation, freedom from a secondary BPO surgical treatment was 96.3% at 5-year follow-up in men with a prostate volume between 80 and 150 mL,²⁰ and the reoperation rate was similar to TURP in a randomized study.²¹ Hence, as for TURP, it becomes imperative to thoroughly and effectively ablate the prostate tissue to ensure the continual patency of the prostatic cavity, especially in patients with a larger prostate.

The surgical procedure itself is not the sole factor associated with reoperation. Some patient-related factors need to be taken into consideration. Interestingly, data support that the risk of repeat TURP increases with age.^7,22 In fact, Eredics et al. demonstrated a higher re-TURP rate in men 80 years of age and older compared with younger men.⁷ The authors speculated that the elevated occurrence of detrusor overactivity, detrusor underactivity, and a reduced frequency of bladder outflow obstruction in the elderly could contribute to a less satisfactory outcome.²³ This might have subsequently led to secondary interventions, potentially explaining these differences.

This study has some limitations. First, the absence of commonly reported data on the learning curve of the involved surgeons could have introduced bias in the reoperation rate. Achieving a truly unbiased comparison among procedures remains quite challenging under these circumstances. Second, postoperative urodynamics was not routinely performed by most of the included studies and the incidence of truly persistent/de novo bladder outlet obstruction cannot be assessed. Third, no data were reported on the outcomes of patients who required reoperation to elucidate the outcomes of the secondary surgery, particularly to understand its true value in those suffering from persistent/recurrent LUTS after primary bladder outlet relief.

No study included in our review reported data on cost-analysis outcomes, and hence no conclusion can be drawn for which procedure is more cost-effective. However, studies focusing on this subject showed inhomogeneous results, some supporting enucleation,²⁴ whereas some favoring TURP²⁵ or minimally invasive procedure²⁶ as the most cost-effective procedure. Finally, no information could be collected on what potential surgical intraoperative technique was used for both groups to make any affirmation on which technique is better for TURP or enucleation, respectively.

Conclusions

In this study, we compared transurethral enucleation and ablation procedures against TURP to estimate the incidence of retreatment for residual/regrowth adenoma after surgery. We found that ablation has the highest rate of reoperation, followed by B-TURP and M-TURP, whereas enucleation has the lowest. Comparing all procedures, ablation shows a significantly higher reoperation rate compared to TURP in early and mid-term but not in long-term follow-up. Conversely, enucleation demonstrates a lower retreatment rate between 1 and 3 years. Our findings can provide urologists with valuable insights to counsel their patients regarding the reoperation rate for residual/regrowth adenoma based on the surgical intervention offered.

Footnotes

Authors' Contributions

Conception and design: D.C., J.Y.-C.T., and V.G. Acquisition of data: D.C., P.T., G.C., A.C., A.R., C.N., L.P., S.S., and V.D.S. Statistics: D.C. Drafting of the article: D.C. Critical revision for important intellectual content: J.Y.-C.T., L.C., B.K.S., and V.G. Supervision: A.B.G. All authors participated in article writing, review, and approval of the final version of the article for submission.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

Supplementary Figure S1

Supplementary Figure S2

Supplementary Figure S3

Supplementary Figure S4

Supplementary Figure S5

Supplementary Figure S6

Abbreviations Used

References

Bushman

. Etiology, epidemiology, and natural history of benign prostatic hyperplasia. Urol Clin North Am, 2009; 36(4):403–415; doi: 10.1016/j.ucl.2009.07.003

Gravas

, Cornu

, Gacci

, et al. EAU Guidelines on Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), Incl. Benign Prostatic Obstruction (BPO); 2023. Available from: https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Non-Neurogenic-Male-LUTS-2022.pdf [Last accessed: December 8, 2023 ].

Huang

S-W

, Tsai

C-Y

, Tseng

C-S

, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: Systematic review and network meta-analysis. BMJ, 2019; 367:l5919; doi: 10.1136/bmj.l5919

Castellani

, Pirola

, Rubilotta

, et al. Greenlight Laser^TM Photovaporization versus transurethral resection of the prostate: A systematic review and meta-analysis. Res Reports Urol, 2021; 13:263–271; doi: 10.2147/RRU.S277482

Rojanasarot

, Cutone

, Durand

, et al. Patients' perspectives on attributes while choosing minimally invasive surgery for benign prostatic hyperplasia procedures: Experience from men undergoing water vapor thermal therapy. J Endourol, 2023; 37(5):575–580; doi: 10.1089/end.2022.0607

Cornu

J-N

, Ahyai

, Bachmann

, 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(6):1066–1096; doi: 10.1016/j.eururo.2014.06.017

Eredics

, Wachabauer

, Röthlin

, et al. Reoperation rates and mortality after transurethral and open prostatectomy in a long-term nationwide analysis: Have we improved over a decade?. Urology, 2018; 118:152–157; doi: 10.1016/j.urology.2018.04.032

Roos

, Wennberg

, Malenka

, et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med, 1989; 320(17):1120–1124; doi: 10.1056/NEJM198904273201705

Castellani

, Pirola

, Pacchetti

, et al. State of the art of thulium laser enucleation and vapoenucleation of the prostate: A systematic review. Urology, 2020; 136:19–34; doi: 10.1016/j.urology.2019.10.022

10.

Saredi

, Pirola

, Pacchetti

, et al. Evaluation of the learning curve for thulium laser enucleation of the prostate with the aid of a simulator tool but without tutoring: Comparison of two surgeons with different levels of endoscopic experience. BMC Urol, 2015; 15:49; doi: 10.1186/s12894-015-0045-2

11.

Seki

, Mochida

, Kinukawa

, et al. Holmium laser enucleation for prostatic adenoma: Analysis of learning curve over the course of 70 consecutive cases. J Urol, 2003; 170(5):1847–1850; doi: 10.1097/01.ju.0000092035.16351.9d

12.

Hirasawa

, Kato

, Fujita

. Transurethral enucleation with bipolar for benign prostatic hyperplasia: 2-year outcomes and the learning curve of a single surgeon's experience of 603 consecutive patients. J Endourol, 2017; 31(7):679–685; doi: 10.1089/end.2017.0092

13.

Elzayat

, Elhilali

. Holmium laser enucleation of the prostate (HoLEP): Long-term results, reoperation rate, and possible impact of the learning curve. Eur Urol, 2007; 52(5):1465–1472; doi: 10.1016/j.eururo.2007.04.074

14.

Elkoushy

, Elshal

, Elhilali

. Reoperation after holmium laser enucleation of the prostate for management of benign prostatic hyperplasia: Assessment of risk factors with time to event analysis. J Endourol, 2015; 29(7):797–804; doi: 10.1089/end.2015.0060

15.

Tasc

, Ilbey

, Tugcu

, et al. Transurethral resection of the prostate with monopolar resectoscope: Single-surgeon experience and long-term results of after 3589 procedures. Urology, 2011; 78(5):1151–1155; doi: 10.1016/j.urology.2011.04.072

16.

Aagaard

, Jonler

, Fuglsig

, et al. Total transurethral resection versus minimal transurethral resection of the prostate—A 10-year follow-up study of urinary symptoms, uroflowmetry and residual volume. Br J Urol, 1994; 74(3):333–336; doi: 10.1111/j.1464-410x.1994.tb16622.x

17.

De Nunzio

, Franco

, Lombardo

, et al. Phamacological treatment of persistant lower urinary tract symptoms after a transurethral resection of the prostate is predictive of a new surgical treatment: 10 Years follow-up study. Neurourol Urodyn, 2021; 40(2):722–727; doi: 10.1002/nau.24616

18.

Ruszat

, Seitz

, Wyler

, et al. GreenLight Laser Vaporization of the prostate: Single-center experience and long-term results after 500 procedures. Eur Urol, 2008; 54(4):893–901; doi: 10.1016/j.eururo.2008.04.053

19.

Kim

, Choi

, Bae

, et al. Risk factors for reoperation after photoselective vaporization of the prostate Using a 120 W GreenLight High Performance System Laser for the treatment of benign prostatic hyperplasia. Photomed Laser Surg, 2016; 34(3):102–107; doi: 10.1089/pho.2015.4050

20.

Bhojani

, Bidair

, Kramolowsky

, et al. Aquablation therapy in large prostates (80–150 ml) for lower urinary tract symptoms due to benign prostatic hyperplasia: Final WATER II 5-Year Clinical Trial Results. J Urol, 2023; 210(1):143–153; doi: 10.1097/JU.0000000000003483

21.

Gilling

, Barber

, Bidair

, et al. Five-year outcomes for aquablation therapy compared to TURP: Results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol, 2022; 29(1):10960–10968

22.

Lu-Yao

, Barry

, Chang

, et al. Transurethral resection of the prostate among medicare beneficiaries in the United States: Time trends and outcomes. Prostate Patient Outcomes Research Team (PORT). Urology, 1994; 44(5):692–699; doi: 10.1016/s0090-4295(94)80208-4

23.

Beltrame

, Ferreira

, Lorenzetti

, et al. Bladder function in obstructed men—Does age matter?. Aging Male, 2015; 18(3):143–148; doi: 10.3109/13685538.2015.1025377

24.

Wymer

, Narang

, Slade

, et al. Evaluation of the cost-effectiveness of surgical treatment options for benign prostatic hyperplasia. Urology, 2023; 171:96–102; doi: 10.1016/j.urology.2022.09.026

25.

Lourenco

, Armstrong

, N'Dow

, et al. Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement. Health Technol Assess, 2008; 12(35):iii, ix–x, 1–146, 169–515; doi: 10.3310/hta12350

26.

Chughtai

, Rojanasarot

, Neeser

, et al. A comprehensive analysis of clinical, quality of life, and cost-effectiveness outcomes of key treatment options for benign prostatic hyperplasia. PLoS One, 2022; 17(4):e0266824; doi: 10.1371/journal.pone.0266824

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB

0.38 MB

0.61 MB

0.28 MB

0.07 MB

0.27 MB

0.07 MB