Efficacy and Tolerability Outcomes of Minimally Invasive Surgical Treatments for Benign Prostatic Hyperplasia: A Random-Effects Network Meta-Analysis

Minimally invasive surgical treatments (MIST) provide emerging alternatives to transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). This network meta-analysis provides a comparative analysis of clinical efficacy and tolerability for individual MIST versus TURP in BPH. A PRISMA-compliant systematic review was performed by searching the PubMed, EMBASE, and Cochrane Library databases from inception to 31 August 2023. Eligible studies compared post-treatment change scores or relative risks between ≥2 distinct BPH interventions for International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), post-void residual urine, Sexual Health Inventory in Men (SHIM) and Men's Sexual Health Questionnaire (MSHQ) scores, and re-intervention rate. Pairwise comparisons were synthesized through a random-effects frequentist model to determine aggregate estimates for treatment-outcome associations. Of 4,416 screened articles, 59 studies were included for quantitative analysis, comprising 21,078 patients across 47 unique cohorts. Prostatic arterial embolization (PAE) and Aquablation appeared to induce similar reductions in IPSS to TURP; however, there was insufficient data to evaluate the tolerability of PAE or Aquablation. Water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) were less efficacious at reducing IPSS than TURP but exhibited greater preservation of SHIM and MSHQ scores. TURP demonstrated the lowest relative risk of re-intervention. PAE and Aquablation appear to be efficacious approaches to BPH management, with PAE also producing a comparable increase in Qmax to TURP. WVTT and PUL appear less effective than TURP but are associated with lower risk of male sexual dysfunction.