OBJECTIVE To assess the efficacy and safety of different endoscopic surgical treatments for benign prostatic hyperplasia. DESIGN Systematic review and network meta-analysis of randomised controlled trials. DATA SOURCES A comprehensive search of PubMed, Embase, and Cochrane databases from inception to 31 March 2019. STUDY SELECTION Randomised controlled trials comparing vapourisation, resection, and enucleation of the prostate using monopolar, bipolar, or various laser systems (holmium, thulium, potassium titanyl phosphate, or diode) as surgical treatments for benign prostatic hyperplasia. The primary outcomes were the maximal flow rate (Qmax) and international prostate symptoms score (IPSS) at 12 months after surgical treatment. Secondary outcomes were Qmax and IPSS values at 6, 24, and 36 months after surgical treatment; perioperative parameters; and surgical complications. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted the study data and performed quality assessments using the Cochrane Risk of Bias Tool. The effect sizes were summarised using weighted mean differences for continuous outcomes and odds ratios for binary outcomes. Frequentist approach to the network meta-analysis was used to estimate comparative effects and safety. Ranking probabilities of each treatment were also calculated. RESULTS 109 trials with a total of 13 676 participants were identified. Nine surgical treatments were evaluated. Enucleation achieved better Qmax and IPSS values than resection and vapourisation methods at six and 12 months after surgical treatment, and the difference maintained up to 24 and 36 months after surgical treatment. For Qmax at 12 months after surgical treatment, the best three methods compared with monopolar transurethral resection of the prostate (TURP) were bipolar enucleation (mean difference 2.42 mL/s (95% confidence interval 1.11 to 3.73)), diode laser enucleation (1.86 (-0.17 to 3.88)), and holmium laser enucleation (1.07 (0.07 to 2.08)). The worst performing method was diode laser vapourisation (-1.90 (-5.07 to 1.27)). The results of IPSS at 12 months after treatment were similar to Qmax at 12 months after treatment. The best three methods, versus monopolar TURP, were diode laser enucleation (mean difference -1.00 (-2.41 to 0.40)), bipolar enucleation (0.87 (-1.80 to 0.07)), and holmium laser enucleation (-0.84 (-1.51 to 0.58)). The worst performing method was diode laser vapourisation (1.30 (-1.16 to 3.76)). Eight new methods were better at controlling bleeding than monopolar TURP, resulting in a shorter catheterisation duration, reduced postoperative haemoglobin declination, fewer clot retention events, and lower blood transfusion rate. However, short term transient urinary incontinence might still be a concern for enucleation methods, compared with resection methods (odds ratio 1.92, 1.39 to 2.65). No substantial inconsistency between direct and indirect evidence was detected in primary or secondary outcomes. CONCLUSION Eight new endoscopic surgical methods for benign prostatic hyperplasia appeared to be superior in safety compared with monopolar TURP. Among these new treatments, enucleation methods showed better Qmax and IPSS values than vapourisation and resection methods. STUDY REGISTRATION CRD42018099583.

中文翻译：

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良性前列腺增生新手术治疗的疗效和安全性比较：系统评价和网络荟萃分析。


目的评价不同内镜手术治疗良性前列腺增生的疗效和安全性。设计随机对照试验的系统回顾和网络荟萃分析。数据来源 对 PubMed、Embase 和 Cochrane 数据库从成立到 2019 年 3 月 31 日的全面检索。 研究选择 比较使用单极、双极或各种激光系统（钬、铥、钾）的前列腺汽化、切除和剜除术的随机对照试验磷酸氧钛，或二极管）作为良性前列腺增生的手术治疗。主要结局是手术治疗后 12 个月的最大流量 (Qmax) 和国际前列腺症状评分 (IPSS)。次要结局是手术治疗后 6、24 和 36 个月的 Qmax 和 IPSS 值；围手术期参数；和手术并发症。数据提取和综合 两名独立评审员提取研究数据并使用 Cochrane 偏差风险工具进行质量评估。使用连续结果的加权平均差和二元结果的比值比来总结效应大小。网络荟萃分析的频率论方法用于估计比较效果和安全性。还计算了每种处理的排序概率。结果 确定了 109 项试验，共有 13 676 名参与者。评估了九种手术治疗方法。在手术治疗后 6 个月和 12 个月时，剜除术获得了比切除和汽化方法更好的 Qmax 和 IPSS 值，并且这种差异在手术治疗后 24 和 36 个月内保持不变。 对于手术治疗后 12 个月的 Qmax，与单极经尿道前列腺电切术 (TURP) 相比，最好的三种方法是双极剜除术（平均差 2.42 mL/s（95% 置信区间 1.11 至 3.73））、二极管激光剜除术（1.86） （-0.17 至 3.88））和钬激光剜除术（1.07（0.07 至 2.08））。表现最差的方法是二极管激光汽化（-1.90（-5.07 至 1.27））。治疗后12个月的IPSS结果与治疗后12个月的Qmax结果相似。与单极 TURP 相比，最好的三种方法是二极管激光剜除术（平均差 -1.00（-2.41 至 0.40））、双极剜除术（0.87（-1.80 至 0.07））和钬激光剜除术（-0.84（-1.51 至 0.58） ））。表现最差的方法是二极管激光汽化（1.30（-1.16 至 3.76））。八种新方法比单极 TURP 能更好地控制出血，从而缩短导管插入时间、减少术后血红蛋白下降、减少血栓滞留事件并降低输血率。然而，与切除方法相比，短期短暂性尿失禁可能仍然是剜除术方法的一个问题（比值比 1.92、1.39 至 2.65）。在主要或次要结局中没有发现直接和间接证据之间存在实质性不一致。结论 与单极 TURP 相比，八种治疗良性前列腺增生的新内窥镜手术方法在安全性上似乎更为优越。在这些新的治疗方法中，剜除方法显示出比汽化和切除方法更好的 Qmax 和 IPSS 值。研究注册 CRD42018099583。