Complications and functional outcomes of endoscopic enucleation of the prostate: a systematic review and meta-analysis of randomised-controlled studies

Introduction: There are several endoscopic enucleation procedures (EEP) using different energy sources: holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), Greenlight^® (GreenVEP) and diode (DiLEP) lasers, and plasma kinetic enucleation of the prostate (PKEP). The comparative outcomes among these EEPs are unclear. We aimed to compare the peri-operative and post-operative outcomes, complications and functional outcomes among different EEPs. Material and methods: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Only randomised-controlled trials (RCT) comparing EEPs were included. The risk of bias was assessed using the Cochrane tool for RCTs. Results: The search identified 1153 articles and 12 RCTs were included. The number of RCTs for each comparison was, HoLEP vs ThuLEP; n = 3, HoLEP vs PKEP; n = 3, PKEP vs DiLEP; n = 3, HoLEP vs GreenVEP; n = 1, HoLEP vs DiLEP; n = 1, ThuLEP vs PKEP; n = 1. Operative time was shorter and blood loss was lower with ThuLEP compared with HoLEP, whereas operative time was shorter for HoLEP compared with PKEP. Blood loss was lower with HoLEP and DiLEP compared with PKEP. There were no Clavien-Dindo IV-V complications, and the incidence of Clavien-Dindo I complications was lower with ThuLEP compared with HoLEP. No significant differences were detected among EEPs regarding urinary retention, stress urinary incontinence, bladder neck contracture or urethral stricture. Lower International Prostate Symptom Score (IPSS) and higher quality of life (QoL) scores were in favour of ThuLEP compared with HoLEP at 1 month. Conclusions: EEP improves symptoms and uroflowmetry parameters with a low incidence of high-grade complications. ThuLEP was associated with shorter operative time, lower blood loss, and lower incidence of low-grade complications compared with HoLEP.