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The impact of surgical treatments for lower urinary tract symptoms/benign prostatic hyperplasia on male erectile function

View Article: PubMed Central - PubMed

ABSTRACT

Lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) is common in adult men and can impair erectile function (EF). It was believed surgical treatments for this illness can improve EF due to the relief of LUTS while they were also reported harmed EF as heating or injury effect. Current network meta-analysis aimed to elucidate this discrepancy.

Randomized controlled trials (RCTs) were identified. Direct comparisons were conducted by STATA and network meta-analysis was conducted by Generate Mixed Treatment Comparison. Random-effects models were used to calculate pooled standard mean difference and 95% confidence intervals and to incorporate variation between studies.

Eighteen RCTs with 2433 participants were analyzed. Nine approaches were studied as transurethral resection of the prostate (TURP), plasmakinetic resection of the prostate (PKRP), plasmakinetic enucleation of the prostate (PKEP), Holmium laser enucleation of the prostate (HoLEP), Holmium laser resection of the prostate (HoLRP), photoselective vaporization of the prostate (PVP), Thulium laser, open prostatectomy (OP), and laparoscopic simple prostatectomy (LSP). In direct comparisons, all surgical treatments did not decrease postoperative International Index of Erectile Function (IIEF)-5 score except PVP. Moreover, patients who underwent HoLEP, PKEP, Thulium laser, and TURP had their postoperative EF significantly increased. Network analysis including direct and indirect comparisons ranked LSP at the highest position on the variation of postoperative IIEF-5 score, followed by PKRP, HoLEP, TURP, Thulium laser, PKEP, PVP, HoLRP, and OP. In subgroup analysis, only PVP was found lower postoperative EF in the short term and decreased baseline group, whereas TURP increased postoperative IIEF-5 score only for patients with normal baseline EF. However, HoLEP and PKEP showed pro-erectile effect even for patients with decreased baseline EF and short-term follow-up. Our novel data demonstrating surgical treatments for LUTS/BPH showed no negative impact on postoperative EF except PVP. Moreover, HoLEP and PKEP were found pro-erectile effect for all subgroups. New technologies, such as LSP, PKRP, and Thulium laser, were ranked at top positions in the network analysis, although they had no pro-erectile effect in direct comparison due to limited original studies or poor baseline EF. Therefore, further studies and longer follow-up are required to substantiate our findings.

No MeSH data available.


A, Forest plot for the association of post-TURP versus pre-TURP IIEF-5 score. The association was indicated as standard mean difference (SMD) estimate with the corresponding 95% confidence interval (CI). The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function.B, Forest plot for the association of postoperative versus preoperative erectile function of PKRP and PKEP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. C, Forest plot for the association of postoperative versus preoperative erectile function of HoLEP, HoLRP, PVP, and Thulium laser. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. D, Forest plot for the association of postoperative versus preoperative erectile function of open prostatectomy and LSP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. HoLEP = Holmium laser enucleation of the prostate, HoLRP = Holmium laser resection of the prostate, LSP = laparoscopic simple prostatectomy, OP = open prostatectomy, PKEP = plasmakinetic enucleation of the prostate, PKRP = plasmakinetic resection of the prostate, PVP = photoselective vaporization of the prostate, TURP = transurethral resection of the prostate.
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Figure 2: A, Forest plot for the association of post-TURP versus pre-TURP IIEF-5 score. The association was indicated as standard mean difference (SMD) estimate with the corresponding 95% confidence interval (CI). The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function.B, Forest plot for the association of postoperative versus preoperative erectile function of PKRP and PKEP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. C, Forest plot for the association of postoperative versus preoperative erectile function of HoLEP, HoLRP, PVP, and Thulium laser. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. D, Forest plot for the association of postoperative versus preoperative erectile function of open prostatectomy and LSP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. HoLEP = Holmium laser enucleation of the prostate, HoLRP = Holmium laser resection of the prostate, LSP = laparoscopic simple prostatectomy, OP = open prostatectomy, PKEP = plasmakinetic enucleation of the prostate, PKRP = plasmakinetic resection of the prostate, PVP = photoselective vaporization of the prostate, TURP = transurethral resection of the prostate.

Mentions: There were 11 studies[35,37,39–42,45,47,49–51] including 24 direct comparisons of post-TURP IIEF-5 score with pre-TURP one. As shown in Fig. 2A, TURP significantly enhanced postoperative EF (P = 0.006, SMD = 0.15, 95% CI 0.04–0.26, I2 = 58.5%, P = 0.000). There were 8 studies[36,37,40,41,46,48,50,52] including 21 direct comparisons of post-PKRP IIEF-5 score with pretreatment one and there were 3 studies[44,47,48] including 12 direct comparisons for PKEP. As demonstrated in Fig. 2B, PKRP had no influence on EF (P = 0.545, SMD = 0.04, 95% CI −0.09 to 0.16, I2 = 59.9%, P = 0.000), whereas PKEP significantly increased postsurgery EF (P = 0.000, SMD = 0.29, 95% CI 0.19–0.39, I2 = 0.0%, P = 0.515). Laser technologies are widely used in prostate surgery. The present study covered HoLEP, HoLRP, PVP, and Thulium laser approaches, of which there were 4,[35,36,42,43] 1,[38] 4,[38–40,51] and 2[45,49] trials containing 9, 3, 9, and 3 direct post versus pretreatment comparisons, respectively. The pooled outcomes of all 4 kinds of laser technologies on EF were displayed in Fig. 2C, which suggested that HoLEP (P = 0.000, SMD = 0.40, 95% CI 0.24–0.56, I2 = 35.9%, P = 0.131) and Thulium laser (P = 0.016, SMD = 0.27, 95% CI 0.05–0.49, I2 = 0.0%, P = 0.851) had pro-erectile effect, whereas PVP (P = 0.045, SMD = −0.12, 95% CI −0.24 to −0.00, I2 = 0.0%, P = 0.458) deteriorated EF, and HoLRP (P = 0.682, SMD = 0.05, 95% CI −0.17 to 0.26, I2 = 0.0%, P = 0.956) showed no effect. The I2 for HoLEP indicated moderate-level heterogeneity and the I2 for HoLRP, PVP, and Thulium laser showed no heterogeneity. LSP mimics OP with less invasive. There were 3 studies[43,44,52] including 9 direct comparisons of post-OP IIEF-5 score with pre-OP one, and there was 1[46] study containing 5 direct comparisons for LSP. As shown in Fig. 2D, both OP (P = 0.220, SMD = 0.19, 95% CI −0.11 to 0.49, I2 = 76.3%, P = 0.000) and LSP (P = 0.831, SMD = 0.02, 95%CI −0.18 to 0.23, I2 = 0.0%, P = 0.999) had no impact on EF with high-level heterogeneity for OP and no heterogeneity for LSP. In general (Fig. 2A–D), all surgical approaches for LUTS/BPH except PVP did not decrease EF when directly comparing postoperative IIEF-5 score with preoperative one. Moreover, patients who underwent HoLEP, PKEP, Thulium laser, and TURP had their postoperative EF significantly increased.


The impact of surgical treatments for lower urinary tract symptoms/benign prostatic hyperplasia on male erectile function
A, Forest plot for the association of post-TURP versus pre-TURP IIEF-5 score. The association was indicated as standard mean difference (SMD) estimate with the corresponding 95% confidence interval (CI). The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function.B, Forest plot for the association of postoperative versus preoperative erectile function of PKRP and PKEP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. C, Forest plot for the association of postoperative versus preoperative erectile function of HoLEP, HoLRP, PVP, and Thulium laser. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. D, Forest plot for the association of postoperative versus preoperative erectile function of open prostatectomy and LSP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. HoLEP = Holmium laser enucleation of the prostate, HoLRP = Holmium laser resection of the prostate, LSP = laparoscopic simple prostatectomy, OP = open prostatectomy, PKEP = plasmakinetic enucleation of the prostate, PKRP = plasmakinetic resection of the prostate, PVP = photoselective vaporization of the prostate, TURP = transurethral resection of the prostate.
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Related In: Results  -  Collection

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Figure 2: A, Forest plot for the association of post-TURP versus pre-TURP IIEF-5 score. The association was indicated as standard mean difference (SMD) estimate with the corresponding 95% confidence interval (CI). The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function.B, Forest plot for the association of postoperative versus preoperative erectile function of PKRP and PKEP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. C, Forest plot for the association of postoperative versus preoperative erectile function of HoLEP, HoLRP, PVP, and Thulium laser. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. D, Forest plot for the association of postoperative versus preoperative erectile function of open prostatectomy and LSP. The association was indicated as SMD estimate with the corresponding 95% CI. The SMD estimate of each study is marked with a solid black square. The size of the square represents the weight that the corresponding study exerts in the meta-analysis. SMD less than 0 indicates decreased erectile function. HoLEP = Holmium laser enucleation of the prostate, HoLRP = Holmium laser resection of the prostate, LSP = laparoscopic simple prostatectomy, OP = open prostatectomy, PKEP = plasmakinetic enucleation of the prostate, PKRP = plasmakinetic resection of the prostate, PVP = photoselective vaporization of the prostate, TURP = transurethral resection of the prostate.
Mentions: There were 11 studies[35,37,39–42,45,47,49–51] including 24 direct comparisons of post-TURP IIEF-5 score with pre-TURP one. As shown in Fig. 2A, TURP significantly enhanced postoperative EF (P = 0.006, SMD = 0.15, 95% CI 0.04–0.26, I2 = 58.5%, P = 0.000). There were 8 studies[36,37,40,41,46,48,50,52] including 21 direct comparisons of post-PKRP IIEF-5 score with pretreatment one and there were 3 studies[44,47,48] including 12 direct comparisons for PKEP. As demonstrated in Fig. 2B, PKRP had no influence on EF (P = 0.545, SMD = 0.04, 95% CI −0.09 to 0.16, I2 = 59.9%, P = 0.000), whereas PKEP significantly increased postsurgery EF (P = 0.000, SMD = 0.29, 95% CI 0.19–0.39, I2 = 0.0%, P = 0.515). Laser technologies are widely used in prostate surgery. The present study covered HoLEP, HoLRP, PVP, and Thulium laser approaches, of which there were 4,[35,36,42,43] 1,[38] 4,[38–40,51] and 2[45,49] trials containing 9, 3, 9, and 3 direct post versus pretreatment comparisons, respectively. The pooled outcomes of all 4 kinds of laser technologies on EF were displayed in Fig. 2C, which suggested that HoLEP (P = 0.000, SMD = 0.40, 95% CI 0.24–0.56, I2 = 35.9%, P = 0.131) and Thulium laser (P = 0.016, SMD = 0.27, 95% CI 0.05–0.49, I2 = 0.0%, P = 0.851) had pro-erectile effect, whereas PVP (P = 0.045, SMD = −0.12, 95% CI −0.24 to −0.00, I2 = 0.0%, P = 0.458) deteriorated EF, and HoLRP (P = 0.682, SMD = 0.05, 95% CI −0.17 to 0.26, I2 = 0.0%, P = 0.956) showed no effect. The I2 for HoLEP indicated moderate-level heterogeneity and the I2 for HoLRP, PVP, and Thulium laser showed no heterogeneity. LSP mimics OP with less invasive. There were 3 studies[43,44,52] including 9 direct comparisons of post-OP IIEF-5 score with pre-OP one, and there was 1[46] study containing 5 direct comparisons for LSP. As shown in Fig. 2D, both OP (P = 0.220, SMD = 0.19, 95% CI −0.11 to 0.49, I2 = 76.3%, P = 0.000) and LSP (P = 0.831, SMD = 0.02, 95%CI −0.18 to 0.23, I2 = 0.0%, P = 0.999) had no impact on EF with high-level heterogeneity for OP and no heterogeneity for LSP. In general (Fig. 2A–D), all surgical approaches for LUTS/BPH except PVP did not decrease EF when directly comparing postoperative IIEF-5 score with preoperative one. Moreover, patients who underwent HoLEP, PKEP, Thulium laser, and TURP had their postoperative EF significantly increased.

View Article: PubMed Central - PubMed

ABSTRACT

Lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) is common in adult men and can impair erectile function (EF). It was believed surgical treatments for this illness can improve EF due to the relief of LUTS while they were also reported harmed EF as heating or injury effect. Current network meta-analysis aimed to elucidate this discrepancy.

Randomized controlled trials (RCTs) were identified. Direct comparisons were conducted by STATA and network meta-analysis was conducted by Generate Mixed Treatment Comparison. Random-effects models were used to calculate pooled standard mean difference and 95% confidence intervals and to incorporate variation between studies.

Eighteen RCTs with 2433 participants were analyzed. Nine approaches were studied as transurethral resection of the prostate (TURP), plasmakinetic resection of the prostate (PKRP), plasmakinetic enucleation of the prostate (PKEP), Holmium laser enucleation of the prostate (HoLEP), Holmium laser resection of the prostate (HoLRP), photoselective vaporization of the prostate (PVP), Thulium laser, open prostatectomy (OP), and laparoscopic simple prostatectomy (LSP). In direct comparisons, all surgical treatments did not decrease postoperative International Index of Erectile Function (IIEF)-5 score except PVP. Moreover, patients who underwent HoLEP, PKEP, Thulium laser, and TURP had their postoperative EF significantly increased. Network analysis including direct and indirect comparisons ranked LSP at the highest position on the variation of postoperative IIEF-5 score, followed by PKRP, HoLEP, TURP, Thulium laser, PKEP, PVP, HoLRP, and OP. In subgroup analysis, only PVP was found lower postoperative EF in the short term and decreased baseline group, whereas TURP increased postoperative IIEF-5 score only for patients with normal baseline EF. However, HoLEP and PKEP showed pro-erectile effect even for patients with decreased baseline EF and short-term follow-up. Our novel data demonstrating surgical treatments for LUTS/BPH showed no negative impact on postoperative EF except PVP. Moreover, HoLEP and PKEP were found pro-erectile effect for all subgroups. New technologies, such as LSP, PKRP, and Thulium laser, were ranked at top positions in the network analysis, although they had no pro-erectile effect in direct comparison due to limited original studies or poor baseline EF. Therefore, further studies and longer follow-up are required to substantiate our findings.

No MeSH data available.