The review included 45 trials, all of which were judged as moderate or poor quality. Only 3 studies performed an appropriate intention-to-treat analysis.
The meta-analysis was based on 47 comparisons (3,970 participants).
There were no significant differences in change in symptom score for any intervention.
Holmium laser enucleation was associated with larger changes in peak urine flow rate at 12 months compared with transurethral resection of the prostate (WMD 1.48 mL/second, 95% confidence interval, CI: 0.58, 2.40, p=0.002). There was no significant difference in change in flow rate for any of the other interventions.
There was no difference in quality of life between any of the interventions and transurethral resection of the prostate, although this result was based on few studies and low statistical power.
Compared with transurethral resection of the prostate, there were lower rates of blood transfusion after holmium laser enucleation (RR 0.27, 95% CI: 0.07, 0.95, p=0.04), laser vaporisation (RR 0.14, 95% CI: 0.05, 0.42, p=0.004) and transurethral vaporisation (RR 0.18, 95% CI: 0.07, 0.46, p<0.001).
The risk of urinary retention requiring recatheterisation was higher after laser vaporisation (RR 2.89, 95% CI: 1.55, 5.42, p<0.001) and transurethral vaporisation (RR 3.10, 95% CI: 1.53, 6.29, p=0.002), than after transurethral resection of the prostate. There were no differences in risk between holmium laser enucleation or bipolar transurethral resection and transurethral resection of the prostate. There were insufficient data on transurethral vaporesection for analysis.
Strictures were less common after laser vaporisation than after transurethral resection of the prostate (RR 0.54, 95% CI: 0.32, 0.90, p=0.02). There were no differences in risk between any of the other interventions and transurethral resection of the prostate.
Laser vaporisation was associated with a higher risk of incontinence than transurethral resection of the prostate, but this effect was driven by one study (RR 2.24, 95% CI: 1.03, 4.88, p=0.04) and the type of incontinence was not described. There was no significant difference in risk for any of the other interventions.
There was no significant difference in risk of urinary tract infection when comparing any of the interventions with transurethral resection of the prostate.
Laser vaporisation (RR 0.22, 95% CI: 0.13, 0.39, p<0.001) and transurethral vaporisation (RR 0.78, 95% CI: 0.64, 0.95, p<0.01) were both associated with a reduced risk of loss of ejaculation compared with transurethral resection of the prostate. Laser vaporisation (RR 8.89, 95% CI: 1.29, 61.37, p=0.03) was associated with a higher risk of erectile dysfunction compared with transurethral resection of the prostate. None of the other interventions were associated with an altered risk of sexual function.
In terms of duration of the operation, holmium laser enucleation took an average of 17 minutes longer (95% CI: 13.45, 20.47, p<0.001) to perform than transurethral resection of the prostate.
Length of hospital stay was significantly shorter for each intervention than for transurethral resection of the prostate, by between 0.5 and 1.5 days.
Reoperation was more likely after laser vaporisation than after transurethral resection (RR 1.68, 95% CI: 1.03, 2.74, p=0.004).