Three RCTs (230 patients), one comparative study with historical controls (132 patients) and 13 case series (between 2,188 and 2,569 patients) assessed HoLRP. Two RCTs (182 patients), one comparative study with historical controls (111 patients) and 10 case series (847 patients) assessed HoLEP. Nineteen RCTs provided TURP study arms (1,682 patients).
The evidence-base was rated as average.
Four of the 5 RCTs were of poor quality. Methodological flaws included: inadequate description of the methods used for randomisation, allocation concealment and blinding; no power calculations; no estimates of outcome effect sizes or CIs; limited information on the inclusion and exclusion criteria; and a lack of reporting the losses to follow-up in 3 RCTs.
The comparative studies suffered from several methodological flaws: a lack of detail about the methods used to select the sample; no inclusion or exclusion criteria; a lack of reporting the adverse events in one study; no actual outcome data reported; and a lack of clarity in reporting data and whether there were any losses to follow-up.
The case series suffered from a number of problems: the difficulty in establishing the extent of overlap in samples between reports; the wide variety of pre-, peri- and post-operative outcomes; inadequate reporting of the outcomes; and considerable losses to follow-up (up to 50% for some series) without reasons.
The holmium laser procedures were considered at least as safe as TURP in terms of blood loss, rate of stricture and urinary tract infection. The relative safety of the holmium laser could not be determined with respect to mortality, perforation rate and other complications.
Both HoLRP and HoLEP reduced several indicators of blood loss (transfusion rates, post-operative bladder irrigation, and duration of catheterisation and length of hospital stay) compared with TURP.
Transfusion rates (3 RCTs): holmium laser treatment significantly reduced transfusion rates compared with TURP (RR 0.2, 95% CI: 0.0, 0.9). No significant heterogeneity was found (P=0.87).
Post-operative bladder irrigation (1 RCT): patients having HoLRP required significantly less post-operative irrigant compared with TURP (WMD 27.5 mL, 95% CI: 21.7, 33.3). Duration of catheterisation: patients required a significantly shorter period of catheterisation after HoLRP compared with TURP; the mean duration (2 RCTs) was -0.8 days (95% CI: -1.0, -0.7). Borderline significant heterogeneity was found (p=0.096). Another 3 RCTs (not included in the meta-analysis) found similar results favouring holmium laser treatment: 1.9 days with HoLRP versus 3.2 days with TURP; a difference of -1.2 days (95% CI: -2.0, -0.4) in favour of HoLEP; and a median duration of catheterisation of 1.0 days with HoLEP versus 2.0 days with TURP (p less than or equal to 0.001).
Duration of hospital stay: in comparison with TURP, patients had a significantly shorter hospital stay after HoLRP: the mean duration (2 RCTs) was -0.9 days (95% CI: -1.1, -0.7, p=0.79). Two other RCTs (not included in the meta-analysis) found similar results: a difference of -1.2 days (95% CI: -2.0, -0.4) in favour of HoLEP; and a median stay of 2.0 days with HoLEP versus 3.0 days with TURP (p<0.001).
Strictures and urinary infection: HoLRP and HoLEP appeared to have similar rates of stricture and urinary infection in comparison with TURP. The RR was 3.0 (95% CI: 0.1, 76.4) for urethral stricture (1 RCT of HoLEP), 5.2 (95% CI: 0.2, 110.0) for bladder neck stricture (1 RCT of HoLEP), 0.5 (95% CI: 0.0, 5.4) and 0.8 (95% CI: 0.2, 3.1) for meatal stricture (1 RCT of HoLEP and 1 RCT of HoLRP, respectively), and 0.3 (95% CI: 0.0, 8.0) and 0.4 (95% CI: 0.0, 5.1) for bulbar or penile (1 RCT of HoLEP and 1 RCT of HoLRP, respectively). There was no significant difference between holmium laser and TURP for urinary infections; the RR (2 RCTs) was 0.4 (95% CI: 0.1, 1.5, p=0.55).
Other: there was insufficient good quality data to compare mortality and rates of perforation and other complications between HoLRP or HoLEP with TURP.
The holmium laser procedure was at least as efficacious as TURP in the short term, but long-term efficacy could not be determined.
HoLRP and HoLEP appeared to produce similar levels of symptom relief compared with TURP. There was no significant difference in symptom scores between holmium laser and TURP at 6 or 12 months post- operatively; the WMD was -0.9 (95% CI: -2.1, 0.2, p=0.07) at 6 months (3 RCTs) and -0.4 (95% CI: -1.8, 1.1, p=0.69) at 12 months (2 RCTs).
Both holmium laser treatment and TURP retrieved sufficient tissue for the detection of undiagnosed prostate cancer, although no studies directly compared holmium laser with TURP for this outcome. One RCT detected prostate cancer in 11.8% of patients having TURP, compared with 0% of those having HoLRP. One comparative study found prostate cancer in 5.5% of patients having HoLEP. Seven case series of HoLRP detected prostate cancer in between 0 and 11.4% of the patients. Ten case series of TURP detected prostate cancer in between 1.7 and 21% of the patients.
TURP reduced operating time in comparison with holmium laser treatment; the WMD (2 RCTs) was 19.3 minutes (95% CI: 13.5, 25.1). There was insufficient long-term follow-up data to compare the durability of HoLRP or HoLEP and TURP.
Results were also reported for all the outcomes listed in the 'Outcomes Assessed' section.