The Efficacy and Safety of Laser and Electrosurgical Transurethral Procedures for the Treatment of BPO in High-Risk Patients: A Systematic Review.

Objective: To compare efficacy and safety outcomes of GreenLight, Holmium and Thulium laser  techniques with standard monopolar and bipolar transurethral resection of the prostate (TURP) in high-risk patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). Methods: We conducted a systematic literature review of studies in patients undergoing BPO surgeries who may be considered high-risk for standard TURP, with higher risk defined as follows: large prostates (≥80 mL) and/or taking antithrombotic agents and/or urinary retention and/or age >80 years and/or significant comorbidity.  Outcomes summarised included bleeding complications, re-intervention rates, hospital length of stay, and standard measures of disease and symptom severity for all available timepoints. Results: A total of 276 studies of 32,722 patients reported relevant data. Studies were heterogeneous in methodology, population and outcomes reported. IPSS reduction, Qmax improvement and PVR were similar across all interventions. Mean values at baseline and after 12 months across interventions were 13.2-29 falling to 2.3-10.8 for IPSS, 0-19 mL/s increasing to 7.5-34.1 mL/s for Qmax and 41.4-954 mL falling to 5.1-138.3 mL for PVR. Laser treatments show some advantages compared with monopolar and bipolar TURP for some adverse events and safety parameters such as bleeding complications. Duration of hospital stay, reinterventions and recatheterisations were lower with GreenLight, HoLEP, Thulium lasers, and bipolar enucleation than TURP. Conclusions: Laser therapies are effective and well-tolerated treatment options in high-risk patients with BPO compared with monopolar or bipolar TURP. The advantageous safety profile of laser treatments means that patients with a higher bleeding risk should be offered laser surgery preferentially to mTURP or bTURP.