Should we perform Retzius‐sparing RALP or standard RALP for | Figure 1

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Should we perform Retzius‐sparing RALP or standard RALP for clinically localized prostate cancer?

Review question
In men with prostate cancer who are having their prostate removed using surgery assisted by a robotic device (called robotic‐assisted laparoscopic prostatectomy or RALP), how does an approach that leaves the tissue connections between the front of the bladder to the back of the abdominal wall intact (so‐called Retzius‐sparing RALP) compare to surgery where these connections are cut (standard RALP).

Background

Urologists often use a robot to remove the prostate in men with prostate cancer. After surgery, men have a catheter that drains urine from their bladder. When this is removed, most men leak urine for some time. This problem is called incontinence and usually gets better within six to 12 months in most men. However, it can be very bothersome during this time.

Study characteristics

We included five studies in which chance determined whether men had Retzius‐sparing RALP or standard RALP. These studies included 571 men with an average age of about 65 years. The average prostate‐specific antigen level (PSA; higher levels of which may indicate that the man has prostate cancer) was 6.9 ng/mL and a little over half (54.2%) had prostate cancer that was found based on the PSA level but could not felt on rectal exam. In 233/331 (70.4%) men, they tried to spare the nerves that are responsible for erections.

Key results

We found that the Retzius‐sparing RALP probably improves continence within one week after the catheter comes out. It may also improve continence three months after surgery. We are very uncertain how serious unwanted effects compare between the two ways of doing the surgery.

Continence after Retzius‐sparing RALP may also be better after six months. At 12 months, continence is probably similar.

Men who have Retzius‐sparing RALP may be more likely to have positive surgical margins, meaning they still have cancer cells right at the cut edge of the prostate when viewed under the microscope. This may make it more likely that the cancer will come back. We are very uncertain about the effect of Retzius‐sparing RALP on PSA level that goes up within 12 months of surgery, which signals that there is cancer left behind. Urinary quality of life at three months may be similar with both types of surgery. We are very uncertain how Retzius‐sparing RALP affects the ability to achieve an erection.

Quality of the evidence

The quality of evidence ranged from moderate to very low depending on the outcome, meaning that we have moderate to very low confidence in the results.

Read the full Cochrane Review here

Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction

Review question

How does surgery using bipolar technology compare with traditional monopolar technology for men with an enlarged prostate causing difficulty with urination?

Background

People with an enlarged prostate can experience difficulty passing urine. This occurs because the enlarged prostate compresses the urinary tube from which urine leaves the bladder. One option for treatment of this condition is telescopic surgery, which acts to remove prostate tissue and relieve the blockage. This is traditionally performed using a technology called monopolar TURP (short for 'transurethral resection of the prostate'). In recent times, a technique called bipolar TURP has been developed. This approach uses saline instead of other watery fluids and may put men at lower risk for a problem called TUR syndrome, which is a rare but potentially serious complication caused by fluid absorption, but it is unclear how the two procedures compare overall.

Study characteristics

We searched the medical literature for clinical trials up to 19 March 2019. We found 59 randomised trials that compared BTURP with MTURP. These studies included a total of 8924 patients. The longest period of follow‐up for the outcomes of interest was 12 months after treatment.

Key results

Compared to MTURP, BTURP probably results in similar reduction in urinary symptoms and bother. It probably slightly reduces both the risk of TUR syndrome and the need for blood transfusion. Erectile function is probably similar after both procedures, as is the risk of urinary incontinence and the need for a repeat procedure.

Quality of evidence

The quality of evidence for the outcomes of ability to pass urine, patient bother, TUR syndrome, need for blood transfusion, and erectile function was considered to be moderate. The quality of evidence for the outcomes of urinary leakage after the procedure and need for a repeat procedure was low.

Convective radiofrequency water vapour thermal therapy for lower urinary tract symptoms in men with benign prostatic hyperplasia

Review Question

What are the effects of convective radiofrequency water vapour thermal therapy in men with bothersome urinary symptoms because of an enlarged prostate?

Background

Prostate enlargement is common in older men, and can cause bothersome urinary symptoms, such as having to pass their water (voiding) often, a weak stream while voiding, or dribbling. If lifestyle changes and medications don't help, a variety of surgical procedures, including transurethral resection of the prostate (TURP), can improve these symptoms. They may also cause unwanted effects, such as problems with ejaculation or erections. Recently, a new procedure called 'convective radiofrequency water vapour thermal therapy' has become available. It is unclear how it compares to other treatments, such as TURP.

Study characteristics

We found a single study, with 197 men, that compared convective radiofrequency water vapour thermal therapy to a sham procedure (men were made to believe they received treatment, while in reality, they did not), funded by the device company. The men's average age was 62.9 years, and most had a moderate degree of bothersome urinary symptoms.

Key results

Compared to a sham procedure, and with a three‐month follow‐up, convective radiofrequency water vapour thermal therapy may improve urinary symptoms (low certainty of evidence). Convective radiofrequency water vapour thermal therapy also likely improves quality of life (moderate certainty of evidence). We are very uncertain whether serious unwanted side effects are more common or not (very low certainty of evidence). Men's erections and ejaculations may be similar in men who have convective radiofrequency water vapour thermal therapy and those who receive the sham procedure (low certainty of evidence).

Findings of this review are up to date until 18 February 2020.

Certainty of the evidence

We judged the certainty of the evidence for the outcomes to be moderate, low or very low. Reasons for not being so confident had to do with the study design and the study size.