The impact of surgical treatments for lower urinary tract symptoms/benign prostatic hyperplasia on male erectile function: A systematic review and network meta-analysis

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.

Figure 1

Flowchart of literature searches.

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.

Figure 3

A, Comparison network of included studies. The size of each point estimates the number of each procedure. The font-weight of each line estimates the number of study which links 2 procedures. B, Rank probability of each procedure from network analysis. Rank 1 is the best result for a given outcome; rank 9 is the worst result for a given outcome. The size of the histogram bar is proportional to the probability of achieving that particular rank for the outcome. 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.

Figure 4

A, Forest plot of short-term subgroup analysis for the association of postoperative versus preoperative erectile function of 8 involved procedures. 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 of long-term subgroup analysis for the association of postoperative versus preoperative erectile function of TURP, 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 of long-term subgroup analysis for the association of postoperative versus preoperative erectile function of HoLEP, HoLRP, PVP, Thulium laser, OP, 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.

Figure 5

A, Forest plot of normal baseline IIEF-5 score for the association of postoperative versus preoperative erectile function of three involved procedures. 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 of decreased baseline IIEF-5 score for the association of postoperative versus preoperative erectile function of TURP. 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 risk of erectile function. C, Forest plot of decreased baseline IIEF-5 score for the association of postoperative versus preoperative erectile function of PKRP and HoLRP. 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 of decreased baseline IIEF-5 score for the association of postoperative versus preoperative erectile function of Thulium laser, OP, 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. E, Forest plot of decreased baseline IIEF-5 score for the association of postoperative versus preoperative erectile function of PKEP, HoLEP, and PVP. 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, LSP = laparoscopic simple prostatectomy, OP = open prostatectomy, PKEP = plasmakinetic enucleation of the prostate, PVP = photoselective vaporization of the prostate, TURP = transurethral resection of the prostate.