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Meta-Analysis
. 2021 Jun 28;6(6):CD004135.
doi: 10.1002/14651858.CD004135.pub4.

Transurethral microwave thermotherapy for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

Juan Va Franco  1 , Luis Garegnani  2 , Camila Micaela Escobar Liquitay  3 , Michael Borofsky  4 , Philipp Dahm  5
Affiliations
Meta-Analysis

Transurethral microwave thermotherapy for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia

Juan Va Franco et al. Cochrane Database Syst Rev. .

Abstract

Background: Transurethral resection of the prostate (TURP) has been the gold-standard treatment for alleviating urinary symptoms and improving urinary flow in men with symptomatic benign prostatic hyperplasia (BPH). However, the morbidity of TURP approaches 20%, and less invasive techniques have been developed for treating BPH. Transurethral microwave thermotherapy (TUMT) is an alternative, minimally-invasive treatment that delivers microwave energy to produce coagulation necrosis in prostatic tissue. This is an update of a review last published in 2012.

Objectives: To assess the effects of transurethral microwave thermotherapy for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia.

Search methods: We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Web of Science, and LILACS), trials registries, other sources of grey literature, and conference proceedings published up to 31 May 2021, with no restrictions by language or publication status.

Selection criteria: We included parallel-group randomized controlled trials (RCTs) and cluster-RCTs of participants with BPH who underwent TUMT.

Data collection and analysis: Two review authors independently assessed studies for inclusion at each stage and undertook data extraction and risk of bias and GRADE assessments of the certainty of the evidence (CoE). We considered review outcomes measured up to 12 months after randomization as short-term and beyond 12 months as long-term. Our main outcomes included: urologic symptoms scores, quality of life, major adverse events, retreatment, and ejaculatory and erectile function.

Main results: In this update, we identified no new RCTs, but we included data from studies excluded in the previous version of this review. We included 16 trials with 1919 participants, with a median age of 69 and moderate lower urinary tract symptoms. The certainty of the evidence for most comparisons was moderate-to-low, due to an overall high risk of bias across studies and imprecision (few participants and events). TUMT versus TURP Based on data from four studies with 306 participants, when compared to TURP, TUMT probably results in little to no difference in urologic symptom scores measured by the International Prostatic Symptom Score (IPSS) on a scale from 0 to 35, with higher scores indicating worse symptoms at short-term follow-up (mean difference (MD) 1.00, 95% confidence interval (CI) -0.03 to 2.03; moderate certainty). There is likely to be little to no difference in the quality of life (MD -0.10, 95% CI -0.67 to 0.47; 1 study, 136 participants, moderate certainty). TUMT likely results in fewer major adverse events (RR 0.20, 95% CI 0.09 to 0.43; 6 studies, 525 participants, moderate certainty); based on 168 cases per 1000 men in the TURP group, this corresponds to 135 fewer (153 to 96 fewer) per 1000 men in the TUMT group. TUMT, however, probably results in a large increase in the need for retreatment (risk ratio (RR) 7.07, 95% CI 1.94 to 25.82; 5 studies, 337 participants, moderate certainty) (usually by repeated TUMT or TURP); based on zero cases per 1000 men in the TURP group, this corresponds to 90 more (40 to 150 more) per 1000 men in the TUMT group. There may be little to no difference in erectile function between these interventions (RR 0.63, 95% CI 0.24 to 1.63; 5 studies, 337 participants; low certainty). However, TUMT may result in fewer cases of ejaculatory dysfunction compared to TURP (RR 0.36, 95% CI 0.24 to 0.53; 4 studies, 241 participants; low certainty). TUMT versus sham Based on data from four studies with 483 participants we found that, when compared to sham, TUMT probably reduces urologic symptom scores using the IPSS at short-term follow-up (MD -5.40, 95% CI -6.97 to -3.84; moderate certainty). TUMT may cause little to no difference in the quality of life (MD -0.95, 95% CI -1.14 to -0.77; 2 studies, 347 participants; low certainty) as measured by the IPSS quality-of-life question on a scale from 0 to 6, with higher scores indicating a worse quality of life. We are very uncertain about the effects on major adverse events, since most studies reported no events or isolated lesions of the urinary tract. TUMT may also reduce the need for retreatment compared to sham (RR 0.27, 95% CI 0.08 to 0.88; 2 studies, 82 participants, low certainty); based on 194 retreatments per 1000 men in the sham group, this corresponds to 141 fewer (178 to 23 fewer) per 1000 men in the TUMT group. We are very uncertain of the effects on erectile and ejaculatory function (very low certainty), since we found isolated reports of impotence and ejaculatory disorders (anejaculation and hematospermia). There were no data available for the comparisons of TUMT versus convective radiofrequency water vapor therapy, prostatic urethral lift, prostatic arterial embolization or temporary implantable nitinol device.

Authors' conclusions: TUMT provides a similar reduction in urinary symptoms compared to the standard treatment (TURP), with fewer major adverse events and fewer cases of ejaculatory dysfunction at short-term follow-up. However, TUMT probably results in a large increase in retreatment rates. Study limitations and imprecision reduced the confidence we can place in these results. Furthermore, most studies were performed over 20 years ago. Given the emergence of newer minimally-invasive treatments, high-quality head-to-head trials with longer follow-up are needed to clarify their relative effectiveness. Patients' values and preferences, their comorbidities and the effects of other available minimally-invasive procedures, among other factors, can guide clinicians when choosing the optimal treatment for this condition.

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Conflict of interest statement

JVAF: none known. LG: none known. CMEL: none known. MB: Boston Scientific (consultant for endourology and stone management), Auris Health (consultant for robotic surgery and endourology). PD: none known.

Figures

1
1
PRISMA 2020 flow diagram.
2
2
1.1
1.1. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 1: Urologic symptoms score (IPSS)
1.2
1.2. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 2: Urologic symptoms score (Madsen‐Iversen)
1.3
1.3. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 3: Urologic symptoms score (SMD) ‐ long‐term
1.4
1.4. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 4: Urologic symptoms score (IPSS) ‐ subgroup analysis (severity)
1.5
1.5. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 5: Quality of life
1.6
1.6. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 6: Quality of life ‐ long term
1.7
1.7. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 7: Major adverse events
1.8
1.8. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 8: Major adverse events ‐ subgroup analysis (severity)
1.9
1.9. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 9: Retreatment
1.10
1.10. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 10: Erectile function
1.11
1.11. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 11: Ejaculatory function
1.12
1.12. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 12: Minor adverse events
1.13
1.13. Analysis
Comparison 1: Transurethral microwave thermotherapy versus transurethral resection of the prostate (TURP), Outcome 13: Acute urinary retention
2.1
2.1. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 1: Urologic symptom scores (IPSS/AUA)
2.2
2.2. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 2: Urologic symptom scores (Madsen score)
2.3
2.3. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 3: Urologic symptom scores (IPSS/AUA) ‐ subgroup (severity)
2.4
2.4. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 4: Urologic symptom score (responder analysis)
2.5
2.5. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 5: Quality of Life
2.6
2.6. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 6: Retreatment
2.7
2.7. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 7: Minor adverse events
2.8
2.8. Analysis
Comparison 2: Transurethral microwave thermotherapy versus sham treatment, Outcome 8: Acute urinary retention
See this image and copyright information in PMC

Update of

References

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References to studies excluded from this review

Albala 2000 {published data only}
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References to studies awaiting assessment

Albala 2000a {published data only}
    1. Albala DM, Turk TM, Fulmer BR, Koleski F, Andriole G, Davis BE, et al. Periurethral transurethral microwave thermotherapy for the treatment of benign prostatic hyperplasia: An interim 1-year safety and efficacy analysis using the TherMatrx TMx-2000â„¢. Techniques in Urology 2000;6(4):288-93. - PubMed
Dahlstrand 1994 {published data only}
    1. Dahlstrand C, Waldén M, Geirsson G, Sommar S, Pettersson S. Transurethral microwave thermotherapy versus transurethral resection for BPH. Progress in Clinical and Biological Research 1994;386:455-61. - PubMed
Dahlstrand 1997 {published data only}
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Dahlstrand 1998 {published data only}
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References to other published versions of this review

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