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BMJ Clin Evid. 2006; 2006: 1801.
Published online 2006 April 1.
PMCID: PMC2907637

Benign prostatic hyperplasia

Robyn Webber, Consultant Urologist

Abstract

Introduction

Symptomatic benign prostatic hyperplasia (BPH) may affect up to 30% of men in their early 70s, causing urinary symptoms of bladder outlet obstruction. Symptoms can improve without treatment, but the usual course is a slow progression of symptoms, with acute urinary retention occurring in 1-2% of men with BPH per year.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of medical, surgical, and herbal treatments? We searched: Medline, Embase, The Cochrane Library and other important databases up to May 2005 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 43 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: 5 alpha-reductase inhibitors, alpha-blockers, beta-sitosterol plant extract, less-invasive surgical techniques, pygeum africanum, rye grass pollen extract, saw palmetto plant extracts, transurethral microwave thermotherapy, transurethral needle ablation, and transurethral resection.

Key Points

Symptomatic benign prostatic hyperplasia (BPH) may affect up to 30% of men in their early 70s, causing urinary symptoms of bladder outlet obstruction.

  • Symptoms can improve without treatment, but the usual course is a slow progression of symptoms, with acute urinary retention occurring in 1-2% of men with BPH per year.

Alpha blockers improve symptoms compared with placebo and with finasteride, and may be most effective in men with more severe symptoms of BPH or with hypertension.

CAUTION: Since the last update of this topic, a drug safety alert has been issued on risk of intraoperative floppy iris syndrome during cataract surgery with tamsulosin (www.mhra.gov.uk).

5 alpha-reductase inhibitors (finasteride) improve symptoms and reduce complications compared with placebo, and may be more effective in men with larger prostates.

Transurethral resection of the prostate (TURP) improves symptoms of BPH more than watchful waiting, and has not been shown to increase the risk of erectile dysfunction or incontinence.

  • Less invasive surgical techniques such as transurethral incision or laser ablation seem to be as effective as TURP at improving symptoms.
  • TURP may be more effective at improving symptoms and preventing retreatment compared with transurethral microwave thermotherapy, but causes more complications.
  • Transurethral microwave thermotherapy reduces symptoms compared with sham treatment or with alpha blockers, but long term effects are unknown.
  • We don't know whether transurethral needle ablation is effective.

Saw palmetto plant extracts may be as effective as alpha blockers and 5 alpha-reductase inhibitors, but few studies have been done.

About this condition

Definition

Benign prostatic hyperplasia is defined histologically. Clinically, it is characterised by lower urinary tract symptoms (urinary frequency, urgency, a weak and intermittent stream, needing to strain, a sense of incomplete emptying, and nocturia) and can lead to complications, including acute urinary retention.

Incidence/ Prevalence

Estimates of the prevalence of symptomatic benign prostatic hyperplasia range from 10-30% for men in their early 70s, depending on how benign prostatic hyperplasia is defined.

Aetiology/ Risk factors

The mechanisms by which benign prostatic hyperplasia causes symptoms and complications are unclear, although bladder outlet obstruction is an important factor. The best documented risk factors are increasing age and normal testicular function.

Prognosis

Community and practice based studies suggest that men with lower urinary tract symptoms can expect slow progression of symptoms. However, symptoms can wax and wane without treatment. In men with symptoms of benign prostatic hyperplasia, rates of acute urinary retention range from 1-2% a year.

Aims of intervention

To reduce or alleviate lower urinary tract symptoms; to prevent complications; and to minimise adverse effects of treatment.

Outcomes

Burden of lower urinary tract symptoms, including peak urinary flow rate; residual urine volume; rates of acute urinary retention and prostatectomy; self rated improvement; and adverse effects of treatment. Symptoms are measured using the validated International Prostate Symptom Score, which includes seven questions measuring symptoms on an overall scale from 0-35, with higher scores representing more frequent symptoms. RCTs reported in this chapter used a variety of symptom based assessment instruments, including the Boyarsky Symptom Score and the American Urological Association Symptom Index (AUASI).

Methods

BMJ Clinical Evidence search and appraisal May 2005. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table
GRADE evaluation of interventions for benign prostatic hyperplasia

Glossary

American Urological Association Symptom Index (AUASI)
is a patient questionnaire which asks seven questions about the severity of symptoms (range 0–35). Mild symptoms score 0–7 points, moderate symptoms 8–19 points, and severe symptoms 20–35 points.
High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
International Prostate Symptom Score (IPSS)
is a patient questionnaire which is essentially the same as the AUASI questionnaire (see above). See benefits of alpha-blockers.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Transurethral microwave thermotherapy (TUMT)
involves the use of a special catheter that contains a microwave antenna. This is passed into the urethra and heats the prostate, which subsequently necroses.
Transurethral needle ablation (TUNA)
uses radiofrequency energy, applied through two needle electrodes, which are inserted into the prostate transurethrally. Following the application of radiofrequency energy, the prostate necroses.
Transurethral resection of the prostate (TURP)
is performed endoscopically. Cutting diathermy is used to cut away the tissue. Any bleeding is treated by electrocautery and the pieces of prostatic tissue are washed out of the bladder.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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2006; 2006: 1801.
Published online 2006 April 1.

Alpha-blockers

Summary

SYMPTOM IMPROVEMENT Any alpha-blocker compared with placebo: Alpha-blockers may be more effective at improving symptom scores ( low-quality evidence ). Tamsulosin compared with placebo: Tamsulosin is more effective at improving Boyarsky symptom scores but not at improving peak urine flow. In men catheterised for acute urinary retention, tamsulosin is more effective at increasing the proportion of men not requiring recatheterisation following trial removal of the cathether ( moderate-quality evidence ). Terazosin compared with placebo: Terazosin is more effective at improving symptom scores and number of episodes of nocturia (moderate-quality evidence). Alfuzosin compared with placebo: Alfuzosin is more effective at improving IPPS scores, peak urinary flow rates at 3 months and at increasing the proportion of men able to pass urine after cathether removal without the need of recatheterisation. However, alfuzosin is not effective at increasing the proportion of men requiring surgery at 6 months (moderate-quality evidence). Doxazosin compared with placebo: Doxazosin is more effective at improving IPPS symptom scores and peak urinary flow rates (moderate-quality evidence). Tamsulosin compared with other alpha-blockers Tamsulosin and other alpha-blockers (terazosin, alfuzosin, and prazosin) are equally effective at improving IPSS, Boyarsky symptom scores and peak urinary flow rates (moderate-quality evidence). Terazosin compared with other alpha-blockers: Terazosin and other alpha-blockers (tamsulosin, alfuzosin, doxazosin and prazosin) seem to be equally effective at improving IPSS, Boyarsky symptom scores and peak urinary flow rates (moderate-quality evidence). Alfuzosin compared with other alpha-blockers: We don't know whether alfuzosin is more effective than other alpha-blockers (tamsulosin, prazosin, doxazosin) at improving IPPS and Boyarsky symptom scores (low-quality evidence). Doxazosin compared with other alpha-blockers: We don't know whether doxasoxin is more effective than terazosin, or alfuzosin at improving IPPS symptom scores (low-quality evidence). Standard doxazosin compared with controlled-release doxazosin: Standard doxazosin and controlled-release doxazosin are equally effective ati improving IPPS scores (moderate-quality evidence). Prazosin compared with other alpha-blockers: We don't know whether prazosin is more effective than tamsulosin, and terazosin at improving IPPS symptom scores and peak urinary flow rates (low-quality evidence). Terazosin compared with 5 alpha-reductase inhibitors: Terazosin may be mopre effective than finasteride at improving AUASI scores ( very low-quality evidence ). Alfuzosin compared with 5 alpha-reductase inhibitors: Alfuzosin seems to be more effective than finasteride at improving IPSS scores (moderate-quality evidence). Doxazosin compared with 5 alpha-reductase inhibitors: Doxazosin is more effective than finasteride at improving IPSS, AUASI symptom scores and peak urinary flow rates (moderate-quality evidence). Tamsulosin compared with 5 alpha-reductase inhibitors: Tamsulosin is more effective than finasteride at improving urinary flow rates at 12 weeks and at improving IPPS, and peak flow rates at 4 weeks but not at 24 weeks (moderate-quality evidence). Alpha-blockers compared with transurethral microwave thermotherapy: Terazosin may be less effective at improving IPPS symptom scores at 6 and at 18 months (low-quality evidence). Alpha-blockers compared with saw palmetto plant extracts: We don't know whether alpha-blockers are more effective at at improving IPPS symptom scores and at improving peak flow rates at 12 months (low-quality evidence). Saw palmetto plant extracts plus alpha blockers compared with alpha-blockers alone: Saw palmetto plant extracts combined with tamsulosin may be no more effective at improving IPPS symptom scores (low-quality evidence). NOTE We found no clinically important results about alpha-blockers compared with other herbal treatments (beta-sitosterol, rye grass pollen extract, and Pygeum africanum) in men with benign prostatic hyperplasia. Prazosin, terazosin, and doxazosin lower blood pressure.

Benefits

Any alpha-blocker versus placebo:

We found two systematic reviews (search dates 1998, 21 RCTs; and 1999, 24 RCTs). Most of the RCTs included in the two reviews found a greater improvement in symptom scores with alpha-blockers compared with placebo, but overall results were not reported (results presented graphically or in tabular form).

Tamsulosin versus placebo:

We found one systematic review (search date 2000, 6 RCTs, 2758 men) and one subsequent RCT (see table 1 ). The review found that tamsulosin significantly improved symptom scores and peak urine flow compared with placebo. The subsequent RCT found that in men catheterised for acute urinary retention, tamsulosin significantly increased the proportion of men not requiring recatheterisation following trial removal of the catheter.

Table 1
Alpha-blockers

Terazosin versus placebo:

We found one systematic review (search date 2001, 10 RCTs, 3941 men) (see table 1 ). The review found that terazosin improved the symptoms and peak urinary flow rates compared with placebo. The largest RCT (2084 men) identified by the review found that terazosin significantly improved International Prostate Symptom Score (IPSS) compared with placebo. Secondary analysis of one of the RCTs included in the review (1229 men randomised, 1078 men analysed) found that terazosin significantly reduced nocturia compared with placebo after 1 year of treatment.

Alfuzosin versus placebo:

We found four RCTs (see table 1 ). Two RCTs found that alfuzosin significantly improved symptom scores compared with placebo. Two RCTs in men catheterised for acute urinary retention due to benign prostatic hypertrophy found that alfuzosin significantly increased the proportion of men who were able to pass urine after catheter removal compared with placebo. One of these RCTs randomised men who successfully passed urine to alfuzosin or placebo for 6 months. It found that alfuzosin significantly decreased the proportion of men requiring surgery compared with placebo at up to 3 months; however, this reduction was not significant at 6 months.

Doxazosin versus placebo:

We found three RCTs (table 1 ). All three RCTs found that doxazosin improved symptom scores compared with placebo.

Tamsulosin versus other alpha-blockers:

We found two systematic reviews (search dates 2000 and 2001) (see table 1 ). The first review found no significant difference in symptom scores between tamsulosin and alfuzosin or between tamsulosin and prazosin. The second review found no significant difference in symptom scores between tamsulosin and terazosin.

Terazosin versus other alpha-blockers:

We found one systematic review (search date 2001) (see table 1 ). The review found no significant difference in symptom scores between terazosin compared with tamsulosin, and found no difference between terazosin compared with doxazosin or terazosin compared with prazosin.

Alfuzosin versus other alpha-blockers:

We found two systematic reviews, and two RCTs(see table 1 ). The reviews found no significant difference in symptom scores between alfuzosin and tamsulosin or terazosin. The first RCT found no significant difference in symptom scores between alfuzosin and prazosin. The second RCT found that doxazosin significantly improved symptoms compared with alfuzosin, but the mean doses of the medications used were not equipotent.

Doxazosin versus other alpha-blockers:

We found one systematic review and three RCTs, two of which (with a total of 1475 men) were combined in a single analysis (see table 1 ). The review found no significant difference between symptom scores between doxazosin and terazosin. The first RCT found that doxazosin significantly improved symptoms compared with alfuzosin, but the mean doses of the medications used were not equivalent. The two combined RCTs found no significant difference between standard and controlled release doxazosin in symptom scores.

Prazosin versus other alpha-blockers:

We found two systematic reviews, which found no significant difference in symptom scores between prazosin and tamsulosin or terazosin (see table 1 ).

Terazosin versus 5 alpha-reductase inhibitors:

We found one systematic review (search date 2001, 1 RCT, 1229 men) (see table 1 ). The RCT identified by the review was of poor quality. It found that terazosin significantly reduced the American Urological Association Symptom Index (AUASI) score compared with finasteride.

Alfuzosin versus 5 alpha-reductase inhibitors:

We found one RCT (1051 men), (see table 1 ). It found that alfuzosin significantly decreased the symptoms from baseline compared with finasteride.

Doxazosin versus 5 alpha-reductase inhibitors:

We found two RCTs, both of which compared four interventions (see table 1 ). The first RCT found that doxazosin significantly improved total International Prostate Symptom Score and peak urinary flow rate over 1 year compared with finasteride alone. The second RCT found that doxazosin improved symptoms but not overall clinical progression compared with finasteride.

Tamsulosin versus 5 alpha-reductase inhibitors:

We found two RCTs comparing tamsulosin versus finasteride (see table 1 ). The first RCT found that tamsulosin improved symptoms compared with finasteride at 4 but not at 24 weeks. The second RCT found that tamsulosin significantly improved urinary flow compared with finasteride after 12 weeks.

Alpha-blockers versus transurethral microwave thermotherapy:

See benefits of transurethral microwave thermotherapy.

Alpha-blockers versus saw palmetto plant extracts:

See benefits of saw palmetto plant extracts.

Alpha-blockers versus beta-sitosterol:

We found no RCTs.

Alpha-blockers versus rye grass pollen extract:

We found no RCTs.

Alpha-blockers versus Pygeum africanum:

We found no RCTs.

Harms

Any alpha-blocker versus placebo:

One systematic review found that withdrawals because of adverse events were similar with alfuzosin, tamsulosin (0.4 mg dose), and placebo (see table 1 ). There was little observable difference in the rates of dizziness between either alfuzosin or tamsulosin compared with placebo. However, terazosin and doxazosin increased dizziness compared with placebo (results presented graphically; CI not reported). One non-systematic review of RCTs (3 RCTs, 830 men) suggested that both selective and less selective alpha-blockers may be associated with abnormal ejaculation; the risk of abnormal ejaculation was significantly higher with tamsulosin than with placebo (4.5% with tamsulosin v 1.0% with placebo; P = 0.042).

Tamsulosin versus placebo:

One systematic review found no significant difference between tamsulosin and placebo in withdrawal because of adverse events (see table 1 ). One subsequent RCT reported that the overall incidence of adverse events was similar with tamsulosin and placebo (no further data reported; significance not stated). Dizziness, somnolence, and withdrawals due to adverse events were more common with tamsulosin than with placebo, but the significance of these differences was not reported (see table 1 ).

Terazosin versus placebo:

One systematic review found that terazosin significantly increased adverse events compared with placebo (see table 1 ).

Alfuzosin versus placebo:

The first RCT did not report harms. The second RCT found that more people had adverse events with alfuzosin than with placebo, but no statistical comparisons were performed. The third RCT found similar rates of dizziness, and asthenia and fatigue between alfuzosin and placebo (see table 1 ). The fourth RCT found that withdrawal due to adverse events at 6 months was greater with placebo than with alfuzosin (see table 1 ).

Doxazosin versus placebo:

Two RCTs found that doxazosin increased some adverse events compared with placebo (see table 1 ). One RCT reported similar adverse event rates with doxazosin and placebo.

Tamsulosin versus other alpha-blockers:

We found two systematic reviews assessing harms (see table 1 ). The first review found no significant difference in withdrawal between tamsulosin and alfuzosin or prazosin. It found no significant difference between tamsulosin and alfuzosin in dizziness, asthenia, or headache. The review also found that the risk of abnormal ejaculation increased with increasing dose of tamsulosin. The second review found that tamsulosin reduced discontinuation of treatment due to adverse effects compared with terazosin.

Terazosin versus other alpha-blockers:

One systematic review found no significant difference in discontinuation rates between terazosin and either prazosin or doxazosin (see table 1 ). The review found no significant difference between terazosin and alfuzosin in dizziness. It found no significant difference in dizziness or headache between terazosin and doxazosin but it may have lacked power to exclude a clinically important effect. The review found that terazosin increased discontinuation of treatment due to adverse effects compared with tamsulosin.

Alfuzosin versus other alpha-blockers:

The reviews found no significant difference in adverse effects between alfuzosin and tamsulosin or terazosin. One RCT found that doxazosin increased withdrawals due to adverse events compared with alfuzosin, but found that similar proportions of men reported any adverse event, dizziness, and serious adverse events with alfuzosin and doxazosin (see table 1 ).

Doxazosin versus other alpha-blockers:

The review found no significant difference between terazosin and doxazosin in adverse events. One RCT found that doxazosin increased withdrawals due to adverse events compared with alfuzosin, but found that similar proportions of men reported any adverse event, dizziness, and serious adverse events with alfuzosin and doxazosin. The two combined RCTs found a similar rate of adverse events with standard and controlled release doxazosin.

Prazosin versus other alpha-blockers:

We found two systematic reviews, which found no significant difference in withdrawal between prazosin and tamsulosin or terazosin (see table 1 ).

Terazosin versus 5 alpha-reductase inhibitors:

One RCT identified by the systematic review found that terazosin increased adverse events compared with finasteride (see table 1 ).

Alfuzosin versus 5 alpha-reductase inhibitors:

The RCT gave no information on adverse effects.

Doxazosin versus 5 alpha-reductase inhibitors:

The RCT found that doxazosin increased asthenia, dizziness, and hypotension compared with finasteride, but withdrawals due to adverse effects were similar in both groups. The second RCT also found increased asthenia, dizziness, and hypotension with doxazosin, whereas decreased libido and erectile dysfunction were more common with finasteride; however, the RCT did not provide statistical comparisons.

Tamsulosin versus 5 alpha-reductase inhibitors:

The second RCT found similar rates of adverse effects between finasteride and tamsulosin.

Alpha-blockers versus transurethral microwave thermotherapy:

See harms of transurethral microwave thermotherapy.

Alpha-blockers versus saw palmetto plant extracts:

See harms of saw palmetto plant extracts.

Drug safety alert

MHRA issues drug safety alert on risk of intraoperative floppy iris syndrome during cataract surgery with tamsulosin (27 July 2006)

Since the last update of this topic, a drug safety alert has been issued on risk of intraoperative floppy iris syndrome during cataract surgery with tamsulosin (www.mhra.gov.uk).

Comment

Men with severe symptoms of benign prostatic hyperplasia can expect the largest absolute fall in their symptom scores with medical treatment. Prazosin, terazosin, and doxazosin lower blood pressure and may be used to treat both hypertension and benign prostatic hyperplasia.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

5 alpha-reductase inhibitors

Summary

SYMPTOM IMPROVEMENT Compared with placebo: Finasteride, and dustasteride are more effective at improving symptom scores and peak urinary flow rates ( moderate-quality evidence ). Compared with terazosin: Finasteride may be less effective than terazosin at improving AUASI scores ( very low-quality evidence ). Compared with alfuzosin: Finasteride seems to be less effective at improving IPSS scores (moderate-quality evidence). Compared with doxazosin: Finasteride is less effective than doxazosin at improving IPSS, AUASI symptom scores and peak urinary flow rates (moderate-quality evidence). Compared with tamsulosin: Finasteride is less effective at improving urinary flow rates at 12 weeks and at improving IPPS, and peak flow rates at 4 weeks but not at 24 weeks (moderate-quality evidence). Compared with saw palmetto plant extracts: We don't know whether finasteride is more effective at improving IPSS symptom scores (very low-quality evidence). NOTE We found no clinically important results about 5 alpha-reductase inhibitors compared with other herbal treatments (beta-sitosterol, rye grass pollen extract, and Pygeum africanum) or surgical treatments in men with benign prostatic hyperplasia.

Benefits

5 Alpha-reductase inhibitors versus placebo:

We found one systematic review (search date 2001, 19 RCTs, 14 729 men) and three subsequent RCTs. The review found that finasteride (5 mg daily) improved total symptom score, maximum urinary flow rate, and prostate volume compared with placebo after a maximum of 48 months of follow up (results pooled and presented graphically; significance not reported). The largest RCT (multiple publications, 3040 men) identified by the review found that after 4 years of treatment, finasteride (5 mg daily) significantly reduced symptom scores compared with placebo (difference in symptom score –1.6 points, 95% CI –2.5 points to –0.7 points [range of score 0–34 points]). It also found that finasteride significantly reduced the risk of acute urinary retention and prostatectomy compared with placebo (urinary retention: 6.6% with placebo v 2.8% with finasteride; NNT 26, 95% CI 22 to 38; prostatectomy: 8.3% with placebo v 4.2% with finasteride; NNT 24, 95% CI 19 to 37). There was a greater effect among men with higher concentrations of prostate specific antigen at baseline (3.3–12.0 ng/mL), reflecting larger prostates (risk of either acute urinary retention or needing prostatectomy: 19.9% with placebo v 8.3% with finasteride; NNT 8, 95% CI 7 to 11). The RCT also found that, after 4 years, finasteride produced a larger fall in International Prostate Symptom Score compared with placebo. The fall was greater for men with prostate specific antigen levels greater than 1.3 ng/mL than for men with prostate specific antigen levels ≤ 1.3 ng/mL. The first subsequent RCT (1095 men) compared four interventions: finasteride, standard doxazosin, doxazosin plus finasteride, and placebo. It found no significant difference between finasteride and placebo in International Prostate Symptom Score or peak urinary flow rate over 1 year (492 men; P reported as non-significant, CI not reported). The second subsequent RCT (4325 men) compared dutasteride versus placebo. It found that dutasteride significantly improved American Urological Association Symptom Index (AUASI) scores and peak urinary flow rate after 24 months compared with placebo (improvement in AUASI score: 4.5 points with dutasteride v 2.3 points with placebo; P < 0.001; peak urinary flow rate: + 2.2 mL/second with dutasteride v + 0.6 mL/second with placebo; P < 0.001). The third subsequent RCT (3047 men) compared finasteride, doxazosin, finasteride plus doxazosin, and placebo. It found that finasteride significantly reduced the risk of clinical progression (defined as acute urinary retention, urinary incontinence, renal insufficiency, current urinary tract infection, and an increase in the AUASI score of at least 4 points above baseline) compared with placebo (risk reduction: 34%; P < 0.002). It also found that finasteride significantly reduced the risks of acute urinary retention and the need for invasive therapy compared with placebo (risk reduction for acute urinary retention: 68%; P = 0.009; risk reduction for invasive therapy: 64%; P < 0.001).

5 Alpha-reductase inhibitors versus alpha-blockers:

See benefits of alpha-blockers.

5 Alpha-reductase inhibitors versus saw palmetto plant extracts:

See benefits of saw palmetto plant extracts.

5 Alpha-reductase inhibitors versus beta-sitosterol:

We found no RCTs.

5 Alpha-reductase inhibitors versus rye grass pollen extract:

We found no RCTs.

5 Alpha-reductase inhibitors versus Pygeum africanum:

We found no RCTs.

5 Alpha-reductase inhibitors versus surgical treatments:

We found no RCTs.

Harms

5 Alpha-reductase inhibitors versus placebo:

The systematic review found that the incidence of sexual dysfunction, impotence, ejaculatory disorders, and reduced libido was significantly higher in men treated with finasteride compared with placebo (figures not reported). One RCT identified by the review (3040 men treated for 4 years) reported harms in some detail. It found that during the first year of the study, 15% of men treated with finasteride and 7% of men treated with placebo experienced treatment-related sexual dysfunction (P < 0.001). There was no significant difference in decreased libido (2.6% v 2.6%) or impotence (5.1% v 5.1%) between finasteride and placebo, but there was a slightly greater rate of ejaculation disorder (0.2% v 0.1%; significance not tested). During the remainder of the trial, there was no difference in the incidence of new sexual adverse events between the two groups (7% in both treatment groups). Overall, 4% of men treated with finasteride and 2% of those treated with placebo discontinued treatment due to sexual dysfunction. On discontinuing therapy, 50% of the finasteride group and 41% of the placebo group experienced resolution of their adverse symptoms. Sexual dysfunction resolved in 12% of the men who continued treatment with finasteride and in 19% of those treated with placebo. Although finasteride reduced concentrations of prostate specific antigen by a mean of 50% (individual responses were highly variable), its use for up to 4 years did not change the rate of detection of prostate cancer compared with placebo. Two of the subsequent RCTs did not address harms. One subsequent RCT reported that erectile dysfunction, decreased libido, and abnormal ejaculation occurred significantly more frequently in men treated with finasteride compared with those taking placebo (P < 0.05 for all three outcomes).

5 Alpha-reductase inhibitors versus alpha-blockers:

See harms of alpha-blockers.

5 Alpha-reductase inhibitors versus saw palmetto plant extracts:

See harms of saw palmetto plant extracts.

5 Alpha-reductase inhibitors versus surgical treatments:

We found no RCTs.

Comment

5 Alpha-reductase inhibitors versus placebo:

We found two non-systematic reviews comparing finasteride versus placebo. One of the non-systematic reviews (6 RCTs) found that finasteride significantly decreased symptom scores compared with placebo (difference in symptom score: –0.9 points, 95% CI –1.2 points to –0.6 points [range of score 0–30 points]). The benefit over placebo was greatest in men with larger prostates (≥ 40 g). The other non-systematic review (meta-analysis of 3 RCTs) found that finasteride reduced acute urinary retention requiring catheterisation after 2 years from 2.7% to 1.1%. The meta-analysis also found that finasteride was significantly more effective than placebo in men with larger prostates at 1–2 years. However, the absolute difference in mean decrease of symptom score from baseline between men with the smallest and largest prostates was only about 1 point. The relative effectiveness of finasteride compared with placebo also seemed higher in men with slightly raised prostate specific antigen levels (assumed to be a proxy for a larger prostate).

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Saw palmetto plant extracts

Summary

SYMPTOM IMPROVEMENT Compared with placebo: Saw palmetto plant extracts may be more effective at increasing self-rated improvement and at reducing nocturia ( very low-quality evidence ). Compared with alpha-blockers: We don't know whether saw palmetto plant extracts are more effective at improving IPPS symptom scores and at improving peak flow rates at 12 months ( low-quality evidence ). Saw palmetto plant extracts plus alpha blockers compared with alpha-blockers alone: Saw palmetto plant extracts combined with tamsulosin may be no more effective at improving IPPS symptom scores (low-quality evidence). Compared with 5 alpha-reductase inhibitors: We don't know whether saw palmetto plant extracts are more effective than finasteride at improving IPSS symptom scores (very low-quality evidence).

Benefits

Saw palmetto plant extracts versus placebo:

We found one systematic review, which included all saw palmetto preparations (search date 2002). The review found that more men reported self rated improvement with saw palmetto compared with placebo (6 RCTs, 659 men; RR 1.7, 95% CI 1.2 to 2.4). It also found a significant reduction in nocturia with saw palmetto compared with placebo (10 RCTs, 634 men; WMD –0.76 episodes/night, 95% CI –0.31 to –1.21).

Saw palmetto plant extracts versus alpha-blockers:

We found one RCT (704 men). It found no significant difference between tamsulosin and saw palmetto in International Prostate Symptom Score (IPSS) or peak flow rate at 12 months (increase in peak flow 1.8 mL/second with saw palmetto v 1.9 mL/second with tamsulosin; P value reported as not significant).

Saw palmetto plant extracts plus alpha-blocker:

We found one RCT (352 men), which compared tamsulosin versus tamsulosin plus saw palmetto. It found no significant difference in symptom score between tamsulosin and tamsulosin plus saw palmetto (improvement in IPSS: 5.2 with tamsulosin v 6.0 with tamsulosin plus saw palmetto; P value reported as not significant).

Saw palmetto plant extracts versus 5 alpha-reductase inhibitors:

We found one systematic review, which included all saw palmetto preparations (search date 2002, 2 RCTs, 1440 men). The review found no significant difference in IPSS between finasteride and saw palmetto (WMD + 0.37 points, 95% CI –0.45 points to + 1.19 points).

Harms

Saw palmetto plant extracts versus placebo:

The systematic review found no significant difference in withdrawal rates between saw palmetto and placebo (9% with saw palmetto v 7% with placebo; P = 0.17). The risk of erectile dysfunction was similar with saw palmetto and placebo (1.1% with saw palmetto v 0.7% with placebo; P = 0.58).

Saw palmetto plant extracts versus alpha-blockers:

In one RCT comparing saw palmetto and tamsulosin, a similar proportion of men withdrew because of adverse events (7.7% with saw palmetto v 8.2% with tamsulosin). The risk of ejaculatory disorder was significantly lower with saw palmetto than with tamsulosin (2/349 [0.6%] with saw palmetto v 15/354 [4.2%] with tamsulosin; P =  0.001).

Saw palmetto plant extracts versus 5 alpha-reductase inhibitors:

The review found no significant difference in withdrawal rates between saw palmetto and finasteride (9% with saw palmetto v 9% with finasteride; P = 1.00). Rates of erectile dysfunction were significantly lower with saw palmetto compared with finasteride (1.1% with saw palmetto v 4.9% with finasteride; P < 0.001).

Comment

The RCTs included in the systematic review were short term and few used a validated symptom score. Different preparations, which may not be equivalent, are available directly to consumers without prescription in many countries. The RCT comparing saw palmetto versus tamsulosin used a standardised preparation of saw palmetto.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Beta-sitosterol plant extract

Summary

SYMPTOM IMPROVEMENT Compared with placebo: Beta-sitosterol plant extracts may be more effective at improving IPPS scores at 4–26 weeks ( very low-quality evidence ). NOTE We found no clinically important results about beta-sitosterol plant extract compared with alpha-blockers, or 5 alpha-reductase inhibitors.

Benefits

Beta-sitosterol plant extract versus placebo:

We found one systematic review (search date 1998, 4 RCTs, 519 men), which compared beta-sitosterol versus placebo. The review found that beta-sitosterol significantly reduced the International Prostate Symptom Score (2 RCTs; WMD –4.9 points, 95% CI –6.3 points to –3.5 points) at 4–26 weeks.

Beta-sitosterol plant extract versus alpha-blockers:

We found no RCTs.

Beta-sitosterol plant extract versus 5 alpha-reductase inhibitors:

We found no RCTs.

Harms

Beta-sitosterol plant extract versus placebo:

Gastrointestinal adverse effects were more common with beta-sitosterol than with placebo (1.6% with beta-sitosterol v 0% with placebo; CI not reported). Impotence was also more common with beta-sitosterol (0.5% beta-sitosterol v 0% with placebo; CI not reported). Withdrawal rates were similar in both groups (7.8% with beta-sitosterol v 8.0% with placebo; CI not reported).

Beta-sitosterol plant extract versus alpha-blockers:

We found no RCTs.

Beta-sitosterol plant extract versus 5 alpha-reductase inhibitors:

We found no RCTs.

Comment

The RCTs included in the review were limited by a short follow up period (maximum 26 weeks). Different preparations are available, which may be of variable content, making it difficult to generalise results.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Rye grass pollen extract

Summary

SYMPTOM IMPROVEMENT Compared with placebo: Rye grass pollen extract may be more effective at increasing self rated improvement and at reducing nocturia at 12–24 weeks ( very low-quality evidence ). NOTE We found no clinically important results about rye grass pollen extract compared with alpha-blockers, or 5 alpha-reductase inhibitors.

Benefits

Rye grass pollen extract versus placebo:

We found one systematic review (search date 1997, 2 RCTs, 163 men), which compared rye grass pollen extract versus placebo. It found that pollen extract significantly increased self rated improvement and significantly reduced nocturia compared with placebo (proportion improved, 1 RCT, 60 men: 20/31 [65%] with pollen v 7/26 [27%] with placebo; RR 2.40, 95% CI 1.21 to 4.75; NNT 3, 95% CI 2 to 9; proportion with reduced nocturia, 2 RCTs: 50/79 [63%] with pollen v 23/74 [31%] with placebo; RR 2.05, 95% CI 1.41 to 3.99). However, the results should be interpreted with caution (see comment below).

Rye grass pollen extract versus alpha-blockers:

We found no RCTs.

Rye grass pollen extract versus 5 alpha-reductase inhibitors:

We found no RCTs.

Harms

Rye grass pollen extract versus placebo:

The review found that nausea occurred in one man taking pollen extract (number in placebo group not stated). Withdrawal rates were not significantly different (4.8% with pollen v 2.7% with placebo; P = 0.26).

Rye grass pollen extract versus alpha-blockers:

We found no RCTs.

Rye grass pollen extract versus 5 alpha-reductase inhibitors:

We found no RCTs.

Comment

Both RCTs included in the review were limited by small sample sizes and a short follow up period (12 and 24 weeks). Concealment of treatment allocation was unclear. The composition of the preparations was unknown, making it difficult to generalise results.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Pygeum africanum

Summary

SYMPTOM IMPROVEMENT Compared with placebo: Pygeum africanum may be more effective at increasing peak urinary flow and at reducing residual urine volume at 4–16 weeks ( very low-quality evidence ). NOTE We found no clinically important results about Pygeum africanum compared with alpha-blockers or 5-alpha reductase inhibitors.

Benefits

Pygeum africanum versus placebo:

We found one systematic review (search date 2000, 18 RCTs, 1562 men) comparing P africanum versus placebo. It found that P africanum significantly improved symptoms compared with placebo (5 RCTs, 430 men; proportion with improved symptoms: 65% with P africanum v 30% with placebo; RR 2.1, 95% CI 1.4 to 3.1). It also found that P africanum significantly increased peak flow compared with placebo at 4–16 weeks (4 RCTs, 384 men; mean increase 23% with P africanum compared with placebo; WMD 2.5 mL/second, 95% CI 0.3 mL/second to 4.7 mL/second) and reduced residual urine volume (2 RCTs, 284 men; mean reduction 24% with P africanum compared with placebo; WMD –13 ml, 95% CI –23.3 mL to –3.0 mL). These results should be interpreted with caution (see comment below).

Pygeum africanum versus alpha-blockers:

We found no RCTs.

Pygeum africanum versus 5 alpha-reductase inhibitors:

We found no RCTs.

Harms

Pygeum africanum versus placebo:

The RCTs identified by the review gave little information on adverse effects. The review found that adverse events in men taking P africanum were “generally mild and similar in frequency to placebo”; the most commonly reported adverse events associated with P africanum were gastrointestinal and were reported in seven men in five RCTs (no further data reported).

Pygeum africanum versus alpha-blockers:

We found no RCTs.

Pygeum africanum versus 5 alpha-reductase inhibitors:

We found no RCTs.

Comment

The RCTs included in the review were limited by their short follow up period (maximum 16 weeks). The designs of the RCTs and the composition of the preparations used varied, making it difficult to generalise results.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Transurethral resection of the prostate versus no surgery

Summary

SYMPTOM IMPROVEMENT Compared with watchful waiting: Transurethral resection (TURP) is more effective at improving symptom scores at 3 years and at 7.5 months and does not increase the risk of erectile dysfunction or incontinence ( high-quality evidence ). NOTE We found no clinically important results from RCTs comparing transurethral resection versus medical treatment.

Benefits

Transurethral resection versus watchful waiting:

We found two RCTs (4 publications) comparing transurethral resection of the prostate (TURP) versus watchful waiting (see table 2 ). Both RCTs found that TURP significantly improved symptom scores (at 3 years and 7.5 months) compared with watchful waiting. The first RCT found that TURP reduced treatment failure compared with watchful waiting.

Table 2
Transurethral resection

Transurethral resection versus sham treatment:

We found no systematic review or RCTs.

Transurethral resection versus medical treatment:

We found no systematic review or RCTs.

Harms

Analysis of administrative data found that mortality in the 30 days after TURP for benign prostatic hyperplasia ranged from 0.4% for men aged 65–69 years to 1.9% for men aged 80–84 years, and has fallen in recent years. In one review of observational studies, TURP for benign prostatic hyperplasia was associated with immediate surgical complications in 12% of men, bleeding requiring intervention in 2%, erectile dysfunction in 14%, retrograde ejaculation in 74%, and incontinence in about 5%. Analysis of claims data found a reoperation rate, implying a need for retreatment, of about 1% a year.

Transurethral resection versus watchful waiting:

The RCTs found that men randomised to prostatectomy did not seem to have a greater rate of erectile dysfunction or incontinence than did men assigned to watchful waiting (see table 2 ). The second RCT found that TURP reduced erectile dysfunction, reduced pain or discomfort on ejaculation, but increased ejaculatory dysfunction compared with watchful waiting.

Transurethral resection versus sham treatment:

We found no systematic review or RCTs.

Transurethral resection versus medical treatment:

We found no systematic review or RCTs.

Comment

Rapid changes in techniques and too few controlled trials with adequate follow up make comparisons between TURP and newer surgical techniques difficult. One systematic review comparing TURP versus electrical vaporisation found that none of the RCTs were blinded or analysed by intention to treat, but four out of five RCTs had less than 10% loss to follow up.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Transurethral resection of the prostate versus other surgical techniques

Summary

SYMPTOM IMPROVEMENT Compared with transurethral incision: Transurethral resection and transurethral incision seem to be equally effective at 12 months at improving IPPS scores ( moderate-quality evidence ). Compared with visual laser ablation: We don't know whether transurethral resection (TURP) is more effective at improving symptom scores but TURP seems to be more effective at reducing resurgical retreatment rates at 5 years ( low-quality evidence ). Compared with contact laser ablation: Transurethral resection (TURP) seems to be more effective than Nd:YAG at improving IPSS symptom scores but not peak urine flow rate. However, when compared with holmium contact laser, TURP seems to be more effective at improving peak urine flow rates but not IPSS symptom scores (moderate-quality evidence). Compared with electrical vaporisation: TURP and electrical vaporisation seem to be equally effective at 12–24 months at improving IPPS scores and flow rates (moderate-quality evidence). Compared with transurethral microwave therapy: Transurethral resection may be less effective at improving symptom scores and peak urinary flow at 6 to12 months ( very low-quality evidence ). Compared with transurethral needle ablation: Transurethral resection may be more effective at 1 year at reducing IPPS symptom scores, but may cause more retrograde ejaculation (low-quality evidence).

Benefits

Transurethral resection versus transurethral incision:

We found one systematic review (search date 1999, 9 RCTs) (see table 2 ). It found no significant difference between TURP and transurethral incision in symptom scores.

Transurethral resection versus visual laser ablation:

We found one systematic review (search date 2002, 8 RCTs, 1024 men) (see table 2 ). The review found that the results of meta-analysis of symptom scores differed depending on how they were assessed by the RCTs. If mean change in symptom scores was assessed, TURP reduced symptoms significantly more than visual laser ablation (non-contact laser) at over 6 months' follow up. However, if mean symptom score at follow up was assessed, there was no significant difference between TURP and visual laser ablation at 6 or 12 months. It found that TURP increased peak urine flow compared with visual laser ablation. Longer term follow up of one of the RCTs (98 men) included in the review found that TURP reduced surgical retreatment rates after 5 years compared with visual laser ablation.

Transurethral resection versus contact laser ablation:

We found one systematic review (search date 2002, 8 RCTs, 851 men) (see table 2 ). The review (search date 2002) analysed results separately for comparisons of TURP versus Nd:YAG or versus holmium contact laser. It found that TURP improved symptoms compared with Nd:YAG contact laser, but found no significant difference between treatments in peak urine flow. It found no significant difference between TURP and holmium contact laser in symptom scores, but found that peak urinary flow was significantly lower with TURP than with holmium contact laser.

Transurethral resection versus electrical vaporisation:

We found one systematic review (search date 1999, 5 RCTs, 454 men) and three subsequent RCTs (see table 2 ). The review and the three subsequent RCTs found no significant difference in symptom scores at 12–24 months between TURP and electrical vaporisation.

Transurethral resection versus transurethral microwave therapy:

See benefits of transurethral microwave therapy.

Transurethral resection versus transurethral needle ablation:

See benefits of transurethral needle ablation.

Harms

Analysis of administrative data found that mortality in the 30 days after TURP for benign prostatic hyperplasia ranged from 0.4% for men aged 65–69 years to 1.9% for men aged 80–84 years, and has fallen in recent years. In one review of observational studies, TURP for benign prostatic hyperplasia was associated with immediate surgical complications in 12% of men, bleeding requiring intervention in 2%, erectile dysfunction in 14%, retrograde ejaculation in 74%, and incontinence in about 5%. Analysis of claims data found a reoperation rate, implying a need for retreatment, of about 1% a year.

Transurethral resection versus transurethral incision:

One systematic review found that more men experienced complications, retrograde ejaculation, or required blood transfusion with TURP compared with transurethral prostatic incision; however, the significance of these findings was not reported (see table 2 ).

Transurethral resection versus visual laser ablation:

The review (search date 2002) found that the RCTs did not comprehensively report adverse effects. Overall, it found that acute urinary retention, urinary tract infections, and dysuria were less common with TURP than with visual laser ablation (see table 2 ).

Transurethral resection versus contact laser ablation:

The systematic review (search date 2002) did not report adverse effect separately for Nd:YAG and holmium contact laser (see table 2 ). It found no significant difference in adverse effects between TURP and contact laser ablation.

Transurethral resection versus electrical vaporisation:

The systematic review found that TURP and electrical vaporisation had similar risks of blood transfusion, irritative symptoms, and urinary tract infections, but found that electrical vaporisation significantly increased urinary retention compared with TURP (see table 2 ). The first subsequent RCT found no significant difference in erectile dysfunction between transurethral resection and electrical vaporisation. The second subsequent RCT found no significant difference between TURP and electrical vaporisation for postoperative incontinence, haemorrhage requiring blood transfusion, or urethral stricture. The third subsequent RCT found no significant difference between treatments in retrograde ejaculation but found that electrical vaporisation increased impotence at 6 months compared with TURP.

Transurethral resection versus transurethral microwave thermotherapy:

See harms of transurethral microwave thermotherapy.

Transurethral resection versus transurethral needle ablation:

See harms of transurethral needle ablation.

Comment

Rapid changes in techniques and too few controlled trials with adequate follow up make comparisons between TURP and newer surgical techniques difficult. One systematic review comparing TURP versus electrical vaporisation found that none of the RCTs were blinded or analysed by intention to treat, but four out of five RCTs had less than 10% loss to follow up.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Transurethral microwave thermotherapy versus no surgery or versus other surgical techniques

Summary

SYMPTOM IMPROVEMENT Compared with sham treatment: Transurethral microwave thermotherapy is more effective at improving IPPS scores ( moderate-quality evidence ). Compared with transurethral resection: Transurethral microwave thermotherapy may be less effective at improving symptom scores and peak urinary flow at 6 to 12 months ( very low-quality evidence ). Compared with alpha-blockers: Transurethral microwave thermotherapy may be more effective than terazosin at improving IPPS symptom scores at 6 and at 18 months (very low-quality evidence).

Benefits

Transurethral microwave thermotherapy versus watchful waiting:

We found no systematic review or RCTs.

Transurethral microwave thermotherapy versus sham treatment:

We found three RCTs comparing transurethral microwave thermotherapy (TUMT) versus sham treatment. The largest RCT (220 men) found that TUMT significantly improved International Prostate Symptom Score (IPSS) compared with sham treatment (mean 5 points lower; P < 0.05). The second RCT (169 men) found that TUMT significantly improved IPSS compared with sham treatment at 6 months (P < 0.05). The third RCT (50 men) compared TUMT versus sham treatment. It found a greater reduction in Madsen symptom score (range 0–27, higher scores indicating worse symptoms) with TUMT compared with sham treatment (reduction in Madsen symptom score 7.3 with TUMT v 3.9 with sham treatment; significance was not tested).

Transurethral microwave thermotherapy versus alpha-blockers:

We found one RCT (103 men). It found that TUMT significantly improved symptom scores at 6 and 18 months compared with terazosin (up to 10 mg/day; difference in IPSS at 18 months, 35%; P < 0.001).

Transurethral microwave thermotherapy versus transurethral resection of the prostate:

We found one systematic review (see comments). It found that transurethral resection of the prostate (TURP) significantly improved symptom scores and peak urinary flow at 6–12 months compared with transurethral microwave thermotherapy (search date 2003, 6 RCTs with minimum follow up of 6 months, 540 men WMD in symptom score, IPPS, or Madsen–Iversen score: –1.83, 95% CI –3.09 to –0.58; WMD in peak urinary flow: 5.37 mL/s, 95% CI 4.22 to 6.51 mL/s). It found no significant difference between treatments in quality of life scores (change in IPPS, 3 RCTs: 4.1 to 1.7 with thermotherapy v 4.1 to 1.2 with TURP, P value not reported).

Transurethral microwave thermotherapy versus electrovaporisation, laser ablation or transurethral needle ablation:

We found no RCTs.

Harms

Transurethral microwave thermotherapy versus watchful waiting:

We found no systematic review or RCTs.

Transurethral microwave thermotherapy versus sham treatment:

Adverse events associated with TUMT varied among trials, but included the need for catheterisation for more than 1 week (8% with TUMT v 2% with sham treatment), persistent irritative symptoms (22% with TUMT v 8% with sham treatment), haematuria (14% with TUMT v 1% with sham treatment), and sexual dysfunction (mostly haematospermia and other ejaculatory abnormalities; 29% with TUMT v 1% with sham treatment).

Transurethral microwave thermotherapy versus alpha-blockers:

The RCT (103 men) comparing TUMT versus alpha-blockers found more adverse events in the alpha-blocker group over the first 6 months (17 events in 52 men with alpha-blockers v 7 events in 51 men with TUMT; CI not reported). With alpha-blockers, the most common adverse effect was dizziness (7 cases) or asthenia (4 cases); in the TUMT group, it was urinary tract infection (3 cases).

Transurethral microwave thermotherapy versus transurethral resection of the prostate:

The systematic review (search date 2003) found that most RCTs did not comprehensively report adverse events in the perioperative period. It found that transurethral microwave thermotherapy significantly reduced the need for transfusion and reduced retrograde ejaculation and retreatment for strictures compared with TURP (need for transfusion, 4 RCTs: 0% with TUMT v 5.7% with TURP, RR 0.11, 95% CI 0.01 to 0.86; retrograde ejaculation, 2 RCTs: 22.2% with TUMT v 57.6% with TURP, RR 0.39, 95% CI 0.21 to 0.75; retreatment for strictures: RR 9.76, 95% CI 2.22 to 42.96). It found that transurethral microwave thermotherapy increased retreatment for benign prostatic hyperplasia compared with TURP (RR 10.0, 95% CI 2.4 to 50.0). It found no significant difference between treatments in erectile dysfunction (4 RCTs: 8/140 [5.7%] with TUMT v 10/72 [13.9%] with TURP; RR 0.41, 95% CI 0.16 to 1.72).

Transurethral microwave thermotherapy versus electrovaporisation, laser ablation or transurethral needle ablation:

We found no RCTs.

Comment

TUMT can be performed in an outpatient setting, and uses heat generated by a microwave antenna in the urethra to coagulate prostate tissue. The long term effects of TUMT have not been adequately evaluated in controlled studies. The systematic review comparing transurethral microwave thermotherapy versus transurethral resection of the prostate reported that all of the included studies had methodological flaws (methods of randomisation and level of blinding not clear and lack of reporting of the change in symptom scores), and in studies following up men for 2 years or more, there were substantial losses to follow up.

Substantive changes

No new evidence

2006; 2006: 1801.
Published online 2006 April 1.

Transurethral needle ablation versus no surgery or versus other surgical techniques

Summary

SYMPTOM IMPROVEMENT Compared with transurethral resection: Transurethral needle ablation may be less effective at 1 year at reducing IPPS symptom scores, but may cause less retrograde ejaculation ( low-quality evidence ).

Benefits

Transurethral needle ablation versus watchful waiting:

We found no RCTs.

Transurethral needle ablation versus transurethral resection:

We found one RCT (121 men) comparing transurethral resection of the prostate (TURP) versus transurethral needle ablation (TUNA). The mean International Prostate Symptom Score was significantly lower with TURP than with TUNA at 1 year (11.1 points with TUNA v 8.3 points with TURP; P = 0.04).

Transurethral needle ablation versus electrovaporisation, laser ablation or transurethral microwave thermotherapy:

We found no RCTs.

Transurethral needle ablation versus medical treatment:

We found no RCTs.

Harms

Transurethral needle ablation versus watchful waiting:

We found no RCTs.

Transurethral needle ablation versus transurethral resection:

Compared with TURP, TUNA was associated with less retrograde ejaculation (38% with TURP v 0% with TUNA) and bleeding (100% with TURP v 32% with TUNA).

Transurethral needle ablation versus electrovaporisation, laser ablation or transurethral microwave thermotherapy:

We found no RCTs.

Transurethral needle ablation versus medical treatment:

We found no RCTs.

Comment

TUNA can be performed in an outpatient setting, and uses radiofrequency energy through two intraprostatic electrodes to generate heat to coagulate prostate tissue. Anaesthesia requirements vary in reported studies. The long term effects of treatment have not been adequately evaluated.

Substantive changes

No new evidence


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