Prostatic Urethral Lift Improves Urinary Symptoms and Flow While Preserving Sexual Function for Men with Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis

Abstract

Context

Treatment for lower urinary tract symptoms resulting from benign prostatic hyperplasia (BPH) is varied, and significant side effects, particularly concerning sexual function, affect uptake. The prostatic urethral lift (PUL) procedure is a recent addition to the armamentarium for BPH treatment, with independent reports suggesting improvement of symptoms, sexual function, and urinary flow.

Objective

We undertook a systematic review and meta-analysis of reported symptomatic, functional, and sexual outcomes following the PUL procedure.

Evidence acquisition

We performed a critical review of Medline, Embase, ScienceDirect, Cochrane Library, and Web of Science databases in May 2014 according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Quality assessment was performed using a modification of the Methodological Index for Non-Randomized Studies tool. All retrospective, prospective, and controlled trials were included for analysis. Symptom scores, sexual health scores, and functional outcomes were pooled and meta-analysed using quality and random-effects models.

Evidence synthesis

Ten articles comprising six independent patient cohorts were included for analysis. Pooled estimates from between 452 and 680 patients suggested overall improvement following PUL, including symptoms (large gain; standardised mean gain range of 1.3–1.6, International Prostate Symptom Score difference of −7.2 to −8.7 points), maximum flow rate (3.8–4.0 ml/s), and quality of life (2.2–2.4 points). Sexual function was preserved with a small improvement estimated at 12 mo (standardised mean gain range of 0.3–0.4). Pooled estimates were mostly heterogeneous across study groups.

Conclusions

PUL is a well-tolerated, minimally invasive therapy for BPH that provides favourable symptom, sexual health, and functional outcomes during follow-up to 12 mo. Longer follow-up and larger randomised studies are required to further confirm these preliminary results.

Patient summary

We reviewed the early results of an innovative procedure directed towards the management of prostate enlargement. The results revealed a well-tolerated procedure that produces improvement in urinary symptoms and function while preserving sexual function.

Introduction

Lower urinary tract symptoms (LUTS) resulting from benign prostatic hyperplasia (BPH) are common, with moderate to severe LUTS estimated to affect up to 30% of men aged >50 yr [1], [2]. Severe LUTS is associated with depression and reduced quality of life in otherwise healthy men [3], and an increasing population requiring treatment is expected, specifically 10.3 million men in the United States in 2020 [1], [4]. Reduced healthcare-related quality of life causes significant economic burden [5]. Current methods of conservative treatment (α1-blockers, 5α-reductase inhibitors) total 11.6 million prescriptions per year across Europe [6] for modest improvements in the International Prostate Symptom Score (IPSS).

Up to 30% of patients require surgical intervention following failure of medical therapy, mostly due to dissatisfaction and side effect profile [1], [7]. Transurethral resection of the prostate (TURP) produces a significant and reliable improvement in LUTS as a result of reducing bladder outlet obstruction [8] at the expense of morbidity, such as ejaculatory dysfunction (53–75%), erectile dysfunction (3.4–32%), urinary incontinence (2.2%), and urethral stricture (2–9%) [9]. Despite alternative therapeutic advances such as photoselective vaporisation of the prostate (PVP), the side effect profile remains prominent, with 8.8% suffering perioperative complications and 13.3% having long-term morbidity with this procedure [10], [11]. Less invasive, or minimally invasive, surgical interventions such as transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA) spare a degree of the side effect profile at the expense of IPSS improvement [10].

Prostatic urethral lift (PUL) is a newly available minimally invasive procedure for LUTS secondary to BPH. Despite being categorised as minimally invasive, PUL is performed in the lithotomy position with the support of a local or general anaesthetic. Initially reported in 2005, the procedure results in anterolateral traction of the lateral lobes of the prostate towards the capsule, expanding the urethral lumen and relieving obstruction [12]. The procedure has been described in detail previously [13]. The lateral lobes are secured by small permanent suture-based implants administered by a preloaded custom implant-delivery device (UroLift System; NeoTract Inc., Pleasanton, CA, USA). Given this targeted mechanism on the lateral lobes, it has been postulated that PUL may have limited efficacy for patients with obstructing median lobes, which has been an important exclusion criterion for many previously published reports. This interventional technique is mechanical and avoids resection or ablation of prostatic tissue. Early results using PUL suggest a beneficial therapeutic effect while avoiding many of the morbidities and complications associated with more conventional surgery.

The aim of this study was to collate available data on PUL using a systematic search strategy and to quantify global treatment effects using meta-analysis. This article was produced without consultation or input from NeoTract Inc.