Functional outcomes of one-, two- and three-lobe technique in anatomical endoscopic enucleation for benign prostatic obstruction: a systematic review and network-meta-analysis

Benign prostatic obstruction (BPO) is a common condition. Anatomical endoscopic enucleation of the prostate (EEP) is the mainstay in therapy for large glands (> 80 ml), but also feasible in smaller prostates. The original three-lobe enucleation technique has been supplemented by two-lobe and one-lobe or en-bloc techniques. One- and two-lobe techniques seem more effective in terms of surgical time and blood loss. The impact of the different techniques on functional outcomes however is unclear. To determine whether the technique used in prostate enucleation influences functional outcomes of surgery. We performed a systematic review of Medline/Pubmed and identified 124 studies, of which 10 were included for network meta-analyses. We included RCTs as well as retrospective and prospective cohort series, comparing one-lobe, two-lobe and three-lobe technique respectively. We assessed functional outcomes including post-void residual urine, Qmax (ml/s), IPSS Score and QoL Score. Additionally we compared stress and urge incontinence rates after three months. The only significantly differing result was in postoperative Qmax increase in favor of one-lobe and two-lobe compared to three-lobe technique. However, with mean differences of 0.989 and 0.749 respectively the effect was clinically negligible. There was no difference in the other functional outcomes including incontinence rates. Our approach is limited by the quality of the data, since retrospective and non-randomized trials were included due to the overall poor amount of studies on the subject. One-lobe/en-bloc, two-lobe and three-lobe technique in endoscopic enucleation of the prostate for benign prostate syndrome all improve micturition. No final conclusion concerning superiority of a specific lobe-technique in terms of functional outcomes can be drawn from the available data. Randomized controlled trials are needed.