Comparative Outcomes of Commonly Used Morcellator Devices in Endoscopic Laser Enucleation of the Prostate: A Systematic Review and Meta-Analysis

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) has now emerged as a new, prostate-size-independent gold standard, largely because of its favorable side-effect profile compared with the previous surgical methods. In this minimally invasive procedure, tissue morcellator devices are used as an important part. This systematic review and meta-analysis compares the outcomes of the different commercial tissue morcellators used in HoLEP procedures. METHODS: Three electronic databases were searched (PubMed, Web of Science, and EMBASE) without date restrictions to find the studies evaluating morcellator device performance during HoLEP. After screening 1145 studies, 34 English, human-subject studies were included. Devices evaluated included Wolf Piranha, CyberBlade, Lumenis VersaCut, Hawk, DrillCut, and MultiCut morcellators. Two reviewers performed the study selection individually to reduce the probable bias. Extracted outcomes included perioperative parameters and complications among different commercial morcellator devices. The review was conducted with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: A total of 7211 patients were analyzed. Meta-analysis showed no statistically significant differences between morcellator systems in morcellation time (mean difference [MD] 1.02 minutes, 95% confidence interval [CI] -1.37 to 3.41), morcellation efficiency (MD 0.75 g/min, 95% CI: -0.46 to 1.97), or catheterization duration (MD 3.22 hours, 95% CI: -1.09 to 7.52). The intraoperative complication rate was low in all studies. Device malfunction (risk ratio [RR] 1.16, 95% CI: 0.23 to 5.70), bladder mucosal injury (RR: 0.85, 95% CI: 0.46 to 1.57), and bladder perforation (RR: 0.35, 95% CI: 0.10 to 1.25) did not differ significantly between devices. Cost data were limited to two studies and there was no significant cost advantage for any device. CONCLUSION: Available evidence shows that commonly used morcellators have comparable operative performance, and safety during HoLEP. No device showed a consistent advantage compared with the others, suggesting that the morcellator choice might be done by surgeon's preference, resource considerations, the health center's policy, and the availability rather than performance differences.