Systematic review of surgical treatments for benign prostatic hyperplasia and presentation of an approach to investigate therapeutic equivalence (non‐inferiority)
Authors: Biester Katharina , Skipka Guido , Jahn Rebecca , Buchberger Barbara , Rohde Volker , Lange Stefan 
Published: September 2011

Study Type – Therapy (systematic review)Level of Evidence 1aWhat's known on the subject? and What does the study add?Numerous newer (non‐standard) procedures for the treatment of benign prostatic hyperplasia (BPH) exist; however, it is unclear whether they actually have an additional patient‐relevant benefit compared to standard treatment.As no trial investigated non‐inferiority, we defined a non‐inferiority threshold on the basis of published literature. The present systematic review found no proof of an additional benefit of non‐standard treatments for BPH; an indictation of an additional benefit was only shown for holium laser resection of the prostate (HoLRP) and thulium laser resection of the prostate (TmLRP).OBJECTIVE
To assess the potential additional benefit of non‐standard vs standard surgical treatments for benign prostatic hyperplasia (BPH) and to present a new methodological approach to investigate therapeutic equivalence (non‐inferiority) regarding symptom reduction.
PATIENTS AND METHODS
We conducted a systematic review and searched MEDLINE, Embase and the Cochrane Library (last search: 10/2009) for randomized controlled trials (RCTs) and non‐randomized controlled clinical trials (CCTs).
Eligible studies were those that included patients with symptomatic BPH requiring surgical treatment and which compared non‐standard procedures (e.g. minimally invasive technologies) with standard ones (e.g. transurethral resection of the prostate, TURP). In addition, only studies analysing patient‐relevant outcomes were considered (e.g. irritative and obstructive symptoms, length of hospital stay, quality of life and adverse events).
The main outcome of interest for the present analysis was superiority or non‐inferiority for symptom reduction.
As no trial investigated non‐inferiority, we defined a non‐inferiority threshold (0.25 standard deviation) on the basis of published literature. If a non‐standard procedure showed non‐inferiority for symptom reduction, additional outcomes were assessed. Meta‐analyses were conducted if feasible and meaningful.
RESULTS
In all, 43 mainly low‐quality trials (RCTs only) compared nine non‐standard surgical treatments with standard ones.
Mean follow‐up ranged from 6 to 84 months.
No non‐standard procedure was superior for symptom reduction. Non‐inferiority for symptom reduction was shown in patients who had undergone holmium laser resection of the prostate (HoLRP) or thulium laser resection of the prostate (TmLRP).
As procedural advantages (e.g. no occurrence of transurethral resection syndrome) and other advantages (e.g. shortened hospital stay) were found, an indication of an additional benefit of HoLRP and TmLRP was determined.
CONCLUSIONS
No proof of superiority for symptom reduction has been shown for non‐standard surgical treatments in patients with BPH.
There is a lack of high‐quality RCTs and trials designed to investigate non‐inferiority.
Future studies should define a non‐inferiority threshold (ideally, uniform) a priori, so that results of individual studies are interpretable and comparable, and future systematic reviews should consider this issue.