The edition · Urology
Cochrane on HoLEP: one advantage over TURP survives the randomised evidence, and it is transfusion
Fifty-two trials and 6,242 men, and at 12 months HoLEP and TURP look alike on symptoms, quality of life, major adverse events, re-treatment and erectile function. Transfusion is the exception, RR 0.19. Plus a randomised trial of PSMA PET-guided biopsy, machine learning for stone composition, a tadalafil ingredient recall, and where the guidelines now agree on lutetium-177.
The edition in brief
A Cochrane review of 52 randomised trials in 6,242 men compared holmium laser enucleation of the prostate with other surgical treatments for benign prostatic hyperplasia, prioritising the comparison with TURP at up to 12 months. HoLEP may make little or no difference to symptom score (IPSS mean difference −0.67, 95% CI −1.20 to −0.14, I² 93%, low certainty), quality of life, or major adverse events (RR 0.75, 0.35 to 1.58), and probably little difference to re-treatment or erectile function. It likely reduces transfusion, RR 0.19 (0.09 to 0.42, moderate certainty) — which the authors call the only advantage the randomised evidence supports as clinically important. Evidence was insufficient for very large prostates or men on anticoagulation, and no trial reported ejaculatory function. A single-centre randomised trial in 217 biopsy-naive men with PI-RADS 4 or 5 lesions compared robotic-arm-assisted gallium-68 PSMA-11 PET/CT-guided biopsy with cognitive-fusion transrectal ultrasound biopsy: cancer detection was 97.1% against 81.0%, complications 10.8% against 51.4%, with less pain and shorter procedures. Machine learning predicted the dominant component of 442 urinary stones with a macro-averaged AUC up to 0.809 from clinical variables alone and up to 0.983 once morphological descriptors were added — but those descriptors are recorded during or after the procedure, so the strong model is not a preoperative tool. The FDA has classified a Class II recall of bulk tadalafil sold for compounding. And a synthesis of six society guidelines finds convergence on lutetium-177 PSMA radioligand therapy for PSMA-positive metastatic castration-resistant disease after an androgen receptor pathway inhibitor and a taxane, at 7.4 GBq every six weeks for up to six cycles.
HoLEP against TURP: similar on almost everything, decisively better on bleeding
Against TURP at 12 months, HoLEP gives similar symptom relief, quality of life, adverse events, re-treatment and erectile function — the one clinically important advantage the randomised evidence supports is a much lower transfusion rate.
PSMA PET-guided robotic biopsy beat cognitive fusion on detection and on complications
PSMA PET-guided robotic biopsy detected cancer in 97.1% of PI-RADS 4 or 5 lesions against 81.0% for cognitive fusion, with a fifth of the complications — from one centre, against the weakest targeted comparator.
Predicting stone composition: the accurate model needs data you only have afterwards
Machine learning predicted dominant stone composition with an AUC of 0.983 — but only using morphological features recorded during or after the procedure; the preoperative model reaches about 0.809.
Bulk tadalafil for compounding under Class II recall
Bulk tadalafil sold for compounding is under a Class II recall for manufacturing practice deviations — licensed tablets are unaffected, but ask any man on a compounded preparation, including for LUTS, where it came from.
Asymptomatic bacteriuria is a culture result, not an infection
Treat urinary symptoms, not urine cultures — outside pregnancy and pre-procedural prophylaxis, asymptomatic bacteriuria needs no antibiotic and treating it does harm.
Where the guidelines now agree on lutetium-177 PSMA, and where they have started to move
Every major guideline except ESMO now endorses lutetium-177 PSMA-617 after an androgen receptor pathway inhibitor and a taxane — so get PSMA imaging and the referral route in place before the patient is too unwell to have six cycles.
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