HoLEP against TURP: similar on almost everything, decisively better on bleeding

Design

Cochrane systematic review and random-effects meta-analysis of randomised trials, RoB 1 and GRADE

Population

6,242 men over 40 with prostate volume 20 mL or more and IPSS 8 or above, across 52 trials; prioritised comparison HoLEP vs TURP at up to 12 months

Primary outcome

Urologic symptom score, quality of life, and major adverse events

Effect

IPSS MD −0.67 (95% CI −1.20 to −0.14, I² 93%); major adverse events RR 0.75 (0.35 to 1.58); transfusion RR 0.19 (0.09 to 0.42)

Fifty-two randomised trials with 6,242 participants were pooled, median ages 65 to 74, baseline prostate volumes from 30 to 142 cc and baseline IPSS from 19.6 to 28.6. The review prioritises HoLEP against TURP at up to 12 months, TURP being the long-standing reference. On the critical outcomes, HoLEP may result in little to no difference in symptom score — mean difference −0.67 on a 0 to 35 scale (95% CI −1.20 to −0.14, I² 93%, low certainty) — in quality of life (MD −0.04, −0.23 to 0.15, low certainty), or in major adverse events (RR 0.75, 0.35 to 1.58, low certainty). Re-treatment (RR 0.45, 0.14 to 1.50) and erectile function (MD −0.03, −0.47 to 0.42) were probably no different, at moderate certainty. Transfusion was less likely with HoLEP, RR 0.19 (0.09 to 0.42, moderate certainty, 15 studies).

The authors say plainly that transfusion is the only advantage the randomised evidence supports as clinically important, and that framing is worth adopting because the case for HoLEP is often made much more broadly. A 0.67-point IPSS difference is well below what a man can perceive, and the statistical significance of that difference is an artefact of pooling 14 heterogeneous trials rather than a clinical finding.

Where HoLEP is usually argued to matter most, the evidence is missing rather than negative. There was insufficient evidence for men with very large prostates or on anticoagulation — the two groups in whom the bleeding advantage would be expected to convert into something larger — and no trial reported ejaculatory function at all, which is the outcome men most often ask about. So the argument for HoLEP in a service with the equipment and the training rests on bleeding, on the plausible extension of that to anticoagulated and large-gland patients, and on evidence yet to be generated. That is a reasonable case; it is not the same as HoLEP being better across the board.

• Base the case for HoLEP on transfusion risk, not on symptom scores — the difference in IPSS is not perceptible.
• Prioritise it in men on anticoagulation or with very large glands, while noting the trial evidence there is insufficient.
• Tell a man asking about ejaculation that no trial in this review reported that outcome.
• Re-treatment and erectile function were probably no different at 12 months.
• The comparison shown is short-term; long-term randomised data remain the gap.

The statistics, in plain English

Two numbers in this review illustrate opposite traps. The IPSS difference of −0.67 excludes zero, so it is statistically significant — but on a 0 to 35 scale with a minimally important difference of about three points, it is clinically meaningless, and heterogeneity of 93% means the trials disagreed so much that the pooled average describes none of them. The transfusion result is the reverse: a risk ratio of 0.19 with an interval of 0.09 to 0.42, no heterogeneity and 15 trials, is both statistically and clinically decisive. GRADE certainty is the third axis: low certainty on the symptom outcomes means future trials could easily change those conclusions, while moderate certainty on transfusion means they probably will not.

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