Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis

RESEARCH ARTICLE Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis Myong Kim1, Chang Wook Jeong2, Seung-June Oh2* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea, 2 Department of Urology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea * Abstract OPEN ACCESS Citation: Kim M, Jeong CW, Oh S-J (2017) Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis. PLoS ONE 12(2): e0172590. doi:10.1371/journal.pone.0172590 Editor: Robert Hurst, University of Oklahoma Health Sciences Center, UNITED STATES Purpose To investigate the diagnostic value of urodynamic bladder outlet obstruction (BOO) in the selection of patients for transurethral surgery of the prostate. Materials and methods We systematically searched online PubMed, Embase, and Cochrane Library databases from January 1989 to June 2014. Received: September 19, 2016 Results Accepted: February 7, 2017 A total of 19 articles met the eligibility criteria for this systematic review. The eligible studies included a total of 2321 patients with a median number of 92 patients per study (range: 12– 437). Of the 19 studies, 15 conducted conventional transurethral prostatectomy (TURP), and 7 used other or multiple modalities. In urodynamic bladder outlet obstruction (BOO) positive patients, the pooled mean difference (MD) was significant for better improvement of the International Prostate Symptom Score (IPSS) (pooled MD, 3.48; 95% confidence interval [CI], 1.72–5.24; p < 0.01; studies, 16; participants, 1726), quality of life score (QoL) (pooled MD, 0.56; 95% CI, 0.14–1.02; p = 0.010; studies, 9; participants, 1052), maximal flow rate (Qmax) (pooled MD, 3.86; 95% CI, 2.17–5.54; p < 0.01; studies, 17; participants, 1852), and postvoid residual volume (PVR) (pooled MD, 32.46; 95% CI, 23.34–41.58; p < 0.01; studies, 10; participants, 1219) compared with that in non-BOO patients. Some comparisons showed between-study heterogeneity despite the strict selection criteria of the included studies. However, there was no clear evidence of publication bias in this meta-analysis. Published: February 27, 2017 Copyright: © 2017 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This study was supported by grant no 23-2015-0050 from Seoul National University Hospital Research Fund. The funders had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Competing interests: The authors have declared that no competing interests exist. Conclusions Our meta-analysis results showed a significant association between urodynamic BOO and better improvements in all treatment outcome parameters. Preoperative UDS may PLOS ONE | DOI:10.1371/journal.pone.0172590 February 27, 2017 1 / 15 Diagnostic value of BOO for transurethral surgery add insight into postoperative outcomes after surgical treatment of benign prostatic hyperplasia. Introduction Traditionally, the primary goal of treatment of benign prostatic hyperplasia (BPH) has been to lessen the bothersome lower urinary tract symptoms (LUTS) caused by prostatic enlargement [1,2]. Surgery is the most invasive option for BPH treatment which can cause irreversible complications[3]. To ensure a better outcome, proper indicators for surgical intervention should be selected. The most recent international treatment guidelines commonly recommend that a surgical intervention should be considered in BPH patients with failure to treatment with oral medications or with complicated LUTS[1,2]. The mechanism for surgery is based on the classic bladder outlet obstruction (BOO) model. Enlarged prostate tissue causes obstruction and increases the urethral resistance to flow, and therefore requires higher intravesical pressure to void[2]. The urodynamic study (UDS) is the only gold standard for the diagnosis of BOO[4]; however, invasiveness, cost, and morbidity of UDS limit its clinical use[5]. In this regard, most guidelines recommend UDS for male LUTS evaluation only in specific situations such as, prior to surgery, previous unsuccessful treatment, functional cystometric capacity < 150mL, post-void residual urine (PVR) > 300mL, patient too young (< 50 years) or too old (> 80 years) for surgery[1], or maximal flow rate (Qmax) > 10mL/s (relative BOO)[2]. However, most of those recommendations are supported by very low level of evidences (LEs) (all LE = 3)[1]. To our knowledge, there have been no randomized studies regarding the usefulness of UDS for guiding clinical application in male LUTS. There are no published randomized controlled trials in men with LUTS that compare the standard investigations such as symptom score or uroflowmetry (UFM) with UDS[1]. Moreover, the utility of performing UDS before transurethral surgery has rarely been studied in a systemic fashion. Because reports on the diagnostic value of urodynamic BOO for LUTS in men are few, a combination of these data to reach a reasonable conclusion is necessary. The objective of the present study was to conduct a systematic review and meta-analysis of published literature investigating the diagnostic value of urodynamic BOO in the selection of patients for transurethral surgery of the prostate and to provide a higher LE for guiding practical use of UDS in BPH patients. Materials and methods Search strategy for relevant studies The whole process for this systematic review and meta-analysis was conducted according to the study protocol approved by all authors and followed the up-dated versions of MOOSE and PRISMA recommendations (S1 and S2 Checklists) [6,7]. We systematically searched online PubMed, Embase, and Cochrane Library database up to June 2014. Our overall search strategies included terms for UDS (urodynamic, cystometry, and pressure flow study), BPH (benign prostatic hyperplasia, benign prostatic obstruction, and male LUTS), and transurethral surgery (transurethral resection, transurethral incision, vaporization, ablation, and enucleation). Detailed queries for search strategy are presented in S1 Table. Manual search of relevant studies were also performed referring to review articles or original research articles on similar subjects. PLOS ONE | DOI:10.1371/journal.pone.0172590 February 27, 2017 2 / 15 Diagnostic value of BOO for transur (...truncated)