Comparing outcomes of Aquablation versus holmium laser enucleation of prostate in the treatment of benign prostatic hyperplasia: A network meta-analysis

Introduction: Water Jet Ablation Therapy (WJAT) and Holmium Laser Enucleation of the Prostate (HoLEP) represent two common surgical treatments for Benign Prostatic Hyperplasia (BPH). Despite their increasing use, there is no study between these two methods. We aim to evaluate their efficacy and safety through a network meta-analysis (NMA), providing critical insights for clinical decision-making in the management of moderate to severe lower urinary tract symptoms (LUTS) due to BPH. Methods: Pubmed, EMBASE and Cochrane Library were searched. Randomized controlled trials and prospective single-arm studies comparing WJAT and HoLEP with TURP, reporting symptom scores, flow rates and adverse events. Data extraction and quality assessments were independently performed. Bayesian modelling in RStudio was used for statistical analysis, evaluating continuous outcomes through mean difference and categorical variables via risk ratios. Risk-of-Bias (RoB) and GRADE assessments were performed. Findings: Twenty-three studies were included (WJAT-11, HoLEP-12). Most studies were at some or high risk of bias. At 12 months, the IPSS, Qol, PVR and Qmax improvements were 4.14 points (95% CI: -0.34 to 8.64, not-significant [NS], GRADE-rating: Low), 0.32-points (95% CI:-10.70 to 3.27, NS, GRADE-rating: Low), 2.45 ml/s (95% CI: -1.85 to 7.05, NS, GRADE-rating: Low), 63.10 ml (95% CI: 39.80 to 87.30, statistically-significant [SS], GRADE-rating: Moderate), respectively, all in favour of HoLEP. Haemoglobin-loss was lower with HoLEP, 1.16 g/dl (95% CI: -2.56 to 0.54 mg/dl, NS, GRADE-rating: Moderate) than WJAT. The risk of incontinence was higher with HoLEP; 4.48 (95% CI: 0.22 to 168.50, NS, GRADE-rating: Very Low) than WJAT in single-arm analysis. The risk of blood transfusion was higher with WJAT (RR = 0.14; 95% CI: 0.00 to 4.21, NS, GRADE-rating: Low) than HoLEP. Risk of Total Serious Adverse Events (Clavien-Dindo grade>3) was higher with HoLEP (RR = 1.12, higher with HoLEP, 95% CI: 0.20 to 12.71, NS, GRADE-rating: Low) than WJAT. Retreatment was lower with HoLEP (RR = 0.46, 95% CI: 0.02 to 10.54 GRADE-rating: Low) than WJAT. Interpretation: Our study suggests that both HoLEP and WJAT are effective treatments for BPH, both with similar IPSS and QoL improvements. HoLEP excels in functional outcomes, particularly in improving Qmax and PVR. Conversely, WJAT, with its shorter operation time and hospital stays, presents a compelling alternative, particularly for outpatient settings.