| Summary: | 博士 === 國立臺灣大學 === 流行病學與預防醫學研究所 === 107 === Background and Objectives
Minimally invasive urologic therapy (MIUT) has reduced surgery-associated complications and facilitates faster recovery compared to conventional open surgeries. In medical conditions such as urolithiasis and benign prostate hyperplasia (BPH), MIUT has gained preference over conventional treatments. Nevertheless, MIUTs are continuously modified and refined for improvement, and new approaches are being introduced for better surgical outcomes. Although extracorporeal shockwave lithotripsy (SWL) is a favored treatment for urolithiasis, much debate has surrounded its association with long-term risk of hypertension and diabetes. On the other hand, despite monopolar transurethral resection of prostate (TURP) being the gold standard surgical treatment for BPH since the 1970’s, numerous methods including the use of different lasers and bipolar probes have been developed and made available since the start of the century. In the current thesis, we adopted the most appropriate and practical approaches of evidence-based medicine (EBM) to: 1) Study whether SWL will increase the subsequent risk of hypertension and diabetes later in life; and 2) Compare the efficacy and complications of new surgical methods with monopolar TURP.
Methods
To evaluate the reported long-term risk of new-onset hypertension and diabetes, associated with SWL in patients with urolithiasis, we sought to adopt the Taiwanese National Health Insurance Research Database, and a retrospective data collection of cohorts who either received SWL or ureteroscopic lithotripsy (URSL). A Cox proportional model and Time-varying Cox models were applied to evaluate the association between SWL and the incidence of hypertension or diabetes. Meanwhile, a meta-analysis of publications reporting on any of the nine BPH MIUTs, selected based on the instrumental and resection method, was performed. The Cochrane risk of bias table was applied to appraise the quality of studies, metafunnel to identify publication bias, followed by random effects generalized linear mixed model to compare the efficacy and safety of these different surgical methods for BPH.
Results
After a median follow-up of 74.9 and 82.6 months, 2,028 and 688 patients developed hypertension in the SWL and URSL groups, respectively. Patients who underwent SWL had a higher probability of developing hypertension than patients who underwent URSL, with a hazard ratio (HR) of 1.20 (95% confidence interval 1.10-1.31) after adjusting for covariates. The risk increased as the number of SWL sessions increased, with a HR of 1.10 (95% CI 1.00-1.20, p=0.05), 1.30 (95% CI 1.15-1.48, p<0.001), 1.55 (95% CI 1.31-1.85, p<0.001), 1.70 (95% CI 1.32-2.19, p<0.001), and 2.00 (95% CI 1.63-2.45, p<0.001) in one, two, three, four and more than five SWL sessions, respectively. However, the risk of diabetes was similar between the two cohorts. In network meta-analysis, we identified 105 trials that enrolled a total of 13,176 participants. Nine surgical treatments were evaluated. Enucleation achieved better maximal flow rate (Qmax) and International Prostate Symptom Score (IPSS) than resection and vaporization, at 6 and 12 months after surgery, and the difference was maintained postoperative up to 24 and 36 months. For 12-month Qmax, the 3 best methods, compared to monopolar TURP, were diode laser enucleation [mean difference (95% Confidence Interval)]: [3.15 (0.63 to 5.67) mL/s], bipolar enucleation [2.80 (1.43 to 4.16) mL/s], and holmium laser enucleation [1.13 (0.13 to 2.13) mL/s]. The worst was diode laser vaporization [-1.90 (-5.04 to 1.24) mL/s]. The eight new methods were all superior in controlling bleeding than monopolar TURP, resulting in shorter catheterization duration, reduced postoperative hemoglobin level declination, fewer blood clot tamponade events, and lower blood transfusion rate. However, short-term transient urinary incontinence was still a concern for enucleation methods. No inconsistency between direct and indirect evidence was detected in either primary or secondary outcomes.
Conclusion
The current thesis found that: SWL increased the long-term risk of new-onset hypertension but not diabetes; new surgical methods for BPH were superior in safety as compared to monopolar TURP: and enucleation methods were the best in primary efficacy. Our thesis demonstrated two best epidemiologic designs to answer contentious issues.
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