LAUSR

In their recent meta-analysis, Zheng et al. evaluated the use of photoselective vaporization of the prostate (PVP) for the treatment of benign prostatic obstruction (BPO)–related lower urinary tract symptoms (LUTS) in high-risk patients on and off systemic antithrombotic treatment (antiplatelets and/or anticoagulants) [1]. Based on their results, PVP represents a safe and effective option for high-risk patients with LUTS/BPO with no difference in terms of perioperative parameters and complications between the groups of patients who remained on or discontinued their antithrombotic treatment, except for catheterization time that was shorter in the non-antithrombotics group. Perioperative management of LUTS/BPO surgical candidates on antithrombotics remains a clinical challenge. Management should be based on weighing the perioperative bleeding risk against the risk of thromboembolic episodes. Current EAU guidelines recommend (weak strength) the use of PVP for the treatment of men receiving antithrombotics with prostatic volumes < 80 g, highlighting, however, the low level of available evidence [2]. In view of this, Zheng et al. performed a meta-analysis of 11 non-randomized and mainly retrospective, comparative trials. To further strengthen their findings, the authors conducted subgroup analysis based on laser power output. Only three studies presented relevant parameters and based on them, a reduction in catheterization time was found in the non-antithrombotics 180 W group. However, some methodological issues need to be discussed. The authors do not report whether a protocol was published prior to starting the review process, have not provided with description of whether and how they approached grey literature and although they report absence of publication bias, they have not described the methods applied to detect and correct for it. For the critical part of risk of bias (RoB) assessment, the authors used the Newcastle–Ottawa Scale which can be applied to assess non-randomised trials but interestingly has not been presented in a peer-reviewed journal, has received criticism about its validity, and its ability to properly distinguish high-RoB studies from the lower risk ones has been challenged. Moreover, its inter-rater reliability has been questioned [3–5]. Other tools to assess RoB could have been applied such as the ROBINS-I (RoB In Non-randomized Studies-of Interventions) tool [6]. Another point of potential criticism has to do with the fact that all antithrombotic medications were approached as a single group, while there is clear clinical heterogeneity of this group. For example, various guidelines do not recommend strict discontinuation of low-dose aspirin for elective operations throughout the perioperative period, while this is certainly not the case for warfarin [7–9]. Moreover, it is unclear why the authors selected to include a study in which anticoagulants were stopped in all the patients prior to operation and low-molecular weight heparin was started in the small number of warfarin patients [10]. Nevertheless, the authors need to be congratulated for aiming to cover the evidence gap with a systematic approach that hopefully will improve the strength of the available recommendations. This can also lead future research activities such as designing a randomized clinical trial that will further improve the quality of the available evidence.