Editorial Comment on: Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy by Zhang et al. (From: Zhang MW,El Tayeb MM,Borofsky MS,et al. J Endourol 2017;31:847–850)

Since holmium laser enucleation of the prostate (HoLEP) was first described 20 years ago, ¹ there have been an increasing number of energy sources and techniques described to endoscopically enucleate the prostatic adenoma for benign prostatic hyperplasia (BPH) management. ² Robot-assisted laparoscopic techniques have developed in parallel, largely driven by Radical Prostatectomy for prostate cancer treatment, but recently applied to simple prostatectomy for BPH. ³ Both HoLEP and robot-assisted simple prostatectomy (RASP) are most compelling when applied to large prostates (>80 g) when procedures such as transurethral resection of the prostate (TURP) and vaporization become less justifiable on both safety and efficacy grounds.

The article by Zhang et al. compares these two techniques in terms of perioperative safety and early efficacy, but issues such as cost-effectiveness and the learning curve were not studied specifically. ⁴ Interestingly, the operative time was shorter in the HoLEP arm in this study than RASP unlike the study of Umari and colleagues, ⁵ wherein the two techniques were of similar duration—the obvious difference being the prolonged surgical time in the RASP group. Although it is tempting to suggest that this was due primarily to the extensive HoLEP experience of the senior author, the RASP group had more than double the operating room (OR) time seen in the Umari study. Clearly, the learning curve for RASP even for experienced robotic surgeons is substantial and likely similar to that for HoLEP in these large glands.

Assuming that each of these techniques is equally effective clinically, the real difference, therefore, appears to be around the costs involved. RASP appears to have significantly greater operative costs (both disposables and machine costs) offset, in part, by the use of robots for other procedures, and also increased perioperative costs with more hospital time and more transfusions. A cost-effectiveness analysis would likely favor endoscopic enucleation at first glance and will become an important additional factor in deciding whether large BPH becomes the domain of the endoscopic or robotic surgeons given the learning curves are similar!