Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis

Abstract

Introduction and Objectives:

Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc.

Materials and Methods:

Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien–Dindo Classification.

Results:

Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (−12.50 vs −9, p = 0.246) as well as improvement of the QoL (−3 vs −3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987).

Conclusion:

Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

Introduction

Bladder outlet obstruction (BOO) and lower urinary tract symptoms (LUTS) secondary to benign prostate enlargement (BPE) represent common urological disorders in older men.¹ Surgical treatment is considered in patients with absolute indications such as recurrent or refractory urinary retention, overflow incontinence, recurrent urinary tract infections (UTI), bladder stones or diverticula, treatment-resistant macroscopic hematuria due to BPE, or dilatation of the upper urinary tract secondary to BOO, with or without renal insufficiency. Furthermore, surgery may be necessary when patients fail to obtain adequate relief from LUTS or postvoid residual volume (PVR) using maximal medical treatment. According to the guidelines of the European Association of Urology (EAU), open simple prostatectomy (OSP) or holmium laser enucleation of the prostate (HoLEP) are recommended as first-line treatment options in patients with large prostates >80 cc.²

Over the years, OSP has consistently demonstrated superior functional outcomes and long-term effectiveness compared with other surgical techniques. However, it is important to note that OSP is associated with a higher risk of perioperative complications and subsequent costs.³ During the past decade, many studies showed that a robot-assisted simple prostatectomy (RASP) approach represents a viable alternative for these men.^4

–11 These studies allowed the shift from an investigational to a well-established procedure. Thus, RASP is now mentioned in the EAU guidelines as a minimally invasive technique with high success rates.² Regarding HoLEP, multiple well-conducted studies have consistently shown remarkable long-term outcomes. Consequently, the EAU guidelines now endorse HoLEP as the recommended standard of care for prostatic glands with a volume exceeding 80 cc.^12,13

In the case of extremely large prostates above 200 cc, current data are limited to a very small number of patients. HoLEP is considered equally suitable for small, medium, and large prostate glands, with clinical outcomes that are independent of prostate size. However, in the current cohort studies, only 0.5%–3% of the study population has a prostate volume of >200 cc.^14
–16 It is well known that HoLEP may have some technical challenges when performed in patients with very large prostates.¹⁶ For RASP, there is also a paucity of available data focusing on patients with very large prostates.¹¹

The aim of this study was therefore to compare HoLEP and RASP as a minimally invasive alternative to OSP in patients with very large prostates ≥200 cc. The primary endpoint was to investigate and compare the perioperative and functional outcomes, while the secondary endpoint was to evaluate the safety in terms of complication rates using the Clavien–Dindo classification.

Materials and Methods

Patient population

A retrospective analysis was conducted at a single tertiary referral center, OLV Hospital in Aalst, Belgium, to evaluate patients who underwent either HoLEP or RASP between 2009 and 2020. Only patients with a prostate volume of 200 cc or more were included in the study. All included patients had either an absolute indication for surgery or were unresponsive to medical therapy. The procedures were performed by three expert surgeons, with one surgeon conducting both procedures, another only RASP, and the third only HoLEP. Each surgeon has extensive experience, having performed over 500 robotic cases and/or HoLEP procedures.

Before surgery, patients underwent comprehensive clinical evaluation, including a detailed medical history, physical examination, transrectal ultrasound, and uroflowmetry. Demographic information such as age, body mass index, Charlson comorbidity index, the presence of a preoperative indwelling catheter (either transurethral or suprapubic), prostate volume, baseline hemoglobin (Hb) level, and prostate-specific antigen (PSA) were recorded. Treatment selection was patient based after being informed about both procedures and at the discretion of the referring/treating urologist. RASP was suggested to patients with large bladder diverticula, multiple or large bladder stones, a history of urethral strictures, and extremely large prostate volumes.

Variable definitions

Baseline functional parameters included the International Prostate Symptom Score (IPSS) and the accompanying quality of life (QoL),¹⁷ maximum urinary flow rate (Qmax), and PVR. These variables were assessed preoperatively and postoperatively. Perioperative outcomes included operative time (OT), catheterization (CV) time, length of stay (LoS), postoperative Hb level, and histopathological assessment of the specimen. Thirty-day complications were recorded and graded according to the Clavien–Dindo classification system.¹⁸

Surgical techniques

Both techniques were extensively described previously.¹⁹ Anticoagulant and antiplatelet therapy was routinely discontinued preoperatively.

Robot-assisted simple prostatectomy

All patients received antibiotic and thromboembolic prophylaxis. All procedures were conducted using the da Vinci Si or Xi surgical system, through a transperitoneal approach and in a four-arm configuration. Robotic trocars were arranged in a fan array, similar to radical prostatectomy. After detaching the bladder, a vertical midline mini vesicocapsulotomy was performed, starting from the prostatovesical junction. The adenoma was dissected bluntly and circumferentially. To reconstruct the prostatic fossa, a double-layer 3-0 V-Loc running suture was placed from the bladder neck to the urethra. A three-way catheter with continuous irrigation was placed and the cystotomy was closed in two layers. A pelvic drain was left behind, which could be removed on day 1 postoperatively. Depending on the hematuria, irrigation and subsequently the transurethral catheter could be removed. Rx cystography was not routinely carried out and only performed in case of a complicated postoperative course.

Holmium laser enucleation of prostate

The procedures were carried out using a 100 W VersaPulse™ holmium:YAG laser with a 550 nm end-firing flexible quartz laser fiber, a continuous flow 26F Iglesias resectoscope (Karl Storz, Tuttlingen, Germany), and a VersaCut™ mechanical tissue morcellator. The irrigation fluid was 0.9% saline solution. To achieve coagulation with a monopolar loop, a 1.5% glycine solution was used. Prostate enucleation was carried out by the two- or three-lobe technique, as previously detailed and the fragmentation of the tissue was performed using a mechanical tissue morcellator. Following the surgery, a 20F three-way catheter was inserted and maintained until urine clarification.

Statistical analyses

Continuous variables were presented as the median and interquartile range, while categorical variables were reported as frequency and proportion. Univariate regression analysis was conducted to test the association between groups (RASP vs HoLEP), functional outcomes (postoperative IPSS, Qmax, and PVR) and 30-day complications. All statistical analyses were performed using SPSS version 24.0 (IBM Corp., released 2016).

Results

A total of 53 consecutive patients with extremely large prostates underwent surgery between 2009 and 2020 at OLV Hospital. Overall, 31 (58%) and 22 (42%) patients underwent RASP and HoLEP, respectively. Preoperative and intraoperative data are summarized in Tables 1 and 2.

Table 1.

Preoperative Characteristics of Patients Affected by Benign Prostate Enlargement and Surgically Treated with Robot-Assisted Simple Prostatectomy or Holmium Laser Enucleation of the Prostate

Variable	Overall population (N = 53)	RASP (n = 31, 58.5%)	HoLEP (n = 22, 41.5%)	p
Age (year), median (IQR)	76 (69, 80)	73 (66.5, 79)	77.5 (72, 82)	0.063
Body mass index, median (IQR)	26.6 (24.3, 30.7)	27.6 (25.7, 30.9)	26.1 (23.3, 28.7)	0.103
ASA score, n (%)				0.190
1	11 (21)	8 (26)	3 (13)
2	33 (62)	20 (64)	13 (60)
3	9 (17)	3 (9)	6 (27)
Charlson Comorbidity Index, n (%)				0.146
0–3	18 (34)	13 (42)	5 (23)
≥4	35 (66)	18 (58)	17 (77)
Medication presurgery, n (%)	37 (70)	22 (71)	15 (68)	0.828
Acute urinary retention, n (%)	34 (64)	18 (58)	16 (73)	0.273
Transurethral catheter, n (%)	11 (21)	8 (26)	3 (14)	0.282
Suprapubic catheter, n (%)	13 (25)	3 (10)	10 (45)	0.003^*
Total preop catheter, n (%)	24 (46)	11 (35)	13 (59)	0.089
Prostate volume TRUS (cc), median (IQR)	220 (204, 240)	225 (220, 260)	204.5 (204, 224)	0.004^*
Preoperative Hb (g/dL), median (IQR)	14.0 (12.7, 15.0)	14.3 (13.2, 15.1)	12.1 (11.3, 12.9)	0.069
Preoperative PSA (ng/mL), median (IQR)	9.8 (6.3, 17.0)	10.4 (6.1, 18.3)	7.5 (7.0, 11.0)	0.206
Preoperative IPSS, median (IQR)	18 (12, 23.3)	18 (13, 26)	15 (12, 19)	0.136
Preoperative QoL, median (IQR)	4 (3, 5)	4 (3, 5)	4 (3, 4)	0.774
Preoperative Qmax (mL/s), median (IQR)	9.2 (6.5, 12.8)	10.0 (6.0, 13.0)	8,2 (8.0, 9.2)	0.925
Preoperative PVR (mL), median (IQR)	70 (0, 160)	70 (0, 200)	64 (25, 140)	0.810

All variables are presented as median (IQR) or frequency (proportion).

ASA = American Society of Anesthesiology; Hb = hemoglobin; HoLEP = holmium laser enucleation of the prostate; IPSS = International Prostate Symptom Score; IQR = interquartile range; PSA = prostate-specific antigen level; PVR = postvoid residual volume; Qmax = maximum flow rate; QoL = quality of life; RASP = robot-assisted simple prostatectomy; TRUS = transrectal ultrasound.

Table 2.

Main Surgical and Functional Outcomes of Patients who Underwent Robot-Assisted Simple Prostatectomy and Holmium Laser Enucleation of the Prostate

Variable	Overall (N = 53)	RASP (n = 31, 58%)	HoLEP (n = 22, 41%)	p
Surgical outcomes
Operating time (minutes), median (IQR)	135 (120, 156.5)	150 (120, 158)	132.5 (120, 155)	0.665
No. of stone removed, n (%)	5 (9)	3 (10)	2 (9)	1.000
No. of diverticulum removed, n (%)	4 (8)	4 (13)	0	0.221
Postoperative Hb (g/dL), median (IQR)	12.8 (11.2, 14.0)	12.9 (11.5, 14.1)	11.5 (10.5, 11.9)	0.254
Hb drop (g/dL), median (IQR)	1.2 (0.35, 2.35)	1.2 (0.3, 2.5)	1 (0.6, 1.5)	0.727
EBL (mL), median (IQR)	NA	400 (300, 750)	NA	NA
Catheterization time (day), median (IQR)	3 (2, 4)	3 (2, 4)	2 (2, 5)	0.748
Length of hospital stay (day), median (IQR)	4 (3, 6)	4 (4, 7)	3 (2, 5)	0.052
Prostatic weight (g), median (IQR)	157.5 (120, 189)	134.5 (110, 162)	180 (151, 202)	0.029^*
Prostate weight/preoperative prostate V (g/cc %), median (IQR)	71.4 (52.4, 84.4)	59.2 (50, 71.4)	86.7 (73, 92.5)	<0.001^*
Histologic report, n (%)
BPH	50 (94)	29 (93)	21 (95)	0.759
Adenocarcinoma	3 (6)	2 (7)	1 (5)	0.759
No. of Clavien grade 30-day complications, n (%)
All grade	19 (34)	10 (32)	8 (36)	0.987
Clavien 1	12 (23)	6 (19)	6 (27)	0.730
Clavien 2	7 (13)	3 (10)	4 (18)	0.625
Clavien 3a	2 (4)	2 (6)	0	0.629
Clavien 3b	2 (4)	1 (3)	1 (5)	1.000
Clavien 4/5	1 (2)	0 (0)	1 (5)	0.862
No. of low-grade complications^a	19 (35)	9 (29)	10 (45)	0.348
No. of high-grade complications^b	5 (9)	3 (10)	2 (9)	1.000
No. of transfusions	0	0	0	1.000
No. of transient urgency	24 (45)	14 (45)	10 (45)	1.000
No. of transient urge incontinence (0–1 pad/day)	7 (13)	3 (10)	4 (18)	0.628
No. of persistent urge incontinence (0–1 pad/day)	1 (2)	0	1 (5)	0.864
Functional outcomes
Postoperative follow-up (months), median (IQR)	1 (1, 2)	1 (1, 2)	1 (1, 1.5)	0.712
Postoperative PSA (ng/mL), median (IQR)	1.15 (0.4, 1.8)	1.8 (1.8, 1.8)	0.4 (0.3, 0.4)	0.009^*
Postoperative IPSS, median (IQR)	6 (4.3, 7.0)	6 (4.5, 7.0)	8 (4.5, 9.0)	0.390
Postoperative QoL, median (IQR)	1 (1, 2)	2 (1, 2)	1 (1, 2)	0.563
Postoperative Qmax (mL/s), median (IQR)	18.0 (15.0, 25.5)	17.0 (15.0, 24.8)	23.0 (18.0,30.0)	0.123
Postoperative PVR (mL), median (IQR)	0 (0, 53)	10 (0, 66)	0 (0, 28)	0.116
Last follow-up (months), median (IQR)	14 (8, 22)	14 (8, 22)	12 (8, 25)	0.312
Last PSA (ng/mL), median (IQR)	1 (0.5, 2.6)	1.2 (0.6, 2.8)	0.8 (0.5, 2.0)	0.736
Last operative IPSS, median (IQR)	3 (2, 3)	3 (2, 3)	3 (2, 4)	0.810
Last operative QoL, median (IQR)	0 (0, 1)	0 (0, 1)	0 (0, 1)	0.667
Last operative Qmax (mL/s), median (IQR)	24 (15, 34.2)	25 (15, 37)	23.7 (10, 32.3)	0.798
Last operative PVR (mL), median (IQR)	0 (0, 43)	0 (0, 53)	0 (0, 30)	0,700

Perioperative complications were stratified by grade, according to the Clavien–Dindo classification, as observed within 30 days from the surgery. All variables are presented as median (IQR) or frequency (proportion).

Low-grade complications = Clavien–Dindo 1 and 2.

High-grade complications = Clavien–Dindo >2.

BPH = benign prostatic hyperplasia; EBL = estimated blood loss; NA = non applicable.

Patients treated with RASP had significantly larger prostate volumes (226 cc vs 204.5 cc, p = 0.004) compared with those who underwent HoLEP. However, patients in the RASP group had a lower rate of preoperative suprapubic CV (10% vs 45%, p = 0.004). Of 31 patients treated with RASP, 9 (29%) were not responding to maximal medical therapy, and 11 (35%) had complicated LUTS, including stones, diverticula, and one or more episodes of acute urinary retention (AUR). Of 22 patients treated with HoLEP, 5 (23%) were nonresponders to maximal medical therapy and 4 (18%) had complicated LUTS. There was no statistical difference in the percentage of patients having an indwelling catheter preoperatively (35% vs 59%, p = 0.089) and there were no statistically significant differences in preoperative IPSS score (18 vs 15, p = 0.136), QoL score (4 vs 4, p = 0.774), Qmax (10 mL/s vs 9.2 mL/s, p = 0.925), or PVR (70 mL vs 64 mL, p = 0.810) between the two groups. Median OT and postoperative Hb were similar in both groups (150 minutes vs 132.5 minutes, p = 0.665 and 1.2 g/dL vs 1 g/dL, p = 0.254, respectively).

Four RASP patients underwent a concomitant diverticulectomy (13% vs 0%, p = 0.221) and a similar number of procedures included bladder stone removal in both groups (10% vs 9%, p = 1.000). The median estimated blood loss in the RASP group was 400 mL. The amount of resected tissue was significantly higher in the HoLEP group (134.5 mL vs 180 mL, p = 0.029). There was no statistically significant difference in the postoperative PSA (1.2 ng/mL vs 0.8 ng/mL, p = 0.112) among the groups. Median CV time was similar in both groups (3 days vs 2 days, p = 0.748), and the LoS was shorter in the HoLEP group (3 days vs 2 days, p = 0.052). Incidental adenocarcinoma was found in 6% of the patients in the study group.

Functional outcomes showed similar improvement compared with baseline values at a median follow-up of 14 months in the RASP group and 12 months in the HoLEP group. There was a comparable increase in Qmax (+10.60 and +10.70 mL/s, p = 0.724) and a significant decrease in IPSS (−12.50 and −9, p = 0.246) and QoL (−3 and −3, p = 0.880) reported for both groups, without any alteration in the PVR (0 and 0 mL, p = 0.907).

Eighteen patients (34%) encountered a combined total of 24 postoperative complications. Among these complications, 19 (79%) were categorized as low grade (Clavien grade II or less), while 5 (21%) were classified as higher grade (Clavien grade III or higher). There were no instances of grade V complications, and none of the patients required a blood transfusion postoperatively. Considering low-grade complications (grade I–II), there were no significant differences (29% RASP vs 45% HoLEP, p = 0.348) among the groups. In the HoLEP group, one patient required bedside evacuation for clot retention and four patients had fever, requiring antibiotics. In the RASP group, one patient required a bedside clot evacuation after AUR. Due to leakage on cystography, the CV time needed to be prolonged in two cases and one patient required antibiotics. Moreover, two patients required antibiotics for UTI and pneumonia, respectively; transient urinary incontinence was recorded in three patients. No complications related to bowel recovery and surgical wounds were reported.

Considering the higher-grade complications (grade III, IV: 10% RASP vs 9% HoLEP, p = 1.000), two patients in the RASP group required flexible cystoscopy for re-CV and removal of clots and one patient required rigid cystoscopy to control bleeding. In the HoLEP group, one patient was readmitted and required a cystoscopy for bleeding control. One Clavien–Dindo grade IV adverse event occurred (acute cardiac event requiring urgent cardiac intervention).

There was no significant difference between the RASP and HoLEP groups regarding postoperative urinary incontinence (11% vs 25%, p = 0.359). Postoperative urinary urge incontinence appeared in six patients, limited to one pad a day. During follow-up, four patients experienced transient urinary incontinence, defined as urine leakage, which resolved within 6 months from surgery. No patients reported stress incontinence. Persistent urge incontinence appeared in one HoLEP patient (5%) and was limited to 0–1 pad a day. During follow-up, we saw no bladder neck contractures, urethral strictures, or reinterventions for recurrent BOO in both groups. PSA decreased substantially in both groups (p < 0.05) without significant differences between the two surgical approaches (p = 0.975), excluding patients with prostate carcinoma in the specimen pathology. On univariate regression analysis (Table 3), there were no statistically significant differences in perioperative and functional outcomes between the surgical techniques.

Table 3.

Univariate Regression Analysis Testing the Association Between Surgical Technique (Holmium Laser Enucleation of the Prostate Vs Robot-Assisted Simple Prostatectomy) with Perioperative and Functional Outcomes

Predictor	Odds ratio	95% Confidential interval	p
Postoperative IPSS	0.83	0.62–1.11	0.215
Postoperative Qmax (mL/s)	0.94	0.86–1.03	0.199
Postoperative PVR (mL)	1.01	0.99–1.03	0.172
30-Day complications	1.02	0.32–3.29	0.973

Discussion

In this study, we have reported data on 53 patients who underwent minimally invasive surgical treatment for very-large-volume BPE at a high-volume, tertiary referral center with significant surgeon experience. This is the first comparative analysis of two well-established minimal invasive techniques for the treatment of LUTS in patients with a prostate volume of 200 cc and higher.

The results of our study highlight that both techniques have similar peri- and postoperative outcomes as well as complications. As IPSS and Qmax were used as main outcome surrogates, no relevant differences in functional outcome were noticed at all. This may be related to the concept of adenoma enucleation, which is the base of both techniques.

Hospitalization and OT

In terms of surgical outcomes, we observed a slightly shorter LoS (4 days vs 3 days) and CV time (3 days vs 2 days) in the HoLEP group, without reaching a level of significance. The hospitalization time in the RASP group was considered acceptable when compared with previous studies. Additionally, the median CV time of 3 days was one of the shortest reported across all published series up to now.^{6

–9,20,21} The OT in the HoLEP group was significantly impacted by the prostatic volume, which is related to the morcellation time. In a large series of 243 patients, we found a median morcellation efficacy of 3.9 g/min (OLV Aalst unpublished data), counting from the start of the morcellation until all pieces were evacuated. Moreover, in the HoLEP group, the median morcellation time was about 20 minutes longer compared with our cohort of glands >100 cc (65 minutes vs 45 minutes).¹⁹ Since this morcellation step is not present in RASP, in extremely large glands, we expected RASP to have an advantage in terms of OT.

In our study, RASP showed a longer median OT than HoLEP, without reaching a level of significance (150 minutes vs 132.5 minutes, p = 0.665). This is probably related to a longer time to set up the robot, including the docking, specimen removal, and the concomitant diverticulectomy in four patients. The OT in both the laser and robotic groups was similar to the ones reported by other authors.^7,16

Prostatic volume

While patients in the RASP group had a higher preoperative prostate volume (226 cc vs. 204.5 cc), the weight of the prostatic specimen was significantly higher in the HoLEP group compared with the RASP group (180 g vs 134.5 g), which has not been shown in other studies, possibly suggesting a more extensive enucleation with the HoLEP procedure. Another explanation could be found in heavier tissue after morcellation, due to the absorption of water or a higher prostatic tissue-specific weight after the fixation with formaldehyde. To rule out the confounding factor of tissue handling by the pathologist, we compared the prostatic tissue weight immediately postprocedure with the results of the pathology report in five random patients. No difference was noted in prostatic weight before and after formaldehyde fixation. Both procedures showed a major decrease in PSA, suggesting a small remnant of prostatic tissue postsurgery.

Diverticulectomy

The prevalence of bladder diverticula seems to be higher in the case of larger prostate volumes. The percentage of patients with significant bladder diverticula in this study was more than double compared with our previous series of patients with prostates >100 cc (13% vs 4%).¹⁹

Complications

No statistically significant differences were found in the rates of postoperative complications between the two groups, either when considering all complications collectively or when analyzing them in subgroups. The majority of these complications were minor incidents that had minimal impact on the patients' postoperative course. However, a higher number of transient urgency cases would be expected in the HoLEP group, almost half as many HoLEP patients experienced transient urinary incontinence (18% vs 10%), yet no level of significance was reached. Statistical significance could be expected in case of a larger sample size.

Learning curve

Additionally, learning curve issues are important to consider. Technical challenges are frequently encountered in HoLEP in extremely large prostates, even after the surgeon has overcome the learning curve. The learning curve requires ∼50 cases, but little is known about the influence that high prostate volumes could have on it.¹⁶ In comparison, robotic simple prostatectomy is thought to have a shorter learning curve, estimated to be 10–12 cases for an experienced robotic surgeon.²² Thus, for surgeons who have attained proficiency by performing a sufficient number of robot-assisted radical prostatectomies, RASP can be regarded as an interesting option.

Costs

In addition to surgical experience, it is essential to take into account the cost aspect when comparing the two techniques. When considering the expenses, a HoLEP procedure requires investment in a holmium laser system and a morcellator. The pricing for these machines can vary depending on the contracts within the health care system, but the initial investment for both devices is considerably lower compared with the da Vinci surgical system, which entails significantly higher upfront costs. On average, the purchase cost for the da Vinci system is around $1.5 million, and the annual maintenance cost is ∼10% of this amount.²³ Compared with the HoLEP, the purchase costs around $120,000 for a holmium laser system and $20,000 for a tissue morcellator, with very low annual service fees. The disposables for one robotic procedure are estimated around $900/procedure, compared with $300 for a HoLEP procedure.

As of now, there have been no published head-to-head prospective cost comparisons between HoLEP and RASP. However, the available series indicate that both techniques exhibit a favorable economic profile when compared with open surgical procedures (OSP). For instance, Matei et al. reported a cost of €3840 per robotic procedure compared with €5404 per open procedure. This cost difference can be attributed primarily to the lower expenses associated with hospitalization and catheter irrigation.²⁴ When comparing HoLEP to OP, Salonia et al. found that mean perioperative costs were €2356.5 ($2919.4) vs €2868.9 ($3556.3), respectively.

They attributed the cost reduction in HoLEP to factors such as shorter length of stay (LoS), decreased need for catheter irrigation, and fewer blood transfusions. Despite higher expenses for operating room setup and disposables associated with HoLEP, the overall costs were lower compared with open surgery.¹³ Meanwhile, the laser device could also be used for other conditions, such as urolithiasis, strictures, and bladder pathology.

RASP is more invasive and costly than HoLEP and leads to a longer LoS, resulting in a questionable indication for RASP procedures. HoLEP appears to be superior for the standard case of large gland BPE, with the strengths of RASP lying elsewhere. For example, RASP has a shorter learning curve, as HoLEP poses challenges in extremely large glands (≥200 cc) due to its complexity and long morcellation time. In our center, we attempted to limit the OT to below 2 hours. Due to the morcellation time, which parallels a larger prostate volume, the enucleation should be performed as efficiently as possible, by an experienced surgeon. In addition, RASP has the advantage of simultaneously treating concomitant pathologies, such as bladder diverticula, large bladder stones, and inguinal hernia. In the case of a history of complex urethral strictures, HoLEP should be abandoned.

The main limitations of this study are:

- Retrospective nature: Potential selection bias may exist regarding the treatment received by the patients. Despite patient treated by RASP had significant larger prostates, the cohorts were homogeneous in terms of preoperative functional data.

- Small sample size, which is inherently due to the relative rarity of these extremely large glands, which makes it difficult to recruit patients. However, this is the largest published cohort so far.

- Functional characteristics such as sexual function and postoperative urgency and frequency were not assessed in this comparison.

- Follow-up is limited to a median of 14 months. To draw conclusions on long-term complications such as urethral strictures and bladder neck contractures, the durability of the functional outcome and reintervention rate, a longer follow-up is necessary.

Conclusion

This retrospective cohort study is the first to compare RASP and HoLEP in the treatment of LUTS secondary to BPE for prostates with a volume of 200 cc or more. This study confirms the efficacy and safety of both techniques in patients with extremely large prostate glands.

Footnotes

Authors' Contributions

Conception and design of study: J.v.d.J., P.U., and P.S.; Data collection: J.v.d.J., P.U., A. Mottaran, E.L., J.V., D.D., R.V., M.G., K.P., and S.S.; Data analysis and interpretation: J.v.d.J. and P.S.; Responsible surgeon or imager: J.v.d.J., P.S., A. Mottrie, and G.D.N.; Statistical analysis: J.v.d.J. and L.R.; Article preparation: J.v.d.J., A. Mottaran, P.S., and C.V.P.; Patient recruitment: J.v.d.J., P.S., A. Mottrie, G.D.N., R.D.G., F.D., and E.P.

Ethics Approval

Our study was approved by the Ethics Committee on September 20, 2022; Study trademark: 2022/098.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

References

Abrams

, Chapple

, Khoury

, et al. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol, 2013; 189(1 SUPPL):S93–S101; doi: 10.1016/j.juro.2012.11.021

European Society of Urology. Management of Non-Neurogenic Male Lower Urinary Tract Symptoms LastName(LUTS), incl. Benign Prostatic Obstruction (BPO); 2021. Available from: https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Non-Neurogenic-Male-LUTS-incl.-BPO-2020.pdf [Last accessed: April 2022].

Gratzke

, Schlenker

, Seitz

, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: Results of a Prospective Multicenter Study. J Urol. 2007; 177(4):1419–1422.

Lerner

, McVary

, Barry

, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. J Urol, 2021; 206(4):818–826.

Sotelo

, Clavijo

, Carmona

, et al. Robotic simple prostatectomy. J Urol, 2008; 179(2):513–515.

Lucca

, Shariat

, Hofbauer

, et al. Outcomes of minimally invasive simple prostatectomy for benign prostatic hyperplasia: A systematic review and meta-analysis. World J Urol, 2015; 33(4):563–570.

Autorino

, Zargar

, Mariano

, et al. Perioperative outcomes of robotic and laparoscopic simple prostatectomy: A European-American Multi-institutional Analysis. Eur Urol, 2015; 68(1):86–94.

Pokorny

, Novara

, Geurts

, et al. Robot-assisted simple prostatectomy for treatment of lower urinary tract symptoms secondary to benign prostatic enlargement: Surgical technique and outcomes in a High-volume Robotic Centre. Eur Urol, 2015; 68(3):451–457; doi: 10.1016/j.eururo.2015.03.003

Sorokin

, Sundaram

, Singla

, et al. Robot-assisted versus open simple prostatectomy for benign prostatic hyperplasia in large glands: A Propensity Score-Matched Comparison of perioperative and short-term outcomes. J Endourol, 2017; 31(11):1164–1169.

10.

, Cao

, Peng

, et al. Comparison between minimally invasive simple prostatectomy and open simple prostatectomy for large prostates: A systematic review and meta-analysis of comparative trials. J Endourol, 2019; 33(9):767–776.

11.

Kordan

, Canda

, Köseoğlu

, et al. Robotic-assisted simple prostatectomy: A systematic review. J Clin Med, 2020; 9(6):1798.

12.

Jones

, Alzweri

, Rai

, et al. Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis. Arab J Urol, 2016; 14(1):50–58; doi: 10.1016/j.aju.2015.10.001

13.

Salonia

, Suardi

, Naspro

, et al. Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: An inpatient cost analysis. Urology, 2006; 68(2):302–306.

14.

Elzayat

, Habib

, Elhilali

. Holmium laser enucleation of the prostate: A size-independent new “gold standard.”. Urology, 2005; 66(5 SUPPL.):108–113.

15.

Kuntz

, Lehrich

, Ahyai

. Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size?. J Endourol, 2004; 18(2):183–188.

16.

Kim

, Piao

, Lee

, et al. Efficacy and safety of holmium laser enucleation of the prostate for extremely large prostatic adenoma in patients with benign prostatic hyperplasia. Korean J Urol, 2015; 56(3):218–226.

17.

Official I-PSS distributed by Mapi Research Trust | ePROVIDE [Internet]. [cited December 28, 2022]. Available from: https://eprovide.mapi-trust.org/instruments/international-prostate-symptom-score [Last accessed: April 2022].

18.

Dindo

, Demartines

, Clavien

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004; 240(2):205–213.

19.

Umari

, Fossati

, Gandaglia

, et al. Robotic assisted simple prostatectomy versus holmium laser enucleation of the prostate for lower urinary tract symptoms in patients with large volume prostate: A comparative analysis from a High Volume Center. J Urol, 2017; 197(4):1108–1114.

20.

Fuschi

, Al Salhi

, Velotti

, al. Holmium laser enucleation of prostate versus minimally invasive simple prostatectomy for large volume (≥120 mL) prostate glands: A prospective multicenter randomized study. Minerva Urol Nephrol, 2021; 73(5):638–648.

21.

Kim

, Byun

. Robotic-assisted simple prostatectomy versus holmium laser enucleation of the prostate for large benign prostatic hyperplasia: A single-center preliminary study in Korea. Prostate Int, 2022; 10(3):123.

22.

Johnson

, Sorokin

, Singla

, et al. Determining the learning curve for robot-assisted simple prostatectomy in surgeons familiar with robotic surgery. J Endourol, 2018; 32(9):865–870; doi: 10.1089/end.2018.0377

23.

Shelton

, Drake

, Vasquez

, et al. Comparison of contemporary surgical outcomes between holmium laser enucleation of the prostate and robotic-assisted simple prostatectomy. Curr Urol Rep, 2023; 1:1.

24.

Matei

, Brescia

, Mazzoleni

, et al. Robot-assisted simple prostatectomy (RASP): Does it make sense?. BJU Int, 2012; 110(11 Pt C):E972–E979.