Abstract
Choudhary and colleagues report in a propensity-matched analysis comparing HoLEP with robot-assisted simple prostatectomy for larger prostates that both techniques provide similar efficacy. 1 However, the HoLEP approach was associated with shorter catheter and hospital times, and they thus concluded that it should be the preferred approach for the management of larger prostates. I would certainly support their conclusions. Furthermore, while complications with robot-assisted simple prostatectomy in this series were low, this approach is considerably more invasive, not to mention much more expensive.
This study did not include PSA data following treatment, a serious omission for several reasons. First, from an academic standpoint, I like to refer to PSA as the “truth serum” for documentation of the completeness of adenoma removal. Complete removal of the transition zone tissue should result in a PSA of around 1. With robot-assisted simple prostatectomy, and especially using the single port approach, adenoma removal is piecemeal and often, I suspect, incomplete. 2
Near-term outcomes will still be acceptable but over the long term are unlikely, in my view, to match HoLEP. The current report is not the only alternative approach to HoLEP for larger prostates that has committed this sin. Aquablation falls into the same hole. 3 One wonders if this is intentional as there are compelling data suggesting that documentation of appropriate PSA reduction after enucleation is important to assess future prostate cancer risk. 4
For 25 years, surgeons have been trying to find alternatives to HoLEP. This report once again suggests that endoscopic enucleation continues to hold the moral high ground.