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Comparison of Perioperative and Short-Terms Outcomes of En-Bloc Holmium Laser Enucleation of the Prostate (HoLEP) and Robot-Assisted Simple Prostatectomy: A Propensity-Score Matching Analysis - Beyond the Abstract

Surgical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) has seen an evolution during the last decade. Holmium laser enucleation of the prostate (HoLEP) has been recently established as one of the most effective surgical treatments for all prostate sizes and in particular, the en-bloc approach showed further benefits in terms of perioperative and functional results.1 At the same time robotic surgery has gained the stage also in the BPH field and robot-assisted simple prostatectomy (RASP) emerged as a valid alternative in larger prostates.2

In the latest issue of Prostate Cancer and Prostatic Disease Journal, my colleagues and I conducted a comparative analysis of prospectively collected patients treated with en-bloc HoLEP and RASP.3 Surgery was conducted at two referral centers (Careggi Hospital - Florence performed HoLEP and San Luigi Gonzaga Hospital – Turin performed RASP) by two highly-experienced surgeons. Propensity-score matching (PSM) analysis was applied to reduce selection bias. Matching variables represented IPSS, prostate volume, and max-flow rate.

Based on our analysis, some clear evidence emerged:

  • En-bloc HoLEP is associated with lower perioperative morbidity, as compared to RASP. In fact, HoLEP cases had shorter median operative time, lower  hemoglobin change and early complications rate, as well as shorter hospitalization and catheterization time (p <0.05). The en-bloc approach allowed to maintain a single dissection plane between the capsule and the prostatic adenoma, thus shorting the overall operative time without affecting the efficacy. Moreover, this technique ensures a laminar irrigation and optimal visualization which enables to maximize the hemostatic effect of the holmium laser. The low rate of significant hematuria in this cohort of patients was thus responsible for a faster hospitalization and catheterization time.
  • Early functional outcomes seem more favorable in the RASP group. One-month max flow and continence rates were considerably higher as compared to the counterpart (p <0.05). Unlike HoLEP, RASP is not burdened by possible injuries caused by the energy delivered to the prostatic capsule as well as by the stretching of the tissues secondary to instrument excursion. These elements prevented transient early urinary incontinence in this cohort of patients. However, it is worth pointing out that the suboptimal results recorded in the HoLEP group might be explained by the facts that in the present study PSM selected very large glands (> 120 cc), and moreover, 15% of HoLEP cases were performed during the first surgical era (first 50 cases). As we know, the ‘learning curve’ factor favors RASP over HoLEP, as 5–10 cases might be estimated for somebody with robotic experience, whereas 40–60 cases seem to be required to become proficient with HoLEP.
  • The last key finding may be ascribed to sexual outcomes. In fact, the rate of ejaculatory function preservation appeared significantly higher in the RASP group (55.3% vs 6.8%; p=0.001).
To conclude, both HoLEP and RASP are safe and effective treatments for LUTS secondary to BPH. HoLEP demonstrated to have lower perioperative risks while is affected by a higher probability of transient early UI. On the other hand, RASP, and in particular the urethral-sparing approach, is more effective in reducing postoperative ejaculatory dysfunction.

Written by: Antonio Andrea Grosso, Department of Experimental and Clinical Medicine, University of Florence – Unit of Oncologic, Minimally, Invasive Urology and Andrology, Careggi Hospital, Florence, Italy

References:

  1. Tuccio A, Grosso AA, Sessa F, Salvi M, Tellini R, Cocci A, et al. En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm? J Endourol. 2021 Nov;35(11):1675-1683.
  2. Porpiglia F, Checcucci E, Amparore D, Niculescu G, Volpi G, Piramide F, et al. Urethral-sparing Robot-assisted Simple Prostatectomy: An Innovative Technique to Preserve Ejaculatory Function Overcoming the Limitation of the Standard Millin Approach. Eur Urol. 2021 Aug;80(2):222-233.
  3. Grosso AA, Amparore D, Di Maida F, de Cillis S, Cocci A, Di Dio M, et al. Comparison of perioperative and short-terms outcomes of en-bloc Holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy: a propensity-score matching analysis. Prostate Cancer Prostatic Dis. 2023 Oct 19.
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