Historically, open simple prostatectomy (OSP) was the preferred treatment for large glands.2 However, minimally invasive alternatives, such as Holmium Laser Enucleation of the Prostate (HoLEP) and Robotic-Assisted Simple Prostatectomy (RASP), have gained popularity in recent years due to their distinct advantages over traditional surgical methods, including procedural safety and favorable functional outcomes. Previous research has shown that HoLEP and RASP can have different post-operative recovery pathways and side effects that are important for providers and patients to discuss during shared decision-making.3,4,5
HoLEP is highly effective in removing the entire transition zone of the prostate, providing long-term symptom relief and low re-treatment rates. Studies show re-treatment rates of just 0–1.4% for HoLEP over 7–10 years, compared to higher rates for TURP and the prostatic urethral lift (PUL).6,7 HoLEP also boasts better hemostasis, shorter catheter times, and shorter hospital stays than TURP.8,9 Meanwhile, RASP has proven similarly effective in removing prostate adenoma and improving symptoms, with lower transfusion rates, reduced blood loss, and shorter hospital stays than OSP.10 Both HoLEP and RASP allow for the complete removal of the prostatic adenoma. However, each procedure has its own recovery considerations, such as longer catheter times following RASP and higher rates of transient stress urinary incontinence (tSUI) after HoLEP.
In our recent study titled “Propensity Score Matching Analysis of Differential Outcomes in Holmium Laser Enucleation of the Prostate vs. Robotic-Assisted Simple Prostatectomy,” we report the first propensity score matching (PSM)-based analysis of comparative surgical outcomes between the two most common procedures utilized for large prostates. The study compares RASP with a bladder neck-sparing technique to HoLEP with early apical release at a single institution. We demonstrate that both surgical modalities are similar in safety and efficacy, albeit with slight variations in perioperative characteristics. After excluding patients with neurological diseases, those undergoing partial HoLEP, simultaneous transabdominal surgery, cystotomy, and use of transurethral bipolar, we collected data from prospectively maintained databases for 36 RASP patients and 156 HoLEP patients treated between July 2021 and November 2023. We then compared preoperative, perioperative, and postoperative outcomes both before and after applying PSM in a 1:1 ratio, using a caliper width of 0.2 times the standard deviation of the logit score of propensity scores based on age and prostate size to control for selection bias.
While previous research has shown differing outcomes between RASP and HoLEP,3,4,5 our study contributes three major findings to the literature. First, in a matched cohort of 31 RASP and 31 HoLEP patients, both techniques demonstrated favorable functional and surgical outcomes for the surgical management of LUTS due to BPH in patients with large prostates. Our analysis revealed no differences in post-void residual volume (PVR), and American Urological Association S Symptom Score (AUASS) before or after applying PSM (p>0.05 for all). Through PSM, our analysis controlled for preoperative prostate size, allowing a fair comparison of each procedure’s average operating time and adenoma removal. Both were found to be comparable in the post-PSM cohorts (p ≥ 0.05 for both). Second, we show that similarly low rates of tSUI are achievable following HoLEP and RASP (7% vs 8% at 3 months, respectively, p = 1). We attribute this to the early apical release technique during HoLEP, early post-operative pelvic floor exercises following both procedures, as well as high surgeon and institutional experience in these procedures. Third, patients undergoing HoLEP experienced significantly shorter catheterization times (1 day for HoLEP vs. 7 days for RASP; p < 0.001), while RASP resulted in shorter hospital stays (1 day for HoLEP vs. 0 day for RASP; p < 0.001).
The purpose of this study was not to indicate one technique’s superiority over the other. Rather, we aim to highlight that both RASP and HoLEP effectively treat large prostate glands, each offering distinct recovery pathways while ensuring comparable symptom relief, low complication rates, and tSUI rates at 3 months. Although HoLEP was associated with shorter postoperative catheterization times, RASP resulted in shorter hospital stays due to our institution’s standard protocol of same-day discharge for RASP, compared to the overnight stay with continuous bladder irrigation required for HoLEP. Both procedures should be considered and discussed as potential surgical interventions, taking into account the patient’s specific condition and recovery preferences. Further research is needed to explore other factors such as cost-efficiency, patient satisfaction, pain management, and postoperative opioid use to provide a more comprehensive evaluation of these treatment modalities.
Written by: Narmina Khanmammadova,1 James F Jiang,1 Ralph Kevin Medina Gomez,1 Ashley Gao,1 Timothy Young Chu,1 Mohammed Shahait,2 Kristene Myklak,1 David I Lee,1 Akhil K Das1
- Department of Urology, University of California Irvine, Orange, CA
- School of Medicine, University of Sharjah, Sharjah, United Arab Emirates.
- Wei, J. T., Calhoun, E., & Jacobsen, S. J. (2005). Urologic diseases in America project: benign prostatic hyperplasia. The Journal of urology, 173(4), 1256–1261.
- Reich, O., Gratzke, C., Bachmann, A., Seitz, M., Schlenker, B., Hermanek, P., Lack, N., Stief, C. G., & Urology Section of the Bavarian Working Group for Quality Assurance (2008). Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. The Journal of urology, 180(1), 246–249.
- Umari, P., Fossati, N., Gandaglia, G., Pokorny, M., De Groote, R., Geurts, N., Goossens, M., Schatterman, P., De Naeyer, G., & Mottrie, A. (2017). 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. The Journal of urology, 197(4), 1108–1114.
- Zhang, M. W., El Tayeb, M. M., Borofsky, M. S., Dauw, C. A., Wagner, K. R., Lowry, P. S., Bird, E. T., Hudson, T. C., & Lingeman, J. E. (2017). Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy. Journal of endourology, 31(9), 847–850.
- Palacios, D. A., Kaouk, J., Abou Zeinab, M., Ferguson, E. L., Abramczyk, E., Wright, H. C., Pramod, N., & De, S. (2023). Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands. Urology, 181, 98–104.
- Krambeck, A. E., Handa, S. E., & Lingeman, J. E. (2013). Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. The Journal of urology, 189(1 Suppl), S141–S145.
- Elmansy, H. M., Kotb, A., & Elhilali, M. M. (2011). Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. The Journal of urology, 186(5), 1972–1976.
- Michalak, J., Tzou, D., & Funk, J. (2015). HoLEP: the gold standard for the surgical management of BPH in the 21(st) Century. American journal of clinical and experimental urology, 3(1), 36–42.
- Cornu, J. N., Ahyai, S., Bachmann, A., de la Rosette, J., Gilling, P., Gratzke, C., McVary, K., Novara, G., Woo, H., & Madersbacher, S. (2015). A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. European urology, 67(6), 1066–1096.
- Baumert, H., Ballaro, A., Dugardin, F., & Kaisary, A. V. (2006). Laparoscopic versus open simple prostatectomy: a comparative study. The Journal of urology, 175(5), 1691–1694.