# Benign prostate hyperplasia over 150 cm3: Should we perform an endoscopic enucleation of the prostate or robotic-assisted simple prostatectomy?

Ugo Pinar, Clément Sarrazin, Julien Anract, Armand Chevrot, Hakim Fassi-Fehri, Jonas Wilisch, Jérôme Gas, Yohann Rouscoff, Emmanuel Dellanegra, Clément Klein, et al.

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Ugo Pinar, Clément Sarrazin, Julien Anract, Armand Chevrot, Hakim Fassi-Fehri, et al. Benign prostate hyperplasia over 150 cm3: Should we perform an endoscopic enucleation of the prostate or robotic-assisted simple prostatectomy?. The French Journal of Urology, 2025, 35, 10.1016/j.fjurol.2025.102877. hal-05106139

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## Literature Review

# Benign prostate hyperplasia over 150 cm³: Should we perform an endoscopic enucleation of the prostate or robotic-assisted simple prostatectomy?

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Ugo Pinar<sup>a,*</sup>, Clément Sarrazin<sup>b</sup>, Julien Anract<sup>c</sup>, Armand Chevrot<sup>d</sup>, Hakim Fassi-Fehri<sup>e</sup>,
Jonas Wilisch<sup>f</sup>, Jérôme Gas<sup>g</sup>, Yohann Rouscoff<sup>h</sup>, Emmanuel Dellanegra<sup>i</sup>, Clément Klein<sup>j,k</sup>,
Hervé Baumert<sup>l</sup>, Steeve Doizi<sup>m</sup>, Souhil Lebdai<sup>n</sup>, Comité des Troubles Mictionnels de l'Homme de
l'Association Française d'Urologie

## ARTICLE INFO

### Keywords:

Benign prostatic hyperplasia

Lower urinary tracts symptoms

Robotic surgery

Endoscopic surgery

## ABSTRACT

**Introduction:** Benign prostatic hyperplasia (BPH) is a prevalent condition in ageing men, often resulting in significant lower urinary tract symptoms (LUTS) that impact quality of life. For patients with huge prostate volumes (> 150 mL), surgical management presents challenges. Traditionally, open simple prostatectomy (OSP) was the gold standard; however, minimally invasive approaches such as robotic-assisted simple prostatectomy (RASP) and endoscopic enucleation of the prostate (EEP), especially holmium laser enucleation of the prostate (HoLEP), offer similar or superior outcomes with reduced morbidity.

**Methods:** This review analyzed studies comparing the perioperative, functional, and complication outcomes of RASP and HoLEP in treating very large prostates (> 150 mL). A comprehensive literature search was performed to evaluate evidence on surgical efficacy, complication rates, and recovery profiles.

**Results:** Both RASP and HoLEP demonstrated excellent perioperative outcomes, with HoLEP providing reduced operative time and hospital stays. HoLEP also showed lower blood loss and a reduced need for transfusions, while RASP offered advantages in terms of precision and surgeon control, especially for anatomically complex cases. Functional outcomes, including improvement in urinary flow and symptom scores, were comparable between the two techniques. However, complications such as transient incontinence were more commonly reported with HoLEP.

**Conclusion:** Both RASP and HoLEP are effective and safe for the management of very large prostates. HoLEP offers significant advantages in perioperative recovery and reduced morbidity, whereas RASP provides excellent outcomes in complex cases requiring precise dissection. The choice between these techniques should be guided by patient-specific factors and surgical expertise. Future studies should focus on long-term functional outcomes to refine surgical recommendations further.

© 2025 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup> Predictive Onco-Urology, AP-HP, Pitié-Salpêtrière Hospital, Department of Urology, 75013 Paris, France</footnote>

<footnote><sup>b</sup> Department of Urology, Grenoble Alpes University Hospital, Grenoble, France</footnote>

<footnote><sup>c</sup> Division of Urology, Cochin Hospital, AP-HP, Paris Cité University, Paris, France</footnote>

<footnote><sup>d</sup> Clinique Rhone-durance, Avignon, France</footnote>

<footnote><sup>e</sup> Department of Urology and Transplant Surgery, Édouard-Herriot Hospital, Hospices Civils de Lyon, Lyon, France</footnote>

<footnote><sup>f</sup> Service d'urologie, Hôpital Privé Natecia, Lyon, France</footnote>

<footnote><sup>g</sup> Uropole de Montauban, Montauban, France</footnote>

<footnote><sup>h</sup> Polyclinique Saint-Georges, Nice, France</footnote>

<footnote><sup>i</sup> Service d'urologie, Hôpital des Côtes d'Armor, Saint-Brieuc, France</footnote>

<footnote><sup>j</sup> Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France</footnote>

<footnote><sup>k</sup> University of Bordeaux, Bordeaux, France</footnote>

<footnote><sup>l</sup> Department of Urology, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France</footnote>

<footnote><sup>m</sup> Hôpital universitaire Tenon, Paris, France</footnote>

<footnote><sup>n</sup> Service d'urologie, CHU d'Angers, Angers, France</footnote>

<footnote>* Corresponding author. Urology Department, Hôpital la Pitié-Salpêtrière, 83, boulevard de l'Hôpital, 75013 Paris, France.
E-mail address: ugopinar@gmail.com (U. Pinar).</footnote>
# 1. Introduction

Benign prostatic hyperplasia (BPH) is a common condition in ageing men, often leading to significant lower urinary tract symptoms (LUTS) that can severely impact the quality of life [1]. When medical management fails, surgical intervention becomes necessary. For patients with extremely large prostate volumes (> 150 cm³), selecting the optimal surgical approach is critical, given the increased complexity and morbidity associated with larger gland sizes [2,3]. Indeed, managing such large prostates presents unique perioperative challenges, including increased blood loss, prolonged operative time, and higher rates of postoperative complications such as clot retention and prolonged catheterization.

Traditionally, open simple prostatectomy (OSP) has been the standard treatment for very large prostates [4,5]. However, the rise of less invasive techniques, particularly endoscopic enucleation of the prostate (EEP) and robotic-assisted simple prostatectomy (RASP) has provided similar or superior outcomes (Table 1) to OSP while minimizing surgical morbidity and facilitating faster recovery [6-8]. On one hand, RASP provides the precision and dexterity of robotic systems enhancing the surgeon's ability to perform a complex dissection with minimal blood loss and improved visualization [9]; on the other hand, EEP techniques, particularly holmium laser enucleation of the prostate (HoLEP), have gained popularity due to their efficacy in completely removing adenomatous tissue while preserving the prostate capsule, thereby reducing the risk of bleeding and other complications [10].

Despite the increasing adoption of both techniques, a clear consensus on their respective advantages and limitations in the context of extremely large prostates is still lacking. The literature remains fragmented, with limited high-quality comparative data assessing their efficacy and safety beyond 150 cm³. Given the growing number of patients requiring surgical intervention for large-volume BPH and the evolving landscape of minimally invasive techniques, a comprehensive analysis comparing these two approaches is essential. This review aims to evaluate and compare the perioperative outcomes, complication rates, and functional results of RASP and HoLEP in prostates > 150 cm³, providing clinicians with evidence-based insights to guide surgical decision-making in this challenging subset of patients.

# 2. Methods

A comprehensive review of the scientific literature was conducted using the PubMed database (http://www.ncbi.nlm.gov/pubmed/) using Mesh keywords ("large prostate", "benign prostate hyperplasia", "prostate enucleation" and "robotic-assisted simple prostatectomy"). The initial screening involved titles and abstracts, followed by a secondary screening of preselected articles. Only articles in French or English were selected for the final analysis; systematic literature reviews were excluded. Full text review was then performed to refine article selection and exclude duplicates. Only articles with prostate volumes > 150 cm³ were included.

# 3. Results

## 3.1. Endoscopic enucleation of the prostate for prostate volumes > 150 cm³: what is the evidence? (Table 1)

Overall, 8 retrospective studies describing laser EEP > 150 cm³ were found. All the studies reported the use of a Holmium generator.

Matlaga et al. were the first to publish their cohort of very large prostates [11] treated by EEP in 2006. They included 86 patients with a mean [IQR] prostate volume of 170 cm³ [125-309] and all procedures were performed by the same operator. For a mean (range) enucleated weight of 140 grams (30-312): enucleation and morcellation times were 94.7 minutes (27-263) and 33.4 minutes (7-120) respectively. The mean (range) length of hospital stay (LOS) was 26 hours (5-144) and the mean

(range) catheter duration was 15.1 hours (2-48). Interestingly, 2 patients had a cystotomy to complete the morcellation because the adenoma occupied all the bladder volume. Unfortunately, due to many patients lost to follow-up, the authors reported little data regarding functional results. According to these results, the EEP for prostate volumes > 150 cm³ could be considered feasible, safe and efficient.

In 2010, the same team published a cohort of 57 patients with BPH > 175 grams [12]. The same operator performed tri-lobe or bi-lobe HOLEP. The mean (range) prostate volume was 217.8 cm³ (175-391). The mean enucleation and morcellation times were similar to their first publication (respectively 91.9 minutes [30-263] and 38.6 minutes [11-133]). The authors had to perform perineal urethrostomy for 2 patients because the resectoscope was not long enough to perform the enucleation and morcellation (pathologic weights 284 cm³ and 532 cm³). It is not mentioned why the operator chose to go for a perineal endoscopic approach instead of a cystotomy. This is a very uncommon complication and has not been reported in other publications. The authors also reported 2 patients with Clavien ≥ 3 complications in their cohort: the first needed surgical clot evacuation and the second an additional morcellation. The functional outcomes were satisfactory with improved peak urinary flow and AUA symptom score (respective % change at 12 months: 33.8% and 77.3%).

Interestingly, some authors reported their series by sorting patients according to the prostate volume and comparing the outcomes.

Kim et al. reported 502 HoLEP procedures. They defined 3 groups according to the prostate volume: < 100 cm³, n = 426; 100-200 cm³, n = 70; > 200 cm³, n = 6 [13]. Enucleation and morcellation times were significantly longer in the > 200 cm³-group compared to the 2 other groups but the enucleation efficacy (in grams/minute) was better in the > 200 cm³-group (0.47 ± 0.27 g/min in the group < 100 cm³ versus 0.93 ± 0.36 g/min in the group 100-200 cm³ and 1.49 ± 0.84 g/min in the > 200 cm³ group). In the > 200 cm³-group, one patient had a cystotomy after enucleation to retrieve the adenoma instead of morcellation, however, no other significant intraoperative event was reported. In the > 200 cm³-group, the mean (±SD) LOS was significantly longer (3.5 ± 1.5 days) than the two other groups (2.3 ± 0.9 days and 2.7 ± 1.8 days, respectively). Additionally, the catheterization was 3 times longer in the > 200 cm³-group (4.8 ± 4.8 days) versus 1.8 ± 2.4 days in the group < 100 cm³ and 1.7 ± 1.6 days in the 100-200 cm³ group. There were no differences regarding complication rate and functional improvement between the 3 groups. Finally, two patients (33.3%) in the > 200 cm³-group had postoperative incontinence compared to 25 (5.9%) in the first group and 3 (4.3%) in the second group (P = 0.006).

In 2017, Glybochko et al. also published a similar study comparing HoLEP procedures according to prostate volume (< 100 cm³, n = 278; 100-200 cm³, n = 169; > 200 cm³, n = 12) [14]. They also reported that enucleation efficiency was significantly higher in the > 200 cm³-group (1.7 g/min versus 1.23 g/min in the 100-200 cm³ group and 1.05 g/min in the < 100 cm³ group). During surgery, one ureteral stenting was needed in the 100-200 group because of a ureteric orifice injury with the laser. Contrary to Kim et al., the authors showed that the catheterization duration was comparable between the three groups (24 hours) [13]. Interestingly, the authors reported 18-month functional results that were comparable and maintained during the 18-month follow-up in the 3 groups. In the 100-200 cm³ group, the overall incontinence rate was 16.7% whereas the rate was 7.2% in the < 100 cm³ group and 9.4% in the 100-200 cm³ group (P-value not mentioned in the study). Finally, the authors concluded that 20 procedures with prostate volume < 100 cm³ were sufficient to perform HoLEP on larger and very large prostate but they did not demonstrate this affirmation.

Finally, in 2023, Porto et al. reported 402 HoLEP procedures using the same study design (group < 40 cm³: n = 27; group 40-200 cm³: n = 332 and group > 200: n = 43) [15]. Functional outcomes, LOS and catheterization duration were comparable between the 3 groups. However, the transfusion rate was significantly higher in the group > 200 cm³ (7.0% versus 1.2% in the group 40-100 cm³ and 0% in the group < 40 cm³) (P = 0.02).
<table><caption>**Table 1**
Summary of endoscopic prostate enucleation study outcomes for each included study.</caption><thead><tr><th>First author</th><th>Type of study</th><th>n</th><th>Age, years</th><th>Prostate volume, mL</th><th>Indwelling catheter, n (%)</th><th>Baseline IPSS total score</th><th>Operative time, min</th><th>Blood transfusion, n (%)</th><th>Length of stay, days</th><th>Time to catheter removal, days</th><th>≤ 90 days postop complication any grade, n (%)</th><th>≤ 90 days postop complication grade ≥ 3, n (%)</th><th>Postoperative IPSS total score</th><th>Postoperative stress urinary incontinence</th><th>12 mo urinary incontinence</th></tr></thead><tbody><tr><td>Porto, 2023</td><td>R</td><td>Group 2 (41–200 cm³): 332<br/>Group 3 (&gt; 200 cm³): 43</td><td>Gr 2: 68.7 ± 8.1<br/>Gr 3: 72.3 ± 9.1</td><td>Gr 2: 100 [75–132]<br/>Gr 3: 232 [210–270]</td><td>NA</td><td>Gr2: 18 [13–24]<br/>Gr3: 21 [15–25]</td><td>Gr2: 150 [109–190]<br/>Gr3: 199 [150–263]</td><td>Gr2: 4 (1.2)<br/>Gr3: 3 (7.0)</td><td>Gr2: 1 [1–1]<br/>Gr3: 1 [1–1]</td><td>Gr2: 1 [1–1]<br/>Gr3: 1 [1–1]</td><td>NA</td><td>NA</td><td>Gr2: 0 [0–2.8]<br/>Gr3: 0 [0–0]<sup>c</sup></td><td>Gr2: 9 (15.5)<sup>a</sup><br/>Gr3: 3 (30)<sup>a</sup></td><td>NA</td></tr><tr><td>Tricard, 2023</td><td>R</td><td>81</td><td>73.9 ± 7.3</td><td>183.3 ± 34.5</td><td>14 (17.3)</td><td>27.2 ± 3</td><td>57.5 ± 29.7</td><td>2 (2.5)</td><td>1.3 ± 0.7</td><td>1.9 ± 0.9</td><td>8 (9.9)</td><td>2 (2.5)</td><td>5.6 ± 2.2<sup>b</sup></td><td>2 (2.5)<sup>b</sup></td><td>NA</td></tr><tr><td>Boxall, 2021</td><td>R</td><td>Group 1 (&gt; 199 cm³): 157<br/>Group 2 (80–199 cm³): 157</td><td>Gr 1: 73 [67–77]<br/>Gr 2: 71 [67–77]</td><td>NA</td><td>Gr 1: 111 (72.1)<br/>Gr 2: 70 (44.6)</td><td>Gr1: 22 [19–26]<br/>Gr2: 23 [18–26]</td><td>Enucleation time<br/>Gr1: 70 [60–90]<br/>Gr2: 45 [40–60]<br/>Morcellation time<br/>Gr1: 45 [30–60]<br/>Gr2: 20 [15–25]</td><td>Gr1: 7 (4.5)<br/>Gr2: 2 (1.3)</td><td>Gr 1: 1 [1–2]<br/>Gr2: 1 [1–1]</td><td>Gr 1: 1 [1–1]<br/>Gr2: 1 [1–1.8]</td><td>NA</td><td>NA</td><td>Gr1: 5 [3–7]<sup>c</sup><br/>Gr2: 4 [3–8]<sup>c</sup></td><td>Gr1: 17 (10.8)<br/>Gr2: 9 (5.8)</td><td>NA</td></tr><tr><td>Zell, 2021</td><td>R</td><td>88</td><td>73.2 ± 7.7</td><td>253 ± 74</td><td>16 (18.2)</td><td>18.6 ± 7.8</td><td>172.2 ± 55.7</td><td>17 (19.3)</td><td>1.8 ± 1.2</td><td>2.6 ± 2.7</td><td>20 (20.5)</td><td>5 (5.7)</td><td>NA</td><td>3 (3.4)</td><td>NA</td></tr><tr><td>Glybochko, 2017</td><td>R</td><td>Group 2 (100–200 cm³): 169<br/>Group 3 (&gt; 200 cm³): 12</td><td>Gr2: 67.1 ± 7.1<br/>Gr3: 70.7 ± 5.1</td><td>Gr2: 148.1 ± 25.2<br/>Gr3: 230 ± 18.1</td><td>NA</td><td>Gr2: 19 ± 3.3<br/>Gr3: 19.5 ± 4.5</td><td>Enucleation time<br/>Gr2: 96.4 ± 24.9<br/>Gr3: 120.9 ± 35<br/>Morcellation time<br/>Gr2: 43.3 ± 11.2<br/>Gr3: 65.3 ± 13.2</td><td>NA</td><td>Gr2: 2.7 ± 1.7<br/>Gr3: 3.3 ± 1.6</td><td>Gr2: 1 ± 1.1<br/>Gr3: 1.1 ± 2.4</td><td>NA</td><td>NA</td><td>Gr2: 6.8 ± 2.1<sup>c</sup><br/>Gr3: 5.6 ± 1.7<sup>c</sup></td><td>Gr2: 15 (9.4)<br/>Gr3: 3 (16.7)</td><td>NA</td></tr><tr><td>Kim, 2015</td><td>R</td><td>Group 2 (100–200 cm³): 70<br/>Group 3 (&gt; 200 cm³): 6</td><td>Gr2: 70.2 ± 7.3<br/>Gr3: 72.7 ± 9.9</td><td>Gr2: 124.8 ± 20.6<br/>Gr3: 252 ± 59.5</td><td>NA</td><td>Gr2: 17 ± 9.1<br/>Gr3: 13.2 ± 3.6</td><td>Enucleation time<br/>Gr2: 58.3 ± 17.6<br/>Gr3: 76.7 ± 19.6<br/>Morcellation time<br/>Gr2: 24.2 ± 16.9<br/>Gr3: 47.6 ± 28.2</td><td>Gr2: 0 (0)<br/>Gr3: 0 (0)</td><td>Gr2: 2.7 ± 1.8<br/>Gr3: 3.5 ± 1.5</td><td>Gr2: 1.7 ± 1.6<br/>Gr3: 4.8 ± 4.8</td><td>NA</td><td>NA</td><td>Gr2: 10.1 ± 7.6<sup>b</sup><br/>Gr3: 3.3 ± 2.2<sup>b</sup></td><td>Gr2: 3 (4.4)<sup>a</sup><br/>Gr3: 2 (33.3)<sup>a</sup></td><td>NA</td></tr><tr><td>Krambeck, 2010</td><td>R</td><td>57</td><td>72 [48–90]</td><td>218 [175–391]</td><td>30 (52.6)</td><td>NA</td><td>Enucleation time<br/>91.9 [30–263]<br/>Morcellation time<br/>38.6 [11–133]</td><td>2 (3.5)</td><td>1.1</td><td>0.8</td><td>3 (5.3)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Matlaga, 2006</td><td>R</td><td>86</td><td>72.6 [48–90]</td><td>170.2 [125–309]</td><td>47 (55)</td><td>NA</td><td>Enucleation time<br/>94.7 [27–263]<br/>Morcellation time<br/>33.4 [7–120]</td><td>1 (1.2)</td><td>1.1</td><td>0.6</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr></tbody></table>

Values are either presented as mean ± SD or as median [IQR]. R: retrospective; NA: not available.

<footnote>a 3 months.</footnote>

<footnote>b 6 months.</footnote>

<footnote>c 12 months.</footnote>
In 2021, the largest cohort composed of 157 patients with prostate volume > 200 (group 1) was published [16]. The patients were compared with a cohort of 157 patients with a prostate volume comprised between 100 and 200 cm³ (group 2); unfortunately, the mean prostate volume was not reported. Mean (range) enucleation and morcellation times were significantly longer in group 1: 70 (60-90) versus 45 minutes (40-60), P < 0.001 and 45 (30-60) versus 20 minutes (15-25), P < 0.001. Intra-operatively, 9 patients (5.7%) in group 1 had a cystotomy after enucleation to retrieve the adenoma and 18 (11.5%) had an additional resection for parts of adenoma that could not be morcellated (described by the authors as “Beachball”). There were no differences regarding postoperative blood transfusion or catheter removal success. Three months after surgery, urinary incontinence requiring pads rates were similar between group 1 and 2 (n = 17 [10.8%] versus n = 9 [5.8%], P = 0.2). Additionally, at 3 months, median [IQR] IPSS and QoL were comparable between the two groups (respectively, 5 [3-7] in the group 1 versus 4 [3-8] in the group 2, P = 0.7 and 1 [0-2] versus 1 [0-2], P = 0.5). Finally, median [IQR] Qmax was 19.3 mL/s [14.5-27.8] in group 1 and 19.2 mL/s [16.8-26.1] in group 2, and was comparable (P = 0.9).

In line with the previous study, Zell et al. have published a cohort of 88 patients with a prostate volume exceeding 200 cm³ [17]. Patients were stratified by prostate size (200-299 cm³ and ≥ 300 cm³). There were no differences regarding enucleation time, LOS, catheter duration and 30-day postoperative complications. Mean morcellation time was significantly longer in the larger prostate volume group (74.5 ± 31.1 minutes versus 46.8 ± 30.2 minutes, P = 0.02). Seven patients (8%) needed a cystotomy to retrieve the adenoma after enucleation. There was no difference between the two groups regarding improvement in IPSS and QoL at 6 and 12 months but the figures were not given. At 12 months, no significant difference for IPSS, QoL or Qmax was noted between the two groups.

Tricard et al. also published a cohort of 81 patients who underwent HoLEP including only prostate volume > 150 cm³ [18]. The mean prostate volume was 183.3 ± 34.5 cm³. The authors defined the success of the procedure using mixed criteria, including complete EEP, absence of blood transfusion or reoperating for bleeding, 3-month improvement of QoL and the absence of incontinence. Surgery success was achieved in 77 patients (95%). The complication rate was 9.9%. Functional improvement was found at six months post-surgery (mean IPSS improvement = 21.1, P < 0.001, mean QoL improvement = 3.5, P < 0.001 and mean Qmax improvement 13.3 mL/s, P < 0.001).

Based on these studies, we can conclude that HoLEP procedures for prostates larger than 150 cm³ are effective and safe (Table 2). Compared with lower prostate volume, operative times are longer and intra-operative adverse events including cystotomy for adenoma retrieval after enucleation or additional resection happen more frequently, especially for prostates > 200 cm³. Data regarding postoperative complications and stress urinary incontinence vary between the studies. All studies showed that functional outcomes are widely improved.

## 3.2. Robotic-assisted simple prostatectomy for prostate > 150 cm³: what is the evidence? (Table 2)

We identified 2 prospective studies and 10 retrospective studies. RASP is performed using different personalized techniques, that differ from one author to another but are based on the transcapsular (Millin) or transvesical (Freyer) approach. Compared to the endoscopic approach, RASP invasiveness and anesthetic risks are higher due to the abdominal approach and require a robotic platform. However, RASP allows performing concomitant procedures such as extracting a large bladder stone or treating a large bladder diverticula.

Using a transperitoneal approach, Vora et al. reported the first significant series of 13 patients undergoing RASP for very large prostates (mean weight 163 g) [19]. The mean operative time was 179 minutes, with an estimated blood loss of 219 mL. Patients had a mean hospital stay

of 2.8 days, and catheters were removed after an average of 8.9 days. One patient had a prolonged urethral catheterization (14 days) for an intraoperative urine leak after bladder closure. At a mean follow-up of 7.2 months, functional outcomes significantly improved (IPSS 18.1 to 5.3, P < 0.001; Qmax 4.3 to 19.1 mL/min, P < 0.001). Continence status was not reported. Several other larger studies, which used similar techniques [20-22] reported comparable outcomes (IPSS reduction from -9 to -18 postoperatively, maximum flow rate increase from +22 mL/s). In a series of 15 patients, Elsamra described the case of a significant capsular perforation, which was not repairable and necessitated a formal vesicourethral anastomosis to be performed after prostatectomy. Two patients developed low-grade complications. Urinary incontinence rate beyond 3 months was 20%, and two patients complained of decreased erectile function. Okullo et al. reported 4 out of 27 patients (18%) who presented Clavien 1 complication that did not require a change in the usual management course.

Leslie et al. published the first series of 25 patients who underwent Retzius-sparing RASP [23]. A midline cystotomy was made at the bladder dome to gain access to the prostate without mobilizing the bladder. Five patients had concomitant procedures (e.g., bladder diverticulectomy, nephrectomy, or hernia repair). All patients had a cystogram 1 week postoperatively before catheter removal. Two patients were noted to have a small leak on the initial cystogram necessitating a longer catheter insertion of 18 and 23 days, respectively. High-grade complications were reported for 3 patients, including readmission for recurrent hematuria leading to clot retention and the need for recatheterization and bladder irrigation (n = 2) and blocked catheter on postoperative day 1 due to clot retention within the bladder associated with extravasation into the peritoneal cavity, leading to robotic exploration with the opening of the cystotomy and clot evacuation under general anesthesia (n = 1). Transfusion rate was 1/25 (4%). Mild incontinence was described for 1 patient at 5 months, none of the other patients had any incontinence. IPSS score showed an 85% improvement from preoperative scores (P < 0.01). Improvement in maximum urine flow rate did not reach statistical significance. Novara et al. described the largest series of 87 patients who underwent Retzius-sparing RASP (median preoperative volume 150 g). Twenty patients (22%) had concomitant significant surgical procedures (bladder stone removal n = 13, bladder diverticulectomy n = 2, inguinal hernia repair n = 3). Twenty-four percent of patients had complications with a 2% of high-grade complication and reported significant improvements in IPSS (median decrease -11) and Qmax (+10 mL/s) at 7 months (P < 0.0001) [24]. Around 14% of patients experienced some level of urinary incontinence. At the last follow-up, one patient had transurethral resection of bladder neck sclerosis and another had fossa navicularis stricture.

In 2022, Wagaskar et al. reviewed 50 patients treated using either Retzius-sparing (n = 8) or non-Retzius-sparing (n = 42) approaches [25]. The selection of one technique over the others was influenced by several factors, including: preference, configuration of the adenoma, and presence of associated pathology. Outcomes for each approach were not reported separately. No complications were noted, with a LOS of 1 day for all patients. The median IPSS total score dropped from 23 preoperatively to 4 postoperatively, and the median Qmax increased from 5 to 15 mL/s. The authors justified these excellent outcomes to be solely related to the surgeon's high experience with RASP. Incontinence rates decreased from 46% at 6 weeks to 16% at 3 months, with complete continence achieved by 9 months. Pathak et al. presented results for 98 patients (mean prostate volume 170 cm³), outlining a decision-making tree based on anatomical and pathological factors to select between Retzius-sparing or non-Retzius-sparing approaches [26]. The total IPSS score decreased from 19 to 5, and the maximum flow rate increased from 7.1 to 15 mL/s between the preoperative assessment and the 12-month follow-up. It is important to note that outcomes were not provided separately for each surgical approach, and no information was available regarding complications or urinary incontinence. Balestrazzi et al. compared the outcomes of two robotic platforms, HUGO™ RAS and Da Vinci® Xi, in 40 patients [26]. No
<table><caption>**Table 2**
Summary of study outcomes for RASP patients.</caption><thead><tr><th>First author</th><th>Type of study</th><th>n</th><th>Age, years</th><th>Prostate volume, ml.</th><th>Indwelling catheter, n (%)</th><th>Baseline total score</th><th>Baseline maximum flow rate at undilatrometry, ml/s</th><th>Surgical platform, surgical approach</th><th>Operative time, min</th><th>Estimated blood loss, ml.</th><th>Blood transfusion, n (%)</th><th>Length of stay, days</th><th>Time to catheter removal, days</th><th>≤90 days postop compaction, grade, n (%)</th><th>≤90 days postop compaction, grade, n (%)</th><th>Post-operative IPSS total score at last follow-up</th><th>Post-operative maximum flow rate at undilatrometry at last follow-up, ml/s</th><th>Urinary incontinence at three months, n (%)</th><th>Urinary incontinence at last follow-up, n (%)</th><th>Urinary incontinence at last follow-up, month</th></tr></thead><tbody><tr><td>Novar, 2024</td><td>P</td><td>87</td><td>69 (63-74)</td><td>150 (125-188)</td><td>26 (30)</td><td>17 (13-21)</td><td>11 (8-14)</td><td>Multipert, retainer, sparing</td><td>175 (140-210)</td><td>350 (200-500)</td><td>1 (1%)</td><td>3 (2-4)</td><td>9 (6-11)</td><td>21 (24%)</td><td>2 (2%)</td><td>6 (4-10)</td><td>21 (16-26)</td><td>NA</td><td>12 (14%)</td><td>7 (3-14)</td></tr><tr><td>Balestrini, 2023</td><td>R</td><td>20</td><td>72 (67-76)</td><td>266 (166-260)</td><td>8 (40)</td><td>NA</td><td>9.7 (6-11.8)</td><td>Multipert, anterior</td><td>165 (123-180)</td><td>400 (300-875)</td><td>0</td><td>4 (3-4)</td><td>1 (1-2)</td><td>8 (20)</td><td>0</td><td>NA</td><td>26.9 (14-26)</td><td>NA</td><td>NA</td><td>4 (1-7)</td></tr><tr><td>Barnes, 2023</td><td>R</td><td>117</td><td>69 ± 5</td><td>162 (136-185)</td><td>NA</td><td>22.5 (NA)</td><td>5 (NA)</td><td>Single port, transurethral</td><td>184 (156-225)</td><td>100 (75-200)</td><td>0</td><td>0.21 (0.17-0.32)</td><td>3 (2-7)</td><td>1 (3.5%)</td><td>0</td><td>1 (NA)</td><td>21.5</td><td>1/28 (3.6)</td><td>0</td><td>12 (12-12)</td></tr><tr><td>Harting, 2023</td><td>R</td><td>38</td><td>70 ± 8</td><td>184 ± 51</td><td>NA</td><td>NA</td><td>NA</td><td>Multipert, anterior, anterior</td><td>154 ± 37</td><td>NA</td><td>3 (7-9)</td><td>8.4 ± 3.7</td><td>7.2 ± 4.4</td><td>16 (42)</td><td>4 (11)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Van der Jeeg, 2023</td><td>R</td><td>31</td><td>73 (66-79)</td><td>225 (220-260)</td><td>11 (35)</td><td>18 (13-26)</td><td>10 (6-13)</td><td>Multipert, anterior</td><td>150 (120-158)</td><td>400 (300-750)</td><td>0</td><td>4 (4-7)</td><td>3 (2-4)</td><td>10 (32)</td><td>3 (10)</td><td>3 (2-3)</td><td>25 (15-37)</td><td>3 (10)</td><td>0</td><td>14 (8-22)</td></tr><tr><td>Palka, 2023</td><td>R</td><td>98</td><td>70 ± 7.2</td><td>152 ± 89</td><td>NA</td><td>19 ± 8.2</td><td>7.1 ± 5.6</td><td>Multipert, anterior or retainer, sparing</td><td>173 ± 72</td><td>194 ± 147</td><td>0</td><td>1.8 ± 1.3</td><td>NA</td><td>NA</td><td>NA</td><td>5.3 ± 3.1</td><td>15 ± 8.1</td><td>NA</td><td>NA</td><td>NA</td><td>11 ± 15</td></tr><tr><td>Okalio, 2023</td><td>R</td><td>27</td><td>67 (55-75)</td><td>160 (88-275)</td><td>NA</td><td>17 (3-35)</td><td>7.9 (2.8-17)</td><td>Multipert</td><td>168 (122-211)</td><td>233 (50-600)</td><td>0</td><td>3.9 (3-8)</td><td>6.7 (4-8)</td><td>5 (18)</td><td>0</td><td>1.2 (0-4)</td><td>30 (9.3-53)</td><td>0</td><td>0</td><td>16 (3-31)</td></tr><tr><td>Abou Zeinab, 2023</td><td>R</td><td>20<sup>a</sup></td><td>69 ± 9</td><td>161 ± 54</td><td>NA</td><td>27 (21-29)</td><td>NA</td><td>Single port, transurethral</td><td>170 ± 33</td><td>150 (50-262)</td><td>NA</td><td>NA</td><td>6.5 (5.7-7)</td><td>6 (30)</td><td>0</td><td>6 (3-7-9)</td><td>NA</td><td>NA</td><td>NA</td><td>4.6 ± 3.6</td></tr><tr><td>Wagener, 2022</td><td>R</td><td>50</td><td>72 (68-75)</td><td>167 (136-198)</td><td>40 (80)</td><td>20 (21-25)</td><td>5 (3-7)</td><td>Multipert, anterior or retainer, sparing</td><td>148 (130-167)</td><td>200 (175-230)</td><td>0</td><td>1 (NA)</td><td>10 (6-12)</td><td>0</td><td>0</td><td>4 (3-5)</td><td>15 (12-18)</td><td>10 (20)</td><td>0</td><td>12 (NA)</td></tr><tr><td>Charval, 2018</td><td>R</td><td>28</td><td>72 (66-73)</td><td>180 (115-220)</td><td>10 (36)</td><td>19 (16-22)</td><td>9 (6-12)</td><td>Multipert, anterior</td><td>180 (160-210)</td><td>200 (100-500)</td><td>0</td><td>2 (1-2)</td><td>8 (7-14)</td><td>4 (14)</td><td>0</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Elsham, 2014</td><td>R</td><td>15</td><td>69 (58-76)</td><td>156 (61-253)</td><td>4 (27)</td><td>16 (NA)</td><td>NA</td><td>Multipert, anterior</td><td>189 (127-289)</td><td>290 (100-500)</td><td>0</td><td>2 (NA)</td><td>8.7 (6-20)</td><td>2 (13)</td><td>0</td><td>5 (NA)</td><td>NA</td><td>3 (20)</td><td>NA</td><td>NA</td></tr><tr><td>Leff, 2013</td><td>P</td><td>25</td><td>73 (54-88)</td><td>150 (91-260)</td><td>8 (32)</td><td>24 (9-35)</td><td>11 (4-20)</td><td>Multipert, anterior</td><td>214 (165-345)</td><td>143 (50-350)</td><td>1 (4)</td><td>4 (2-6)</td><td>9 (7-23)</td><td>4 (20)</td><td>3 (12)</td><td>3.6 (0-4)</td><td>20 (12-35)</td><td>NA</td><td>1 (4)</td><td>6 (NA)</td></tr><tr><td>Vera, 2012</td><td>R</td><td>13</td><td>67 ± 8.2</td><td>163 (110-220)</td><td>NA</td><td>18 ± NA</td><td>4.4 ± NA</td><td>Multipert, anterior</td><td>179 ± 57</td><td>219 ± 157</td><td>0</td><td>2.8 ± 2.1</td><td>8.9 ± 2.5<sup>b</sup></td><td>1 (7.7)</td><td>0</td><td>5.3 ± NA</td><td>19 ± NA</td><td>NA</td><td>NA</td><td>7.2 (NA)</td></tr></tbody></table>

Values are either presented as mean ± S, mean (range) or as median [108].

RASP: robotic-assisted simple prostatectomy; NA: not available; P: prospective; R: retrospective.

a

Only the data from one of the three centers was included, as the series from Center 1 was redundant with (1), and the mean prostate volume in the series from Center 2 was less than 150 ml.

b

Only the data from the HUGO RASP System cohort was included, as the cohort of Da Vinci Surgical system is redundant with Van der Jeeg 2023.
significant differences were observed between the platforms in terms of functional outcomes and complications, with minor complications occurring in 15% of the HUGO group and 20% of the Da Vinci group.

Kaouk et al. first reported on single-port transvesical RASP using the da Vinci single-port platform in 2020 [27]. This technique utilizes a 3 cm suprapubic incision to access the bladder intravesically, avoiding peritoneal violation. Urethral reconstruction was achieved using a 360° bladder mucosa advancement flap. In this series of 10 patients, all cases were completed successfully without conversion to open surgery. The median [IQR] preoperative prostate size was 159 g [108–223]. No intraoperative or perioperative complications were noted. The median [IQR] operative time was 190 minutes [146–203], with a median [IQR] estimated blood loss of 100 mL [68–175]. Median [IQR] hospital stay was 19 hours [17–28]. At follow-up (1–9 months), all patients reported improved urinary flow without episodes of acute urinary retention; incontinence or clinical scores were not documented.

In 2023, Ramos updated this series with 117 patients (median prostate volume 162 mL) [27]. No major complications occurred, although two patients experienced venous air embolism. Catheter removal occurred at a median of 3 days. There was a sustained improvement in the median IPSS (22 vs. 1) and median maximum flow rate (5 mL/s vs. 21.5 mL/s) after 1 year. Only one patient experienced transient stress urinary incontinence, which resolved within 6 months.

Abou Zeinab presented a multi-institutional series involving 91 patients treated with single-port transvesical RASP by three experienced surgeons [28]. Half of the patients (43/91) were part of the cohort described above, one center included 20 patients with a mean prostate volume of 156 mL and the other center included patients with a mean prostate volume of 100 mL. Complication rate and functional results were similar between the 2 centers which operated mostly on very large prostate glands, showing a good reproducibility of the surgery when performed by experienced hands.

Most of the studies highlight that RASP procedures were performed by highly experienced surgeons, and thus, outcomes may not be generalizable to all surgeons.

RASP is a feasible and safe procedure, providing good short- to mid-term functional outcomes. The robotic approach enables the treatment of coexistent pathologies, such as large or multiple bladder stones and bladder diverticula. While various multiport approaches exist, no single technique has demonstrated clear superiority. The single-port platform offers a cosmetic advantage with outcomes comparable to the multiport system, and it can be safely used in patients with a history of complex abdominal surgery, broadening its indications even though an endoscopic approach would be safer in this case. However, data remain limited due to retrospective follow-up, the lack of long-term outcomes, and inconsistent reporting, particularly concerning urinary incontinence.

### 3.3. Comparison EEP versus RASP: clinical outcomes

Currently, most studies on RASP are retrospective, especially for prostate volume > 150 cm³. Adequately powered RCT against the current standard which is EEP is needed to compare efficacy, safety, LOS, learning curve and costs.

Three retrospective studies compared the outcomes of RASP and laser enucleation for very large prostate glands. In 2023, Van der Jeugdt et al. compared the results of 53 patients with prostates over 200 mL who underwent either HoLEP (n = 22) or non-Retzius-sparing RASP (n = 31) [29]. The RASP group had a larger prostate volume compared with HoLEP (226 cm³ vs. 204.5 cm³, P = 0.004), while other baseline characteristics were similar. The median operative times were comparable (150 vs. 132.5 minutes, P = 0.665), though more tissue was resected in the HoLEP group (180 mL vs. 134.5 mL, P = 0.029). Time to catheter removal (3 vs. 2 days, P = 0.748) and length of hospital stay (3 vs. 2 days, P = 0.052) were not significantly different. Both groups showed significant improvement in functional outcomes, including IPSS and Qmax, with

no notable differences between the groups. Complication rates were similar, with low-grade complications occurring in 29% of RASP and 45% of HoLEP cases (P = 0.348). Postoperative urinary incontinence was also comparable between the groups (11% RASP vs. 25% HoLEP, P = 0.359).

Lee et al. compared Retzius-sparing RASP (n = 65) with HoLEP (n = 209) in patients with a mean prostate volume of 150 mL [30]. The HoLEP group had significantly shorter operative time (1.4 vs. 3.8 hours), length of stay (0.65 vs. 2.6 days), and catheter duration (0.38 vs. 11.2 days) (all P < 0.0001). Blood transfusion rates were similar, but RASP had a higher readmission rate (18.5% vs. 4.3%, P = 0.0002). Complication rates were comparable (23.1% RASP vs. 9.6% HoLEP, P = 0.01), although RASP had four Clavien 3b complications, while all HoLEP complications were low grade.

Hartung et al. performed a propensity score matching analysis of non-Retzius-sparing RASP (n = 38) and ThuLEP (n = 38) in patients with prostates averaging 180 g [31]. ThuLEP had shorter operative time (109 vs. 154 min, P < 0.001), catheterization time (3.3 vs. 7.2 days, P < 0.001), and hospital stay (5.4 vs. 8.4 days, P < 0.001). Complication rates were similar between the ThuLEP and RASP groups. While three patients required transfusion in the RASP group compared to none in the ThuLEP group, this difference did not reach statistical significance. Functional outcomes were not assessed in this study.

If we widen our scope to prostate volumes > 120 cm³, we can consider an RCT by Fuschi et al comparing HoLEP versus minimal invasive simple prostatectomy (MISP), including both RASP and laparoscopic simple prostatectomy (LSP) [32]. The study included 110 patients (36 in LSP, 32 in RASP and 42 in HoLEP-group). Mean (SD) prostate volumes were 142 cm³ (30) and 147 cm³ (31) for HoLEP and MISP respectively. In the reported outcomes, there was no significant difference for IPSS, Qmax, PVR, removed tissue weight, blood loss, complication rates (< IIIa and ≥ IIIa), and urethral structures. At one month after the procedure, 4, 5 and 4 patients in the HoLEP, LSP and RASP groups reported mild stress urinary incontinence treated and solved by pelvic floor rehabilitation at 90 days postoperatively. However, MISP resulted in longer hospitalization and catheterization times. One month after surgery, in the HoLEP group a higher percentage of patients with new-onset irritative symptoms (burning/pain, urgency and increased urinary frequency not associated with urinary tract infection) was recorded than MISP group (33.3% vs. 13.2%; P = 0.02). All these symptoms were solved, by medical therapy, at the 3 months. Retrograde ejaculation was recorded in all patients.

### 3.4. Comparison EEP versus RASP: cost

To date, no prospective head-to-head cost comparisons between HoLEP and RASP have been published. HoLEP requires investment in a holmium laser system and a morcellator, while RASP involves the use of the Da Vinci surgical system, which comes with substantially higher upfront costs. Currently, only indirect comparisons can be made by evaluating each technique against OSP.

Wyomer et al. [33] performed a Markov model-based cost-utility analysis comparing HoLEP with OSP for prostates larger than 80 cm³, demonstrating that HoLEP was less expensive ($6585 vs. $15,404). Similarly, Salonia et al. randomized 63 patients with large prostates (70 to 220 cm³), finding that HoLEP had lower mean perioperative costs than OSP (€2356.5 vs. €2868.9), despite higher equipment-related expenses [34]. Schiavina et al. also reported significantly lower median global costs for HoLEP compared to OSP (€2174.15 vs. €4064.97, P < 0.001) for prostates larger than 70 cm³ [33]. Finally, Hawken et al. found that in high-volume centers, the cost of both procedures was equivalent [35].

Given the widespread use of robotic surgery in urology, it could be argued that RASP is easier to implement and more cost-effective in institutions that already have an established robotic surgery program, as no additional technology investment would be required [36]. However, when excluding the initial investment and maintenance costs of robotic systems, studies show conflicting results regarding the cost-effectiveness
of RASP compared to OSP. While Matei et al. [37] found that RASP was less expensive than OSP, largely due to reduced hospitalization costs (total cost €3840 vs. €5404, respectively), Sutherland et al. reported that the average operative cost of RASP was $5212, compared to $2415 for OSP [38]. Additionally, Bhanvadia et al. [36] found that the average cost of RASP, including hospitalization, was higher than that of OSP (median [IQR], $10,855 [$7,965–$15,675] vs. $13,467 [$10,572–$17,722], $<0.01).

These data suggest that HoLEP may offer more economic advantages in terms of procedural and short hospitalization costs. However, no direct cost comparison or specific cost-effectiveness analysis has been performed for very large prostate glands.

### 3.5. Comparison EEP versus RASP: learning curve

The learning curve is a critical consideration in comparing surgical techniques. Johnson et al. conducted a retrospective review of 120 consecutive RASP cases performed by two experienced robotic surgeons from 2014 to 2017 [39]. Blood loss and tissue yield showed the greatest improvement over time, but neither showed significant improvement beyond 12 cases. This trend aligns with findings from Wagaskar et al. [25]. It is also worth noting that the learning curve for larger prostate glands remains undetermined, although RASP appears to be largely size-independent [40].

For the single-port (SP) platform, Pellegrino et al. reported that complication rates decreased significantly after 30 SP-RASP cases [41].

In contrast, the learning curve for HoLEP is steep, with a plateau typically reached after 30–50 cases [42]. However, the influence of large prostate volumes on the HoLEP learning curve is not well-understood.

Therefore, the learning curve may favor RASP over HoLEP for very large prostate glands, particularly for surgeons with extensive experience in robot-assisted procedures.

## 4. Conclusion

In conclusion, for extremely large prostate glands both RASP and laser EEP seem to provide comparable perioperative and functional outcomes. While RASP allows for effective treatment of complex cases, such as those requiring concurrent procedures, thulium or holmium laser enucleation may offer advantages in shorter operative times, catheterization duration, and hospital stay for very large glands. Complication rates, including urinary incontinence, are generally similar between the techniques, though EEP may be slightly superior in minimizing minor perioperative complications. Cost-effectiveness appears to be better with EEP.

For urologists not specialised in one of the two techniques, it is crucial to consider the training requirements and equipment availability. HoLEP has a steep learning curve, requiring significant experience and structured training programs to master the technique. In contrast, RASP offers a shorter learning curve, particularly for surgeons already familiar with robotic surgery. In terms of equipment, HoLEP requires investment in a holmium laser system and a morcellator, while RASP uses a robotic system, often available in large hospitals as it can be shared between surgical specialties. Urologists should also be prepared to manage technique-specific complications, such as cystotomy for adenoma retrieval in HoLEP and capsular perforations in RASP. Ultimately, the choice between HoLEP and RASP depends on the surgeon's expertise, available resources, and the specific needs of the patient.

While this review provides a comprehensive comparison of HoLEP and RASP for large prostates, several limitations should be acknowledged. The studies included are predominantly retrospective, which may introduce selection bias and limit the generalizability of the findings. Additionally, the lack of high-quality comparative data and randomized controlled trials (RCTs) makes it challenging to draw definitive conclusions about the superiority of one technique over the other. Furthermore, the learning curve for both techniques, particularly HoLEP,

is steep, which may affect the outcomes reported in studies with less experienced surgeons. Cost considerations and equipment availability also vary widely among institutions, influencing the feasibility of adopting these techniques. Future research should focus on conducting well-designed RCTs and long-term follow-up studies to provide more robust evidence.

Ultimately, the choice of the technique should be based on surgeon expertise, patient characteristics, and the presence of concomitant pathologies.

## Disclosure of interest

The authors declare that they have no competing interest.

## Acknowledgements

None.

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