Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study between HoLEP and Robotic Simple Prostatectomy

Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study between HoLEP and Robotic Simple Prostatectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study between HoLEP and Robotic Simple Prostatectomy Silvia Juste Alvarez, Claudia Zaccaro, Javier Gil-Moradillo, Javier Romero Otero, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6001722/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To compare perioperative outcomes, functional results, quality of life, and complications between robot-assisted simple prostatectomy (RASP) and Holmium laser prostate enucleation (HoLEP) as minimally invasive techniques for treating benign prostatic hyperplasia (BPH) in large prostates (>150 cm³). Methods : This retrospective, multicentre, randomized, observational study (2007–2023) included patients with >150 cm³ prostate volumes who underwent either HoLEP or robot-assisted prostatectomy. Primary outcomes: success rate (complete enucleation, without transfusion or reintervention), good postoperative quality of life (IPSS 8 th question score: 0-2), and continence at 6 months (no pads). Secondary outcomes: operative and catheterization time, hospital stay, enucleated gland weight, PSA reduction, Qmax improvement, and perioperative complications. Results : We included 95 HoLEP and 50 RASP patients with similar demographics and prostate volume (HoLEP: 187.72 cm³; RASP: 203.38 cm³). The success rate (HOLEP: 83.2%; RASP: 74%), continence rate (HoLEP: 85.1%; RASP: 86%) and quality of life (HoLEP: 83.2%; RASP 94%) were similar (p=0.275; p=1; p=0.075; respectively). HoLEP had shorter operative time (97.58 vs 122.4 min) and catheterization duration, with similar hospitalization duration (HoLEP: 3.46 days; RASP: 4.22 days). Although there was no significant difference in enucleated gland weight, HoLEP was more efficient (1.28 g/min vs 1.06 g/min). Complication rates were similar (HOLEP: 15.5%; RASP: 26%; p=0.12). Conclusions : Both RASP and HoLEP are safe for treating BPH in prostates >150 cm³, reporting similar success and continence rates, and good quality of life after surgery. However, HoLEP achieved results with shorter operative time and catheterization duration. benign prostatic hyperplasia robotic simple prostatectomy HoLEP Large-volume prostate Figures Figure 1 Introduction Open simple prostatectomy (OSP) has been the standard surgical treatment of moderate to severe urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) obstruction refractory to medical treatment, or associated with acute urinary retention, recurrent urinary tract infections and/or renal insufficiency in large prostates [1]. The high rate of complications, morbidity and long stay have driven the pursuit of less invasive techniques and more comfortable for patients. In 1998, Gilling et al [2] described the first Holmium laser enucleation of the prostate (HoLEP) and morcellation. In 2008, Sotelo et al . [3] described the first robotic-assisted laparoscopic simple prostatectomy (RASP). Progressively, both techniques have been perfected and currently constitute two minimally invasive alternatives for the surgical treatment of large-volume prostates (>150 cm3), given the lower complication rate, less bleeding and shorter hospital stay compared to OSP, with similar rate of complications and long term results[4,5]. During the last years, clinical practice guidelines have embraced prostatic enucleation with a strong rate of recommendation in experienced centres. However, laparoscopic or robotic approaches are still considered experimental techniques executed only by skilled surgeons. The choice will be based on the experience of the surgeon, the availability of technology, as well as the comorbidities or preferences of the patient [6]. The aim of this study is to compare the outcomes between these two minimally invasive techniques, RASP versus HoLEP, in prostates with a volume ≥150 cm³, in terms of procedural success and postoperative quality of life. Secondary objectives include assessment of the effectiveness of these techniques in terms of surgical time, enucleation efficiency, catheterization time, and hospital stay duration, as well as comparing the safety of the surgical techniques by analysing perioperative complications according to the Clavien-Dindo classification [7]. Materials and methods A retrospective, multicentre, observational study was conducted, collecting data from male patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) who were candidates for surgical treatment according to the European Urology Guidelines [1] between January 2007 and January 2023. The primary inclusion criterion was a prostate volume >150 cm³, measured preoperatively by transrectal ultrasound (TRUS), external ultrasound, and/or multiparametric prostate magnetic resonance imaging (mpMRI), as available. Exclusion criteria included surgical treatment for bladder outlet obstruction in the context of prostate cancer and concomitant bladder stones. Patients included in the study were treated at two centres with extensive experience in each technique. In one centre, patients underwent HoLEP; and, in the other, RASP technique was performed. Surgical Techniques HoLEP was performed in all cases using the 2- or 3-lobe technique with a Holmium-YAG laser device (Lumenis® Versa-Pulse®; Yokneam, Israel) with a power setting of 100 W (2J and 50Hz) and a 550 nm flexible quartz fibre. For adenoma morcellation, two types of morcellators were used: VersaCut® (Lumenis®; Yokneam, Israel) or Multicut® (Jena Surgical®; Jena, Germany), depending on availability. Since 2017, a small technical modification was introduced, leaving an anterior mucosal flap at the apex to avoid damaging the external sphincter and, thus, to preserve continence. The RASP technique was performed in all cases using the Da Vinci Xi® system (Intuitive Surgical®; Sunnyvale, CA, USA) with an intraperitoneal approach and subsequent anterior transcapsular dissection according to Millin technique [8]. Four robotic arms and an assistant port were used. The specimen is morcellated using a MorSafe® morcellation bag (Veol Medical Technologies®; Navi Mumbai, India). Analysed variables Demographic data: age (years), Charlson comorbidity index [9], history of urological surgery and/or pelvic radiotherapy (RT) (yes/no), permanent catheterization prior to surgery (yes/no). Preoperative variables: maximum flow rate on uroflowmetry (Qmax) (ml/s), International Prostate Symptom Score (IPSS), quality of life score (IPSS-QoL), prostate-specific antigen (PSA) (ng/dl), prostate volume (cm³), and preoperative haemoglobin (g/dl). Intraoperative variables: surgical time (min), enucleated gland weight (g), and surgical efficiency (g/min). Postoperative variables: hospital stay (days), catheterization time (days), haemoglobin at discharge (g/dl), postoperative PSA at 6 months (ng/dl), postoperative Qmax at 6 months (ml/s), and IPSS and IPSS-QoL scores at 6 months. Perioperative complications: categorized according to the Clavien-Dindo classification [7]. Additionally, three predefined concepts were established corresponding to the primary objectives: Procedural success: complete adenoma enucleation (endoscopic or robotic) without complications, technical conversion, blood transfusion, or reintervention. Good postoperative quality of life: defined as an IPSS-QoL score between 0 and 2. Postoperative continence: defined by the absence of leakage and no need for absorbent pads 6 months after surgery. Statistical Analysis A statistical analysis was conducted, in which demographic, clinical, and pathological characteristics of the patients were described for the entire cohort using mean and standard deviation (SD) or range, or relative frequencies, depending on the variable type. For continuous variables, the T-test was used, while for categorical variables, either the Chi-square test or Fisher's exact test was applied, depending on which was more appropriate for each variable. A p-value of less than 0.05 was considered statistically significant (95% confidence interval). IBM SPSS Statistics 23 (IBM®; Armonk, NY, USA) was used for data analysis. Results Based on the inclusion and exclusion criteria, a total of 145 patients were included, of which 95underwent HoLEP (mean age 7.36±8.92 years) and 50 underwent RASP (mean age 72.4±7.78 years), with similar demographic characteristics. Demographic and preoperative, intraoperative, and postoperative variables are presented in Tables 1, 2, and 3 , respectively. The perioperative complication rate was 15.5% for HoLEP and 26% for RASP (p=0.12). In the HoLEP cohort, complications were: urinary infection (UTI) in 5/97 (5.15%), mild haematuria in 2/97 (2.1%), and significant haematuria requiring transfusion in 8/97 (8.2%), all classified as Grade II according to the Clavien-Dindo system [7]. Three patients required conversion to an open approach due bladder injury in one case and to extract a large adenoma in two cases. In the RASP cohort, complications were: UTI in 6/50 (12%), haematuria requiring transfusion in 3/50 (6%), wound bleeding in 2/50 (4%), wound dehiscence in 1/50 (2%), and pneumothorax in 1/50 (2%). According to the Clavien-Dindo classification [7], 6% were Grade I, 20% were Grade II, and 2% were Grade III. No patient required conversion to an open approach. Regarding the primary outcomes of procedural success, postoperative quality of life, and continence, the results are shown in Figure 1. Discussion This study compares the outcomes between two series of HoLEP and RASP for large prostates (>150 cm³) to determine if one technique is more suitable than the other for these cases. Our main finding is that both techniques are safe alternatives for the surgical treatment of BPH, but the quality of life perceived by patients is better with RASP, albeit at the expense of longer operative, hospitalization, and catheterization times. With respect to HoLEP, advances in laser technology and technique refinement have enabled adequate haemostasis in experienced hands for large prostate volumes, leading to progressively shorter catheterization and hospitalization times [10,11], with excellent perioperative and long-term outcomes [12,13,14] Zhang et al . [15] were the first to compare the functional outcomes of HoLEP and RASP for any prostate volume, demonstrating their efficiency and safety profile. However, the sample distribution in their study was highly unbalanced (32 RASP vs. 600 HoLEP), which could complicate comparison and limit the generalizability of the results. In our series, we have two cohorts for the treatment of prostates >150 cm³ (95 HoLEP and 50 RASP), similar in terms of age and Charlson index score [9], as well as in preoperative prostate volume (187.72 cm³ for HoLEP vs. 203.38 cm³ for RASP; p=0.192). However, patients undergoing RASP had a higher rate of prior urological endoscopic surgeries than those undergoing HoLEP (p<0.01), and the rate of permanent catheterization prior to surgery was higher in the HoLEP group (p=0.01). In this study, we defined primary and secondary objectives to compare the two techniques. For the primary objectives, we were inspired by Tricard T. et al. [16] who conducted an analysis of endoscopic management of prostates >150 cm³, defining a successful procedure as complete enucleation without the need for transfusion or reintervention, no need for absorbent pads at 3 months post-surgery, and a 2-point improvement in IPSS-QoL. In their series, they reported a 95% success rate. Following these criteria, although we analysed them separately, we found that the procedure was completed successfully (no complications, no need for transfusion or reintervention) in 83.2% of HoLEP and 74% of RASP, with no significant difference between both techniques (p=0.275). Postoperative continence rate (86% for RASP vs. 85.1% for HoLEP (p=1)), and quality of life rate 6 months after surgery (94% for RASP, 83.2% for HoLEP, p=0.075) were similar. A meta-analysis by Kowalewski et al . [17] compared perioperative outcomes between RASP and HoLEP and found no statistically significant differences in postoperative functional outcomes, including transient urinary incontinence. The incontinence rates observed after HoLEP in our series are consistent with the literature, ranging from 10-40%, depending on surgeon expertise [10]. The slightly higher incontinence rate associated with HoLEP can be mitigated by the early apical mucosal release technique, leaving a mucosal flap to avoid damage to the external sphincter. Since incorporating this technique in 2017 in our study, the continence rate has improved from 75% to 86.07% (p=0.33). Additionally, the extended period for patient inclusion in the HoLEP arm may negatively affect overall continence results, as it has been shown that surgeon experience significantly influences postoperative continence [18,19]. Nonetheless, it is essential to inform patients of the possibility of transient incontinence to set realistic expectations and not significantly impact overall satisfaction [10]. Both techniques were highly effective in improving postoperative parameters such as Qmax and PSA, although few studies report data on these parameters [20]. Qmax improved similarly, with a 174.67% increase after HoLEP and 190.67% after RASP. A significant PSA reduction was observed after both procedures: 88.99% after HoLEP and 89.64% after RASP , within a range of 0.5-2 ng/mL, similar to what is reported in the literature [21]. Tricard et al [16] reported a 164.2% improvement in Qmax and an 88.2% reduction in PSA after HoLEP. Regarding intraoperative outcomes, operative time was significantly shorter for HoLEP compared to RASP (97.58 min vs. 122.4 min, respectively, p<0.01). This result is consistent with the literature [15]. Additionally, the enucleated tissue weight was similar between both techniques, making the efficiency greater for HoLEP (p=0.01). The shorter surgical time for HoLEP can be explained by the absence of additional time-consuming surgical manoeuvres, such as creating a transperitoneal access, robot docking and undocking, adhesiolysis, and cystorrhaphy [17]. We also observed a significant reduction in catheterization time for HoLEP compared to RASP (p<0.01) and in hospital stay, although this last difference is not statistically significant (p=0.079). Most patients had their catheter removed before discharge after HoLEP, while this was done on an outpatient basis after RASP. These results align with the findings of Kowalewski et al [17]. One reason for the longer hospital stay after RASP could be the intestinal manipulation, pneumoperitoneum, and steep Trendelenburg position required, which may affect early postoperative recovery, increase opioid use, and potentially elevate the rate of intestinal complications [22]. In our study, the complication rate was lower for HoLEP (15.5%) than for RASP (26%), although this difference was not statistically significant (p=0.12). The results reported in the literature are similar. Umari et al. [23] Umari et al . [22] reported an overall perioperative complication rate of 29%, and Agreda-Castañeda et al . reported a haematuria rate after HoLEP of 0-12% and a UTI rate of 0-14% [23]. The main limitation of the robotic technique compared to the open procedure is the availability of the technology, the need for robotic expertise, and the certification required to operate the robot [24,25]. Similarly, the primary challenge for the endoscopic technique compared to simple prostatectomy, either open or robotic, is the steep learning curve and its impact on postoperative functional outcomes [26,27]. Brunckhorst et al. established that, for experienced surgeons performing HoLEP on large prostates, achieving the learning curve requires between 20-60 cases, while for RASP, only 10-12 cases are needed [28]. An important factor in selecting the most appropriate technique for each patient is the urethral condition. To minimize the risk of urethral stricture after HoLEP, anterior urethral calibration is often performed in patients without permanent catheters, and efforts are made to minimize surgical time. Regarding RASP, transcapsular approach results in a lower risk of urethral stricture. Situations favouring the endoscopic approach include the need to resect concomitant bladder tumors to prevent tumor cell seeding through the cystostomy. However, the presence of large intravesical calculi or large bladder diverticula may prompt a preference for RASP [10]. Limitations of this study include its retrospective nature without true randomization, as patients were subjected to one technique or the other depending on the centre where they were treated. Additionally, both series include the learning curve periods for each technique, which may influence intraoperative and postoperative outcomes. However, this can also enhance the generalizability of the data, as the series reflect real-world scenarios and come from centres with significant expertise in both techniques (16 years for HoLEP and 7 years for RASP). Conclusion Both RASP and HoLEP are safe for treating BPH in prostates >150 cm³, reporting similar success rates, continence rates and quality of life after surgery. HoLEP achieved results with shorter operative time and catheterization duration. The choice of technique should be based on patient preferences, comorbidities, surgeon experience, or technological availability. However, RASP may be preferable in patients with unfavourable urethral access, a significant burden of bladder stones, or diverticula, while HoLEP could be considered for patients with high anaesthetic risk. Declarations CONFLICT OF INTEREST The authors declare that they have no known competing financial interest or personal relationships that should have appeared to influence the work reported in this paper. FUNDING SOURCES No funding sources involved. We have not been paid to write this original article. Authors were not precluded from accessing data in the study, and they accept responsibility to submit for publication. STATEMENT OF ETHICS- PATIENT’S CONSENT Informed consent was obtained from all individual participants included in the study. This is an observational study. The 12th October University Hospital Ethics Committee has confirmed that no ethical approval is required. DATA SHARING STATEMENT What data in particular will be shared? Clinical anonymous data and statistical analysis When will data be available? Immediately following publication; no end date What other documents will be available? Written consent if requested at [email protected] . With whom? Researchers who provide a methodologically sound proposal. References Management of Non-neurogenic Male LUTS. In: EAU Guidelines. 2024. Gilling PJ, Cass CB, Cresswell MD, et al (1996) Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 47:48. Sotelo R, Clavijo R, Carmona O, et al (2008) Robotic simple prostatectomy. J Urol 179:513-5. Autorino R, Zargar H, Mariano MB, at al (2015) Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis. Eur Urol 68(1):86-94. van Rij S, Gilling PJ (2012) In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new «gold standard». Curr Urol Rep 13: 427-432. Sandhu JS, Bixler BR, Dahm P, et al (2023) Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline amendment. J Urol. Clavien PA, Barkun J, de Oliveira ML, et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187-196. Millin T. Retropubic prostatectomy (1946). Br J Urol 18:33-38. Roffman CE, Buchanan J, Allison GT (2016) Charlson Comorbidities Index. J Physiother 62(3):171. Palacios DA, Kaouk J, Abou Zeinab M, et al (2023) Holmium laser enucleation of the prostate vs transvesical single-port robotic simple prostatectomy for large prostatic glands. Urology 181:98-104. Jones P, Alzweri L, Rai BP, et al (2016) Holmium laser enucleation versus simple prostatectomy for treating large prostates: results of a systemic review and metaanalysis. Arab J Urol 14:50-58. Assmus MA, Large T, Lee MS, et al (2021) Same-day discharge following holmium laser enucleation in patients assessed to have large gland prostates (≥175 cc). J Endourol 35:1386-1392. Agarwal DK, Rivera ME, Nottingham CU, et al (2020) Catheter removal on the same day of holmium laser enucleation of the prostate: outcomes of a pilot study. Urology 146:225-229. Gauhar V, Gilling P, Pirola GM, et. al (2022) Does MOSES technology enhance the efficiency and outcomes of standard holmium laser enucleation of the prostate? Results of a systematic review and meta-analysis of comparative studies. Eur Urol Focus 8:1362-1369. Zhang MW, El Tayeb MM, Borofsky MS, et al (2017) Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy. J Endourol 31:847-850. Tricard T, Xia S, Xiao D, et al (2023) Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead. World J Urol. 41(8):2249-2253 Kowalewski KF, Hartung FO, von Hardenberg J, et al (2022) Robot-assisted simple prostatectomy vs endoscopic enucleation of the prostate: a systematic review and meta-analysis of comparative trials. J Endourol 36:1018-1028. Cho MC, Park JH, Jeong MS, et al (2011) Predictor of de novo urinary incontinence following holmium laser enucleation of the prostate. Neurourol Urodyn 30:1343-1349. Kobayashi S, Yano M, Nakayama T, et al (2016) Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period. Int Braz J Urol 42:740-746. Bove AM, Brassetti A, Ochoa M, et al (2023) Robotic simple prostatectomy vs HOLEP, a «multi single-center» experiences comparison. Cent European J Urol 76(2):128-134. Pavan N, Zargar H, Sanchez-Salas R, et al (2016) Robot-assisted versus standard laparoscopy for simple prostatectomy: multicenter comparative outcomes. Urology 91:104-110. Umari P, Fossati N, Gandaglia G, et al (2017) Robotic Assisted Simple Prostatectomyversus 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 197:1108-1114. Agreda Castañeda F, Buisan Rueda Ó,Areal Calama JJ (2020) The complications of the HoLEP learning curve. A systematic review. Actas Urol Esp 44:1-8. Nestler S, Bach T, Herrmann T, et. al (2019) Surgical treatment of large volume prostates: a matched pair analysis comparing the open, endoscopic (ThuVEP) and robotic approach. World J Urol 37:1927-1931. Moschovas MC, Timóteo F, Lins L, et al (2021) Robotic surgery techniques to approach benign prostatic hyperplasia disease: a comprehensive literature review and the state of art. Asian J Urol 8:81-88. Enikeev D, Morozov A, Taratkin M, et al (2021) Systematic review of the endoscopic enucleation of the prostate learning curve. World J Urol 39:2427-3827. Lee MS, Assmus MA, Ganesh M, et al (2023) An outcomes comparison between holmium laser enucleation of the prostate, open simple prostatectomy, and robotic simple prostatectomy for large gland benign prostatic hypertrophy. Urology 173:180-186. Brunckhorst O, Ahmed K, Nehikhare O, et al (2015) Evaluation of the Learning Curve for Holmium Laser Enucleation of the Prostate Using Multiple Outcome Measures. Urology. 86(4):824-829. Tables Table 1. Demographic and preoperative variables . HoLEP (95 patients) RASP (50 patients) p value Age Mean (SD) 72.36(8.92) 72.4(7.78) 0.978 Charlson index Mean (SD) 3.54(1.09) 3.46(1.36) 0.712 Prior urological surgery and/or pelvic RT (%) 0 10% 0.004 Prostatic volume ( cm 3 ) Mean (SD) 187.72 (45.91) 203.38(98.06) 0.192 Prior urethral catheter (%) 42.1% 20% 0.013 Qmax (ml/s) Mean (SD) 10.89(5.84) 8.12(3.46) 0.002 IPSS score Mean (SD) 21.66 (4.9) 21.92(4.9) 0.765 PSA Mean (SD) 8.73(8) 7.73(4.21) 0.414 Haemoglobin (g/dl) Mean (SD) 14.41(1.57) 14.41(1.52) 0.998 HoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy; Qmax: maximum flow rate on uroflowmetry; RT: radiotherapy; IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen Table 2. Intraoperative variables HoLEP RASP p value Surgical time (minutes) Mean(SD ) 97.58(39.83) 122.4(25.13) <0.01 Enucleated gland weight(g) Mean(SD) 124.85(51.1) 129.6(102.53) 0.712 Surgical efficiency (g/min) Mean(SD) 1.28 1.06 0.01 HoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy. Table 3. Postoperative variables HoLEP RASP p value Hospital stay (days) Mean(SD) 3.46(2.67) 4.22(1.94) 0.079 Catheterization time (days) Mean(SD) 3.6(2) 5.9(0.9) 0.01 PSA Mean(SD) 0.96(1.44) 0.8(0.7) 0.462 Q max (ml/s) Mean(SD) 29.91(11.62) 23.6(6.66) <0.001 IPSS Score Mean(SD) 6.64(5.40) 4(3.49) 0.002 Good quality of life (%) 83.2% 94% 0.075 Haemoglobin (g/dl) Mean(SD) 12.29(2.24) 11.71(1,49) 0.104 HoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy; Qmax: maximum flow rate on uroflowmetry; RT: radiotherapy; IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6001722","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":415544403,"identity":"ff8c2e05-274b-4831-8622-f5195fbbaf3d","order_by":0,"name":"Silvia Juste Alvarez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIie3PsUrEMBjA8YRAXQJdUzjsK0QKN/oiTofQm7JKwHrGpS6C6w1y9wqK0DkhkC6f+AAu3nJzxaUuYu66eEPbVTB/ksAH+UGCUCj0J9P7c9IN0m9C1Djxi3YD7AgeI+gXweX+HCbpDWSfjTylvH7ZbL5WV2fxrSetrHoJ1zBlGs4ph3nGk6oWS4sVvoO3foJgikxJaKLyiJ1UTihPCC77Saoga8z3NU3ut0ft7MGJ9RhBGjgzytKY5REyqhCPY4Rrd8HA1Z5sSaKcFk+emKG/pEv73Mji8jiKc/zRFguxerXmvZUDD2P6YLTda/vv+2J1MC4GL4dCodD/7AcqBV7G4k+EIwAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital Universitario 12 de Octubre","correspondingAuthor":true,"prefix":"","firstName":"Silvia","middleName":"Juste","lastName":"Alvarez","suffix":""},{"id":415544404,"identity":"ebbac1bb-5369-4ab0-84bb-0c5ef5647208","order_by":1,"name":"Claudia Zaccaro","email":"","orcid":"","institution":"Hospital Universitario La Zarzuela","correspondingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"","lastName":"Zaccaro","suffix":""},{"id":415544405,"identity":"6d750750-fd79-411b-b038-12b163a0b44c","order_by":2,"name":"Javier Gil-Moradillo","email":"","orcid":"","institution":"Hospital Universitario 12 de Octubre","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"","lastName":"Gil-Moradillo","suffix":""},{"id":415544406,"identity":"5e2491fe-15f1-4a3c-8fd7-558167388fc5","order_by":3,"name":"Javier Romero Otero","email":"","orcid":"","institution":"HM Hospitales","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"Romero","lastName":"Otero","suffix":""},{"id":415544407,"identity":"5ba66ce9-f46f-4433-8c91-f73c91131fd1","order_by":4,"name":"Ignacio Moncada Iribarren","email":"","orcid":"","institution":"Hospital Universitario La Zarzuela","correspondingAuthor":false,"prefix":"","firstName":"Ignacio","middleName":"Moncada","lastName":"Iribarren","suffix":""},{"id":415544408,"identity":"248e7c41-a723-4ee4-903d-d055e2ecbfc2","order_by":5,"name":"Alfredo Rodríguez Antolín","email":"","orcid":"","institution":"Hospital Universitario 12 de Octubre","correspondingAuthor":false,"prefix":"","firstName":"Alfredo","middleName":"Rodríguez","lastName":"Antolín","suffix":""},{"id":415544409,"identity":"80786dad-548a-4179-a894-18b4dd044f65","order_by":6,"name":"Borja García Gómez","email":"","orcid":"","institution":"Hospital Universitario 12 de Octubre","correspondingAuthor":false,"prefix":"","firstName":"Borja","middleName":"García","lastName":"Gómez","suffix":""}],"badges":[],"createdAt":"2025-02-10 19:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6001722/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6001722/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76284447,"identity":"5f427027-f128-48bf-9f1f-8d5d2263c07f","added_by":"auto","created_at":"2025-02-14 10:56:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":214043,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"JusteFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6001722/v1/c9d7a6b93aa7a0c2157d6ed8.png"},{"id":76925226,"identity":"507bf705-3f97-445d-bbb7-55db820a6111","added_by":"auto","created_at":"2025-02-22 12:46:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":921147,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6001722/v1/609df98a-8b01-4c7d-8144-3832c3d79932.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMinimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study between HoLEP and Robotic Simple Prostatectomy\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOpen simple prostatectomy (OSP) has been the standard surgical treatment of moderate to severe urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) obstruction refractory to medical treatment, or associated with acute urinary retention, recurrent urinary tract infections and/or renal insufficiency in large prostates [1]. The high rate of complications, morbidity and long stay have driven the pursuit of less invasive techniques and more comfortable for patients.\u003c/p\u003e\n\u003cp\u003eIn 1998, Gilling \u003cem\u003eet al\u003c/em\u003e [2] described the first Holmium laser enucleation of the prostate (HoLEP) and morcellation. In 2008, Sotelo \u003cem\u003eet al\u003c/em\u003e. [3] described the first robotic-assisted laparoscopic simple prostatectomy (RASP). Progressively, both techniques have been perfected and currently constitute two minimally invasive alternatives for the surgical treatment of large-volume prostates (\u0026gt;150 cm3), given the lower complication rate, less bleeding and shorter hospital stay compared to OSP, with similar rate of complications and long term results[4,5].\u003c/p\u003e\n\u003cp\u003eDuring the last years, clinical practice guidelines have embraced prostatic enucleation with a strong rate of recommendation in experienced centres. However, laparoscopic or robotic approaches are still considered experimental techniques executed only by skilled surgeons.\u003c/p\u003e\n\u003cp\u003eThe choice will be based on the experience of the surgeon, the availability of technology, as well as the comorbidities or preferences of the patient [6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to compare the outcomes between these two minimally invasive techniques, RASP versus HoLEP, in prostates with a volume \u0026ge;150 cm\u0026sup3;, in terms of procedural success and postoperative quality of life. Secondary objectives include assessment of the effectiveness of these techniques in terms of surgical time, enucleation efficiency, catheterization time, and hospital stay duration, as well as comparing the safety of the surgical techniques by analysing perioperative complications according to the Clavien-Dindo classification [7].\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA retrospective, multicentre, observational study was conducted, collecting data from male patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) who were candidates for surgical treatment according to the European Urology Guidelines [1] between January 2007 and January 2023. The primary inclusion criterion was a prostate volume \u0026gt;150 cm\u0026sup3;, measured preoperatively by transrectal ultrasound (TRUS), external ultrasound, and/or multiparametric prostate magnetic resonance imaging (mpMRI), as available. Exclusion criteria included surgical treatment for bladder outlet obstruction in the context of prostate cancer and concomitant bladder stones.\u003c/p\u003e\n\u003cp\u003ePatients included in the study were treated at two centres with extensive experience in each technique. In one centre, patients underwent HoLEP; and, in the other, RASP technique was performed.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSurgical Techniques\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eHoLEP was performed in all cases using the 2- or 3-lobe technique with a Holmium-YAG laser device (Lumenis\u0026reg; Versa-Pulse\u0026reg;; Yokneam, Israel) with a power setting of 100 W (2J and 50Hz) and a 550 nm flexible quartz fibre. For adenoma morcellation, two types of morcellators were used: VersaCut\u0026reg; (Lumenis\u0026reg;; Yokneam, Israel) or Multicut\u0026reg; (Jena Surgical\u0026reg;; Jena, Germany), depending on availability. Since 2017, a small technical modification was introduced, leaving an anterior mucosal flap at the apex to avoid damaging the external sphincter and, thus, to preserve continence.\u003c/p\u003e\n\u003cp\u003eThe RASP technique was performed in all cases using the Da Vinci Xi\u0026reg; system (Intuitive Surgical\u0026reg;; Sunnyvale, CA, USA) with an intraperitoneal approach and subsequent anterior transcapsular dissection according to Millin technique [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour robotic arms and an assistant port were used. The specimen is morcellated using a MorSafe\u0026reg; morcellation bag (Veol Medical Technologies\u0026reg;; Navi Mumbai, India).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAnalysed variables\u003c/u\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eDemographic data: age (years), Charlson comorbidity index\u0026nbsp;[9], history of urological surgery and/or pelvic radiotherapy (RT) (yes/no), permanent catheterization prior to surgery (yes/no).\u003c/li\u003e\n \u003cli\u003ePreoperative variables: maximum flow rate on uroflowmetry (Qmax) (ml/s), International Prostate Symptom Score (IPSS), quality of life score (IPSS-QoL), prostate-specific antigen (PSA) (ng/dl), prostate volume (cm\u0026sup3;), and preoperative haemoglobin (g/dl).\u003c/li\u003e\n \u003cli\u003eIntraoperative variables: surgical time (min), enucleated gland weight (g), and surgical efficiency (g/min).\u003c/li\u003e\n \u003cli\u003ePostoperative variables: hospital stay (days), catheterization time (days), haemoglobin at discharge (g/dl), postoperative PSA at 6 months (ng/dl), postoperative Qmax at 6 months (ml/s), and IPSS and IPSS-QoL scores at 6 months. Perioperative complications: categorized according to the Clavien-Dindo classification [7].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAdditionally, three predefined concepts were established corresponding to the primary objectives:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eProcedural success: complete adenoma enucleation (endoscopic or robotic) without complications, technical conversion, blood transfusion, or reintervention.\u003c/li\u003e\n \u003cli\u003eGood postoperative quality of life: defined as an IPSS-QoL score between 0 and 2.\u003c/li\u003e\n \u003cli\u003ePostoperative continence: defined by the absence of leakage and no need for absorbent pads 6 months after surgery.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA statistical analysis was conducted, in which demographic, clinical, and pathological characteristics of the patients were described for the entire cohort using mean and standard deviation (SD) or range, or relative frequencies, depending on the variable type.\u003c/p\u003e\n\u003cp\u003eFor continuous variables, the T-test was used, while for categorical variables, either the Chi-square test or Fisher\u0026apos;s exact test was applied, depending on which was more appropriate for each variable. A p-value of less than 0.05 was considered statistically significant (95% confidence interval). IBM SPSS Statistics 23 (IBM\u0026reg;; Armonk, NY, USA) was used for data analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBased on the inclusion and exclusion criteria, a total of 145 patients were included, of which 95underwent HoLEP (mean age 7.36\u0026plusmn;8.92 years) and 50 underwent RASP (mean age 72.4\u0026plusmn;7.78 years), with similar demographic characteristics. Demographic and preoperative, intraoperative, and postoperative variables are presented in \u003cstrong\u003eTables 1, 2, and 3\u003c/strong\u003e, respectively.\u003c/p\u003e\n\u003cp\u003eThe perioperative complication rate was 15.5% for HoLEP and 26% for RASP (p=0.12). In the HoLEP cohort, complications were: urinary infection (UTI) in 5/97 (5.15%), mild haematuria in 2/97 (2.1%), and significant haematuria requiring transfusion in 8/97 (8.2%), all classified as Grade II according to the Clavien-Dindo system [7]. Three patients required conversion to an open approach due bladder injury in one case and to extract a large adenoma in two cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the RASP cohort, complications were: UTI in 6/50 (12%), haematuria requiring transfusion in 3/50 (6%), wound bleeding in 2/50 (4%), wound dehiscence in 1/50 (2%), and pneumothorax in 1/50 (2%). According to the Clavien-Dindo classification [7], 6% were Grade I, 20% were Grade II, and 2% were Grade III. No patient required conversion to an open approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the primary outcomes of procedural success, postoperative quality of life, and continence, the results are shown in \u003cstrong\u003eFigure 1.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study compares the outcomes between two series of HoLEP and RASP for large prostates (\u0026gt;150 cm\u0026sup3;) to determine if one technique is more suitable than the other for these cases. Our main finding is that both techniques are safe alternatives for the surgical treatment of BPH, but the quality of life perceived by patients is better with RASP, albeit at the expense of longer operative, hospitalization, and catheterization times.\u003c/p\u003e\n\u003cp\u003eWith respect to HoLEP, advances in laser technology and technique refinement have enabled adequate haemostasis in experienced hands for large prostate volumes, leading to progressively shorter catheterization and hospitalization times [10,11], with excellent perioperative and long-term outcomes [12,13,14]\u003c/p\u003e\n\u003cp\u003eZhang \u003cem\u003eet al\u003c/em\u003e. [15] were the first to compare the functional outcomes of HoLEP and RASP for any prostate volume, demonstrating their efficiency and safety profile. However, the sample distribution in their study was highly unbalanced (32 RASP vs. 600 HoLEP), which could complicate comparison and limit the generalizability of the results.\u003c/p\u003e\n\u003cp\u003eIn our series, we have two cohorts for the treatment of prostates \u0026gt;150 cm\u0026sup3; (95 HoLEP and 50 RASP), similar in terms of age and Charlson index score [9], as well as in preoperative prostate volume (187.72 cm\u0026sup3; for HoLEP vs. 203.38 cm\u0026sup3; for RASP; p=0.192). However, patients undergoing RASP had a higher rate of prior urological endoscopic surgeries than those undergoing HoLEP (p\u0026lt;0.01), and the rate of permanent catheterization prior to surgery was higher in the HoLEP group (p=0.01).\u003c/p\u003e\n\u003cp\u003eIn this study, we defined primary and secondary objectives to compare the two techniques. For the primary objectives, we were inspired by Tricard T. \u003cem\u003eet al.\u003c/em\u003e [16] who conducted an analysis of endoscopic management of prostates \u0026gt;150 cm\u0026sup3;, defining a successful procedure as complete enucleation without the need for transfusion or reintervention, no need for absorbent pads at 3 months post-surgery, and a 2-point improvement in IPSS-QoL. In their series, they reported a 95% success rate. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing these criteria, although we analysed them separately, we found that the procedure was completed successfully (no complications, no need for transfusion or reintervention) in 83.2% of HoLEP and 74% of RASP, with no significant difference between both techniques (p=0.275). Postoperative continence rate (86% for RASP vs. 85.1% for HoLEP (p=1)), and quality of life rate 6 months after surgery (94% for RASP, 83.2% for HoLEP, p=0.075) were similar.\u003c/p\u003e\n\u003cp\u003eA meta-analysis by Kowalewski\u0026nbsp;\u003cem\u003eet al\u003c/em\u003e. [17] compared perioperative outcomes between RASP and HoLEP and found no statistically significant differences in postoperative functional outcomes, including transient urinary incontinence. The incontinence rates observed after HoLEP in our series are consistent with the literature, ranging from 10-40%, depending on surgeon expertise [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe slightly higher incontinence rate associated with HoLEP can be mitigated by the early apical mucosal release technique, leaving a mucosal flap to avoid damage to the external sphincter. Since incorporating this technique in 2017 in our study, the continence rate has improved from 75% to 86.07% (p=0.33). Additionally, the extended period for patient inclusion in the HoLEP arm may negatively affect overall continence results, as it has been shown that surgeon experience significantly influences postoperative continence [18,19]. Nonetheless, it is essential to inform patients of the possibility of transient incontinence to set realistic expectations and not significantly impact overall satisfaction [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth techniques were highly effective in improving postoperative parameters such as Qmax and PSA, although few studies report data on these parameters [20]. Qmax improved similarly, with a 174.67% increase after HoLEP and 190.67% after RASP. A significant PSA reduction was observed after both procedures: 88.99% after HoLEP and 89.64% after RASP , within a range of 0.5-2 ng/mL, similar to what is reported in the literature [21]. Tricard\u0026nbsp;\u003cem\u003eet al\u003c/em\u003e [16]\u0026nbsp;reported a 164.2% improvement in Qmax and an 88.2% reduction in PSA after HoLEP.\u003cbr\u003e\u0026nbsp;Regarding intraoperative outcomes, operative time was significantly shorter for HoLEP compared to RASP (97.58 min vs. 122.4 min, respectively, p\u0026lt;0.01). This result is consistent with the literature\u0026nbsp;[15].\u0026nbsp;Additionally, the enucleated tissue weight was similar between both techniques, making the efficiency greater for HoLEP (p=0.01). The shorter surgical time for HoLEP can be explained by the absence of additional time-consuming surgical manoeuvres, such as creating a transperitoneal access, robot docking and undocking, adhesiolysis, and cystorrhaphy\u0026nbsp;[17].\u003c/p\u003e\n\u003cp\u003eWe also observed a significant reduction in catheterization time for HoLEP compared to RASP (p\u0026lt;0.01) and in hospital stay, although this last difference is not statistically significant (p=0.079). Most patients had their catheter removed before discharge after HoLEP, while this was done on an outpatient basis after RASP. These results align with the findings of Kowalewski \u003cem\u003eet al\u003c/em\u003e [17]. One reason for the longer hospital stay after RASP could be the intestinal manipulation, pneumoperitoneum, and steep Trendelenburg position required, which may affect early postoperative recovery, increase opioid use, and potentially elevate the rate of intestinal complications [22].\u003c/p\u003e\n\u003cp\u003eIn our study, the complication rate was lower for HoLEP (15.5%) than for RASP (26%), although this difference was not statistically significant (p=0.12). The results reported in the literature are similar. Umari et al. [23] Umari \u003cem\u003eet al\u003c/em\u003e. [22] reported an overall perioperative complication rate of 29%, and Agreda-Casta\u0026ntilde;eda \u003cem\u003eet al\u003c/em\u003e. reported a haematuria rate after HoLEP of 0-12% and a UTI rate of 0-14% [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe main limitation of the robotic technique compared to the open procedure is the availability of the technology, the need for robotic expertise, and the certification required to operate the robot [24,25]. Similarly, the primary challenge for the endoscopic technique compared to simple prostatectomy, either open or robotic, is the steep learning curve and its impact on postoperative functional outcomes [26,27]. Brunckhorst \u003cem\u003eet al.\u003c/em\u003e established that, for experienced surgeons performing HoLEP on large prostates, achieving the learning curve requires between 20-60 cases, while for RASP, only 10-12 cases are needed [28].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn important factor in selecting the most appropriate technique for each patient is the urethral condition. To minimize the risk of urethral stricture after HoLEP, anterior urethral calibration is often performed in patients without permanent catheters, and efforts are made to minimize surgical time. Regarding RASP, transcapsular approach results in a lower risk of urethral stricture. Situations favouring the endoscopic approach include the need to resect concomitant bladder tumors to prevent tumor cell seeding through the cystostomy. However, the presence of large intravesical calculi or large bladder diverticula may prompt a preference for RASP [10].\u003c/p\u003e\n\u003cp\u003eLimitations of this study include its retrospective nature without true randomization, as patients were subjected to one technique or the other depending on the centre where they were treated. Additionally, both series include the learning curve periods for each technique, which may influence intraoperative and postoperative outcomes. However, this can also enhance the generalizability of the data, as the series reflect real-world scenarios and come from centres with significant expertise in both techniques (16 years for HoLEP and 7 years for RASP).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBoth RASP and HoLEP are safe for treating BPH in prostates \u0026gt;150 cm\u0026sup3;, reporting similar success rates, continence rates and quality of life after surgery. HoLEP achieved results with shorter operative time and catheterization duration. The choice of technique should be based on patient preferences, comorbidities, surgeon experience, or technological availability. However, RASP may be preferable in patients with unfavourable urethral access, a significant burden of bladder stones, or diverticula, while HoLEP could be considered for patients with high anaesthetic risk.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interest or personal relationships that should have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFUNDING SOURCES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding sources involved.\u003c/p\u003e\n\u003cp\u003eWe have not been paid to write this original article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors were not precluded from accessing data in the study, and they accept responsibility to submit for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTATEMENT OF ETHICS- PATIENT\u0026rsquo;S CONSENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eThis is an observational study. The 12th October University Hospital Ethics Committee has confirmed that no ethical approval is required.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eDATA SHARING STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhat data in particular will be shared? Clinical anonymous data and statistical analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen will data be available? Immediately following publication; no end date\u003c/p\u003e\n\u003cp\u003eWhat other documents will be available? Written consent if requested at [email protected].\u003c/p\u003e\n\u003cp\u003eWith whom? Researchers who provide a methodologically sound proposal. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eManagement of Non-neurogenic Male LUTS. In: EAU Guidelines. 2024. \u003c/li\u003e\n\u003cli\u003eGilling PJ, Cass CB, Cresswell MD, et al (1996) Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 47:48. \u003c/li\u003e\n\u003cli\u003eSotelo R, Clavijo R, Carmona O, et al (2008) Robotic simple prostatectomy. J Urol 179:513-5. \u003c/li\u003e\n\u003cli\u003eAutorino R, Zargar H, Mariano MB, at al (2015) Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis. Eur Urol 68(1):86-94. \u003c/li\u003e\n\u003cli\u003evan Rij S, Gilling PJ (2012) In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new \u0026laquo;gold standard\u0026raquo;. Curr Urol Rep 13: 427-432. \u003c/li\u003e\n\u003cli\u003eSandhu JS, Bixler BR, Dahm P, et al (2023) Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline amendment. J Urol.\u003c/li\u003e\n\u003cli\u003eClavien PA, Barkun J, de Oliveira ML, et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187-196.\u003c/li\u003e\n\u003cli\u003eMillin T. Retropubic prostatectomy (1946). Br J Urol 18:33-38.\u003c/li\u003e\n\u003cli\u003eRoffman CE, Buchanan J, Allison GT (2016) Charlson Comorbidities Index. J Physiother 62(3):171.\u003c/li\u003e\n\u003cli\u003ePalacios DA, Kaouk J, Abou Zeinab M, et al (2023) Holmium laser enucleation of the prostate vs transvesical single-port robotic simple prostatectomy for large prostatic glands. Urology 181:98-104.\u003c/li\u003e\n\u003cli\u003eJones P, Alzweri L, Rai BP, et al (2016) Holmium laser enucleation versus simple prostatectomy for treating large prostates: results of a systemic review and metaanalysis. Arab J Urol 14:50-58. \u003c/li\u003e\n\u003cli\u003eAssmus MA, Large T, Lee MS, et al (2021) Same-day discharge following holmium laser enucleation in patients assessed to have large gland prostates (\u0026ge;175 cc). J Endourol 35:1386-1392. \u003c/li\u003e\n\u003cli\u003eAgarwal DK, Rivera ME, Nottingham CU, et al (2020) Catheter removal on the same day of holmium laser enucleation of the prostate: outcomes of a pilot study. Urology 146:225-229. \u003c/li\u003e\n\u003cli\u003eGauhar V, Gilling P, Pirola GM, et. al (2022) Does MOSES technology enhance the efficiency and outcomes of standard holmium laser enucleation of the prostate? Results of a systematic review and meta-analysis of comparative studies. Eur Urol Focus 8:1362-1369. \u003c/li\u003e\n\u003cli\u003eZhang MW, El Tayeb MM, Borofsky MS, et al (2017) Comparison of Perioperative Outcomes Between Holmium Laser Enucleation of the Prostate and Robot-Assisted Simple Prostatectomy. J Endourol 31:847-850. \u003c/li\u003e\n\u003cli\u003eTricard T, Xia S, Xiao D, et al (2023) Outcomes of holmium laser enucleation of the prostate (HoLEP) for very large-sized benign prostatic hyperplasia (over 150 mL): open simple prostatectomy is dead. World J Urol. 41(8):2249-2253 \u003c/li\u003e\n\u003cli\u003eKowalewski KF, Hartung FO, von Hardenberg J, et al (2022) Robot-assisted simple prostatectomy vs endoscopic enucleation of the prostate: a systematic review and meta-analysis of comparative trials. J Endourol 36:1018-1028. \u003c/li\u003e\n\u003cli\u003eCho MC, Park JH, Jeong MS, et al (2011) Predictor of de novo urinary incontinence following holmium laser enucleation of the prostate. Neurourol Urodyn 30:1343-1349. \u003c/li\u003e\n\u003cli\u003eKobayashi S, Yano M, Nakayama T, et al (2016) Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period. Int Braz J Urol 42:740-746. \u003c/li\u003e\n\u003cli\u003eBove AM, Brassetti A, Ochoa M, et al (2023) Robotic simple prostatectomy vs HOLEP, a \u0026laquo;multi single-center\u0026raquo; experiences comparison. Cent European J Urol 76(2):128-134. \u003c/li\u003e\n\u003cli\u003ePavan N, Zargar H, Sanchez-Salas R, et al (2016) Robot-assisted versus standard laparoscopy for simple prostatectomy: multicenter comparative outcomes. Urology 91:104-110. \u003c/li\u003e\n\u003cli\u003eUmari P, Fossati N, Gandaglia G, et al (2017) Robotic Assisted Simple Prostatectomyversus 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 197:1108-1114. \u003c/li\u003e\n\u003cli\u003eAgreda Casta\u0026ntilde;eda F, Buisan Rueda \u0026Oacute;,Areal Calama JJ (2020) The complications of the HoLEP learning curve. A systematic review. Actas Urol Esp 44:1-8. \u003c/li\u003e\n\u003cli\u003eNestler S, Bach T, Herrmann T, et. al (2019) Surgical treatment of large volume prostates: a matched pair analysis comparing the open, endoscopic (ThuVEP) and robotic approach. World J Urol 37:1927-1931. \u003c/li\u003e\n\u003cli\u003eMoschovas MC, Tim\u0026oacute;teo F, Lins L, et al (2021) Robotic surgery techniques to approach benign prostatic hyperplasia disease: a comprehensive literature review and the state of art. Asian J Urol 8:81-88. \u003c/li\u003e\n\u003cli\u003eEnikeev D, Morozov A, Taratkin M, et al (2021) Systematic review of the endoscopic enucleation of the prostate learning curve. World J Urol 39:2427-3827. \u003c/li\u003e\n\u003cli\u003eLee MS, Assmus MA, Ganesh M, et al (2023) An outcomes comparison between holmium laser enucleation of the prostate, open simple prostatectomy, and robotic simple prostatectomy for large gland benign prostatic hypertrophy. Urology 173:180-186. \u003c/li\u003e\n\u003cli\u003eBrunckhorst O, Ahmed K, Nehikhare O, et al (2015) Evaluation of the Learning Curve for Holmium Laser Enucleation of the Prostate Using Multiple Outcome Measures. Urology. 86(4):824-829.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e \u003cstrong\u003eDemographic and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003epreoperative variables\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHoLEP (95 patients)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRASP (50 patients)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e72.36(8.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e72.4(7.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.978\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharlson index\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.54(1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.46(1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrior urological surgery and/or pelvic RT (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProstatic volume (\u003c/strong\u003e\u003cstrong\u003ecm\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e187.72 (45.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e203.38(98.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrior urethral catheter (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e42.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQmax (ml/s)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10.89(5.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8.12(3.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPSS score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e21.66 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e21.92(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.765\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8.73(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7.73(4.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaemoglobin (g/dl)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e14.41(1.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e14.41(1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003eHoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy; Qmax: maximum flow rate on uroflowmetry; RT: radiotherapy; IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntraoperative variables\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHoLEP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRASP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical time\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(minutes)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e97.58(39.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e122.4(25.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnucleated gland weight(g)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e124.85(51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e129.6(102.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical efficiency (g/min)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003eHoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy.\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 3. Postoperative variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHoLEP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRASP\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital stay (days)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.46(2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.22(1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCatheterization time (days)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.6(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5.9(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.96(1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.8(0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ max (ml/s)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e29.91(11.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e23.6(6.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPSS Score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6.64(5.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4(3.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood quality of life (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e83.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaemoglobin (g/dl)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e12.29(2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e11.71(1,49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003eHoLEP: Holmium Laser Enucleation of the prostate; RASP: Robotic Assisted Simple Prostatectomy; Qmax: maximum flow rate on uroflowmetry; RT: radiotherapy; IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"benign prostatic hyperplasia, robotic simple prostatectomy, HoLEP, Large-volume prostate","lastPublishedDoi":"10.21203/rs.3.rs-6001722/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6001722/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To compare perioperative outcomes, functional results, quality of life, and complications between robot-assisted simple prostatectomy (RASP) and Holmium laser prostate enucleation (HoLEP) as minimally invasive techniques for treating benign prostatic hyperplasia (BPH) in large prostates (\u0026gt;150 cm³).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This retrospective, multicentre, randomized, observational study (2007–2023) included patients with \u0026gt;150 cm³ prostate volumes who underwent either HoLEP or robot-assisted prostatectomy. Primary outcomes: success rate (complete enucleation, without transfusion or reintervention), good postoperative quality of life (IPSS 8\u003csup\u003eth\u003c/sup\u003e question score: 0-2), and continence at 6 months (no pads). Secondary outcomes: operative and catheterization time, hospital stay, enucleated gland weight, PSA reduction, Qmax improvement, and perioperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: We included 95 HoLEP and 50 RASP patients with similar demographics and prostate volume (HoLEP: 187.72 cm³; RASP: 203.38 cm³). The success rate (HOLEP: 83.2%; RASP: 74%), continence rate (HoLEP: 85.1%; RASP: 86%) and quality of life (HoLEP: 83.2%; RASP 94%) were similar (p=0.275; p=1; p=0.075; respectively). HoLEP had shorter operative time (97.58 vs 122.4 min) and catheterization duration, with similar hospitalization duration (HoLEP: 3.46 days; RASP: 4.22 days). Although there was no significant difference in enucleated gland weight, HoLEP was more efficient (1.28 g/min vs 1.06 g/min). Complication rates were similar (HOLEP: 15.5%; RASP: 26%; p=0.12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Both RASP and HoLEP are safe for treating BPH in prostates \u0026gt;150 cm³, reporting similar success and continence rates, and good quality of life after surgery. However, HoLEP achieved results with shorter operative time and catheterization duration.\u003c/p\u003e","manuscriptTitle":"Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study between HoLEP and Robotic Simple Prostatectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-14 10:56:10","doi":"10.21203/rs.3.rs-6001722/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bea4ae5b-233e-40e8-94f0-6e43e9177e35","owner":[],"postedDate":"February 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-22T12:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-14 10:56:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6001722","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6001722","identity":"rs-6001722","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}