Transurethral surgery for enlarged prostates is technically demanding and may be associated with prolonged operative times and increased risks of urethral stricture and ejaculatory dysfunction. This study compared the efficacy and safety of Robot-Assisted Simple Prostatectomy (RASP) and Holmium Laser Enucleation of the Prostate (HoLEP) in patients with large-volume benign prostatic hyperplasia (BPH ≥80 mL), using 1-year outcomes from a multicentric prospective randomized clinical trial.
A total of 780 patients with BPH (prostate size ≥80 mL) were randomized 1:1 to undergo either RASP or HoLEP. Exclusion criteria included cardiopulmonary disease, bladder stones, neurogenic bladder, malignancy, prior prostate surgery, and coagulopathies. Perioperative and postoperative outcomes were assessed over a 12-month follow-up.
Baseline characteristics were comparable between groups. RASP was associated with longer operative time (150.4 ± 80.3 vs. 100.8 ± 35.3 minutes, P = 0.035), greater hemoglobin decrease (2.5 ± 0.6 vs. 1.3 ± 0.5 g/dL, P < 0.001), longer catheterization (160.8 ± 56.6 vs. 67.2 ± 21.7 hours, P < 0.001), and extended hospital stay (7.3 ± 3.5 vs. 3.4 ± 1.2 days, P < 0.001). However, bladder irrigation time was shorter in the RASP group (5.8 ± 4.8 vs. 20.4 ± 18.3 hours, P < 0.001). No significant differences were found in resected tissue weight (P = 0.865) or postoperative complications (Clavien–Dindo ≥II). Both groups showed significant International Prostate Symptom Score (IPSS) improvement at 1 month, with no between-group differences. At 1 year, IPSS, QoL, Qmax, and IIEF-5 were comparable. However, RASP demonstrated superior ejaculatory preservation, with lower rates of retrograde ejaculation (16% vs. 68%, P < 0.001) and higher MSHQ-EjD-SF scores (P = 0.032). Urethral strictures occurred only in the HoLEP group (n=3).
RASP and HoLEP provide comparable functional outcomes and safety in large BPH. Despite longer operative time and catheterization, RASP offers advantages in ejaculatory function preservation and lower urethral stricture risk. It may represent a valuable minimally invasive option for patients prioritizing sexual function and reduced urethral complications.
