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Article

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

by
Silvia Juste-Alvarez
1,*,
Claudia Zaccaro
2,
Javier Gil-Moradillo
1,
Javier Romero-Otero
3,4,
Ignacio Moncada
2,
Alfredo Rodríguez-Antolín
1 and
Borja Garcia-Gomez
1
1
Hospital Universitario 12 de Octubre, Avenida Córdoba 41, 28041 Madrid, Spain
2
Hospital Universitario La Zarzuela, Calle Pléyades 25, 28023 Madrid, Spain
3
HM Hospitales, Calle Oña 10, 28050 Madrid, Spain
4
ROC Clinic, Paseo del General Martínez Campos 17, 28010 Madrid, Spain
*
Author to whom correspondence should be addressed.
Surg. Tech. Dev. 2025, 14(2), 17; https://doi.org/10.3390/std14020017
Submission received: 25 February 2025 / Revised: 3 April 2025 / Accepted: 25 April 2025 / Published: 28 May 2025
Browse Figure
Versions Notes

Abstract

:
Background/Objectives: The aim of this research was 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, multicenter, 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 8th 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, and p = 0.075, respectively). HoLEP had a 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.

1. Introduction

Open simple prostatectomy (OSP) has been the standard surgical treatment of moderate to severe lower 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, such as significant bleeding and need for transfusion (7–14%), infections (up to 20%: urinary, wound infections, etc.), bladder neck or urethral stricture (6%), and transient urinary incontinence (up to 10%) [1], morbidity, and long stay have driven the pursuit of less invasive and more comfortable techniques 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, lower bleeding rate, and shorter hospital stay and catheterization time, compared to OSP, with a similar rate of complications and long-term results [4,5]. Particularly, RASP leverages the precision and dexterity of robotic systems, allowing surgeons to perform complex dissections with minimal blood loss and enhanced visualization. Meanwhile, HoLEP is very effective in completely removing adenomatous tissue while preserving the prostate capsule, thereby minimizing bleeding and other potential complications [6].
During the last years, clinical practice guidelines have embraced prostatic enucleation with a strong rate of recommendation in experienced centers. 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, and the comorbidities or preferences of the patient [7].
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 analyzing perioperative complications according to the Clavien–Dindo classification [8].

2. Materials and Methods

A retrospective, multicentre, observational study was conducted, collecting data from male patients with LUTS associated with 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, the RASP technique was performed.

2.1. 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 50 Hz) and a 550 nm flexible quartz fiber. 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 the Millin technique [9]. Four robotic arms and an assistant port were used. The specimen is morcellated using a MorSafe® morcellation bag (Veol Medical Technologies®; Navi Mumbai, India).

2.2. Analyzed Variables

  • Demographic data: age (years), Charlson comorbidity index [10], 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 [8].
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.

2.3. 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.

3. Results

Based on the inclusion and exclusion criteria, a total of 145 patients were included, of which 95 underwent 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 Table 1, Table 2, and Table 3, respectively. Even if not statistically significant, the size of the gland was larger in the RASP group.
The perioperative complication rate was 15.5% for HoLEP and 26% for RASP (p = 0.12). Complications according to the Clavien–Dindo system [8] are described in Table 4 and Table 5. After HoLEP, three patients required conversion to an open approach due to bladder injury in one case and to extract a large adenoma in two cases. No patient required conversion to an open approach after RASP.
Regarding the primary outcomes of procedural success, postoperative quality of life, and continence, the results are shown in Figure 1.

4. 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. We find that both techniques are safe alternatives for the surgical treatment of BPH, with no differences in the quality of life perceived by patients. However, RASP achieves these results at the expense of longer operative, hospitalization, and catheterization times for RASP.
With respect to HoLEP, advances in laser technology and technique refinement have enabled adequate hemostasis in experienced hands for large prostate volumes, leading to progressively shorter catheterization and hospitalization times [11,12], with excellent perioperative and long-term outcomes [13,14,15]
Zhang et al. [16] 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 the 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 [10], 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. [17] 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 analyzed 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 cases, 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. [18] 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 to 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 [19,20]. Nonetheless, it is essential to inform patients of the possibility of transient incontinence to set realistic expectations and not significantly impact overall satisfaction [11].
Both techniques were highly effective in improving postoperative parameters such as Qmax and PSA, although few studies report data on these parameters [21]. 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 [22]. Tricard et al. [17] 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 [16]. 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 maneuvers, such as creating transperitoneal access, robot docking and undocking, adhesiolysis, and cystorrhaphy [18].
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 performed on an outpatient basis after RASP. These results align with the findings of Kowalewski et al. [18]. 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 [23].
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] 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% [24].
While this study offers a good representation of the surgical and perioperative outcomes, our study does not capture long-term results, as it was not feasible to standardize the clinical follow-up of patients and evaluation of sustained quality of life improvements or delayed complications such as stricture or recurrence rate. Additionally, this study did not assess sexual function outcomes, as it was not routinely monitored during patient follow-ups. We recognize the importance of long-term follow-up and the need for standardized monitoring of these patients in order to conduct future studies which include the analysis of these variables. Regarding long-term results reported in the literature after HoLEP, Elmansy et al. [25] described that at 10 years follow-up, IPSS was 3.6, Q max was 23.4 mL/s, and the PSA reduction was stable at 84%. Bladder neck contracture and urethral stricture developed in 0.8% and 1.6% of patients, respectively. The reoperation rate as a result of recurrent obstruction from residual adenoma was 0.7%. The reduction in PSA remained at lower levels for up to 7 years, suggesting that the glandular size reduction after HoLEP is durable. As for the long-term results after RASP, Leslie et al. [26] reported significant improvements in IPSS (median decrease −11) and Qmax (+10 mL/s) at 7 months (p < 0.01), similar to Pathak et al. [27] (median IPSS decrease −14 and Qmax +7.9 mL/s at 12 months). During this period, 14% of patients experienced some level of urinary incontinence, 4% had transurethral resection of bladder neck sclerosis, and 4% had fossa navicularis stricture. Wagaskar et al. [28] described decreasing incontinence rates from 46% at 6 weeks to 16% at 3 months, with complete continence achieved by 9 months. However, most of the studies highlight that RASP procedures were performed by highly experienced surgeons, and thus, outcomes may not be generalizable to all surgeons.
The main limitations of the robotic technique compared to the open procedure are the availability of the technology, the need for robotic expertise, the economic cost, and the certification required to operate the robot [29,30]. 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 [31,32]. Brunckhorst et al. established that, for experienced surgeons performing HoLEP on large prostates, achieving the learning curve requires between 20 and 60 cases, while for RASP, only 10–12 cases are needed [33]. The effect of the learning curve on the clinical outcomes was also examined by Elmansy et al. [25] by comparing the results of patients treated in the first 3 years to the results of those treated in the last 3 years. There was a significant improvement in all variables measured (IPSS, QOL, PVR, and Qmax), comparing the outcome of treatment in the first 3 years with the last 3 years (p < 0.01). 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, a 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 [11]. Although the literature is still scarce, it seems that prostatic-urethra-sparing techniques in RASP provide benefits in the maintenance of preoperative potency and antegrade ejaculation but also accomplish faster patient recovery without the need to use a urinary catheter and fewer complications. This technique might be the future standard technique for sexually active men with large BPH requiring surgery. In our study, the RASP sparing technique was not performed [34].
An additional factor to consider when choosing a certain technique is the financial implications. 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 and may not be feasible in all healthcare settings. Currently, only indirect comparisons can be made by evaluating each technique against OSP or among endoscopic techniques [6]. HOLEP has demonstrated better cost-effectiveness compared to other endoscopic techniques and OSP for the treatment of BPH, regardless of prostate size. Some authors compared HoLEP to OSP, such as Wymer et al. [35] whose cost–utility analysis demonstrated that HoLEP was less expensive than OSP (USD 6585 vs. USD 15,404, respectively). On the other hand, 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 [6]. 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. Some authors [36] found that RASP was less expensive than OSP, largely due to reduced hospitalization costs (total cost USD 3840 vs. USD 5404, respectively), while others [37] reported higher costs for RASP than OSP. These data suggest that HoLEP may offer more economic advantages in terms of procedural and short hospitalization costs than OSP and RASP. However, no direct cost comparison or specific cost-effectiveness analysis has been performed for very large prostate glands, so further prospective and randomized control trials are needed to study the cost-effectiveness of both techniques for BPH.
Before undergoing surgery for BPH treatment, it is essential to rule out the presence of prostate cancer. All our patients had benign prostatic hyperplasia with no evidence of clinically significant prostate cancer before surgery. In accordance with European guidelines [1], for those with elevated PSA levels, mpMRI was performed, and if suspicious lesions were detected, a targeted biopsy was conducted. In addition, incorporating advanced diagnostic biomarkers, such as Progensa PCA3, MyProstateScore, ExoDx, SelectMDx, PHI, 4K, Stockholm3, and ConfirmMDx, could further enhance preoperative decision-making and better patient selection for surgery, reducing the likelihood of misdiagnosis, avoiding unnecessary biopsy and optimizing surgical outcomes [38].
The limitations of this study include its retrospective nature without true randomization, as patients were subjected to one technique or the other depending on the center where they were treated, which may increase the risk of selection bias. 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 reflects real-world scenarios and comes from centers with significant expertise in both techniques (16 years for HoLEP and 7 years for RASP). According to our results and considering the limitations of our study which may introduce potential biases—including its retrospective nature, variability in surgical expertise, and absence of randomization—future prospective, randomized controlled trials should be proposed to strengthen the conclusions and address these shortcomings.

5. Conclusions

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.

Author Contributions

Conceptualization, S.J.-A. and B.G.-G.; methodology S.J.-A., C.Z. and B.G.-G.; software, S.J.-A., C.Z. and J.G.-M.; validation, S.J.-A., I.M., J.R.-O., A.R.-A. and B.G.-G.; formal analysis, S.J.-A., A.R.-A. and B.G.-G., investigation, S.J.-A. and C.Z.; resources J.G.-M., J.R.-O., I.M., A.R.-A. and B.G.-G.; data curation S.J.-A. and C.Z.; writing—original draft preparation, S.J.-A.; writing—review and editing, S.J.-A., A.R.-A. and B.G.-G.; supervision, B.G.-G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This is an observational study. The 12th October University Hospital Ethics Committee confirmed that no ethical approval is required.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Clinical anonymous data and statistical analysis are available immediately following publication, with no end date. Written consent can be provided upon request to sjustealvarez@gmail.com. This information will be shared with researchers who provide a methodologically sound proposal.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
RASProbot-assisted simple prostatectomy
HoLEPholmium laser enucleation of the prostate
BHPbenign prostatic hyperplasia
IPSSInternational Prostate Symptom Score
PSAprostate-specific antigen
Q maxmaximum flow rate
OSPopen simple prostatectomy
LUTSlower urinary tract symptoms
IPSS-QoLInternational Prostate Symptom quality of life score
TRUStransrectal ultrasound
mpMRImultiparametric prostate magnetic resonance imaging
SDstandard deviation
UTIurinary tract infection

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Std 14 00017 g001
Figure 1. Primary objectives.
Figure 1. Primary objectives.
Std 14 00017 g001
Table 1. Demographic and preoperative variables.
Table 1. Demographic and preoperative variables.
HoLEP 1 (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 (%)010%0.004
Prostatic volume (cm3)
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
1 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.
Table 2. Intraoperative variables.
HoLEP 1RASPp 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)		1.281.060.01
1 HoLEP: holmium laser enucleation of the prostate; RASP: robotic-assisted simple prostatectomy.
Table 3. Postoperative variables.
Table 3. Postoperative variables.
HoLEP 1 RASPp 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
Qmax (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
Hospital stay (days)
Mean (SD)		3.46 (2.67)4.22 (1.94)0.079
1 HoLEP: holmium laser enucleation of the prostate; RASP: robotic-assisted simple prostatectomy; Qmax: maximum flow rate on uroflowmetry; IPSS: International Prostate Symptom Score; PSA: prostate-specific antigen.
Table 4. Perioperative complications after HoLEP.
Table 4. Perioperative complications after HoLEP.
Clavien–Dindo System [8]Type of Complication n (%)
Grade I-0
UTI 15 (5.15)
Grade IIMild Haematuria2 (2.1)
Significant haematuria + transfusion8 (8.2)
Grade III-0
Conversion to
an open approach		 3 (3.09)
1 UTI: urinary tract infection.
Table 5. Perioperative complications after RASP.
Table 5. Perioperative complications after RASP.
Clavien–Dindo System [8]Type of Complication n (%)
Grade IWound dehiscence
Wound bleeding		1 (2)
2 (4)
Grade IIUTI 16 (12)
Significant haematuria + transfusion3 (6)
Grade IIIpneumothorax1 (2)
Conversion to
an open approach		 0
1 UTI: urinary tract infection.
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MDPI and ACS Style

Juste-Alvarez, S.; Zaccaro, C.; Gil-Moradillo, J.; Romero-Otero, J.; Moncada, I.; Rodríguez-Antolín, A.; Garcia-Gomez, B. Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study Between HoLEP and Robotic Simple Prostatectomy. Surg. Tech. Dev. 2025, 14, 17. https://doi.org/10.3390/std14020017

AMA Style

Juste-Alvarez S, Zaccaro C, Gil-Moradillo J, Romero-Otero J, Moncada I, Rodríguez-Antolín A, Garcia-Gomez B. Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study Between HoLEP and Robotic Simple Prostatectomy. Surgical Techniques Development. 2025; 14(2):17. https://doi.org/10.3390/std14020017

Chicago/Turabian Style

Juste-Alvarez, Silvia, Claudia Zaccaro, Javier Gil-Moradillo, Javier Romero-Otero, Ignacio Moncada, Alfredo Rodríguez-Antolín, and Borja Garcia-Gomez. 2025. "Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study Between HoLEP and Robotic Simple Prostatectomy" Surgical Techniques Development 14, no. 2: 17. https://doi.org/10.3390/std14020017

APA Style

Juste-Alvarez, S., Zaccaro, C., Gil-Moradillo, J., Romero-Otero, J., Moncada, I., Rodríguez-Antolín, A., & Garcia-Gomez, B. (2025). Minimally Invasive Techniques for Large-Volume Benign Prostatic Hyperplasia: A Comparative Study Between HoLEP and Robotic Simple Prostatectomy. Surgical Techniques Development, 14(2), 17. https://doi.org/10.3390/std14020017

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