Robot-Assisted Simple Prostatectomy Versus Endoscopic Enucleation for Large-Volume Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis of Perioperative Outcomes and Complications

Introduction/Background: Large-volume benign prostatic hyperplasia (≥80 mL) requires complete anatomical removal of the adenoma. Robot-assisted or minimally invasive simple prostatectomy (RASP/MISP) and anatomic endoscopic enucleation of the prostate (AEEP) have both emerged as minimally invasive alternatives to open simple prostatectomy, but their comparative perioperative performance in very large glands remains incompletely defined. Objective: To systematically review and quantitatively synthesize the perioperative outcomes and complications of RASP/MISP versus AEEP in the surgical management of large-volume BPH. Methodology: Following PRISMA 2020, PubMed, Embase, Scopus and the Cochrane Library were searched from inception to 7 June 2026 for randomized and non-randomized comparative studies of RASP/MISP versus AEEP in men with mean or median prostate volume ≥ 80 mL reporting at least one perioperative or functional outcome and at least one Clavien–Dindo grade ≥ III complication. Continuous outcomes were pooled as mean differences (MD) and dichotomous outcomes as risk ratios using random-effects models (REML with Knapp–Hartung adjustment); heterogeneity was assessed with I². Risk of bias was evaluated with the Newcastle–Ottawa Scale and ROBINS-I, and certainty of evidence with GRADE. Publication bias and leave-one-out sensitivity analyses were performed where the number of studies permitted. Results: Five comparative cohort studies published between 2017 and 2025 were included, comprising 271 patients treated with RASP/MISP and 998 treated with AEEP. AEEP was associated with a significantly shorter catheterization time (pooled MD 5.95 days; 95% CI 1.98–9.92; p = 0.014) and a shorter hospital stay (pooled MD 2.73 days; 95% CI 1.07–4.39; p = 0.010), both with high heterogeneity (I² 99.0% and 96.1%, respectively). Perioperative hemoglobin drop tended to favor AEEP without reaching significance (pooled MD 0.65 g/dL; 95% CI −0.33 to 1.63; p = 0.103), and transfusion risk was lower but not statistically significant (pooled RR ≈ 0.46; 95% CI 0.18–1.15). PSA reduction was substantial and broadly equivalent between techniques. Functional outcomes (IPSS, QoL, Qmax, PVR) improved comparably with both approaches. Leave-one-out analyses confirmed that the catheterization and length-of-stay advantages of AEEP were robust, and no evidence of publication bias was detected. Certainty of evidence was low to moderate, reflecting the observational designs. Leave-one-out analyses indicated that the catheterization and length-of-stay differences were not driven by any single study; publication bias could not be assessed reliably because fewer than ten studies contributed to any outcome. Certainty of evidence was low to moderate, reflecting the observational designs, the small number of studies, and substantial between-study heterogeneity, and the findings should be regarded as hypothesis-generating. Conclusions: In large-volume BPH, AEEP and RASP/MISP achieve comparable functional improvement and adenoma debulking, but AEEP offers superior perioperative efficiency, with markedly shorter catheterization and hospital stay and at least comparable safety. RASP/MISP remains a valuable option where robotic infrastructure is available but high-volume enucleation expertise is lacking. These findings, drawn from observational evidence of low-to-moderate certainty, support AEEP as the more resource-efficient minimally invasive option for very large glands and underline the need for randomized comparative trials.