Benign Prostatic Hyperplasia Patient Outcomes in Various Robotic-Assisted Simple Prostatectomy Approaches vs Prostate Enucleation in Large Prostates: A Systematic Review and Bayesian Network Meta-Analysis

BACKGROUND AND OBJECTIVE: Benign prostatic hyperplasia (BPH) represents a common condition in aging males. For prostates exceeding 80 g, robotic-assisted simple prostatectomy (RASP) and transurethral prostate enucleation have emerged as leading treatments. This study aimed to comprehensively compare outcomes between these approaches. METHODS: We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials and cohort studies. Outcomes included changes in urinary flow rate, International Prostate Symptom Score (IPSS), complication rates, operative bleeding, operative time, hospitalization duration, and catheterization period. Robotic interventions were classified as single-port (SP) or multiport with transvesical (TV), transperitoneal, or transcapsular techniques. Enucleation methods included holmium laser (HoLEP), thulium laser, bipolar, and GreenLight laser vapo-enucleation.Key Findings and Limitations:We included data from 25 studies with 3924 patients. Network meta-analysis showed no significant difference in overall complication rates between RASP and enucleation techniques, though RASP had the highest surface under the cumulative ranking curve scores in the SP approaches, particularly the SPTV approach. Both RASP and enucleation approaches showed similar improvements in urinary flow rates. RASP approaches, particularly SPTV, had the highest decrease in IPSS, but the changes were not statistically significant. Despite longer operative times and Foley catheterization durations for RASP, blood loss was comparable to enucleation techniques. CONCLUSION AND CLINICAL IMPLICATIONS: Our results suggest that robotic approaches have similar performance to HoLEP when managing large prostates. However, robotic approaches may have slight differences including improved symptom scores, lower incontinence rates, longer operative times, and longer hospital stays. PATIENT SUMMARY: In this study, we compared two modern surgical approaches for treating enlarged prostates over 80 g-robotic surgery and laser/electrical techniques that remove prostate tissue through the urethra. We found both approaches work equally well for improving urinary flow, with similar bleeding risks, though the robotic approach may better reduce urinary symptoms but requires longer surgery and hospital stays. This information helps doctors and patients choose the most suitable treatment option for large prostate enlargement.