Comparative Outcomes of En-Bloc Holmium Laser Enucleation of the Prostate and Transvesical Robot-Assisted Simple Prostatectomy for the Management of Benign Prostatic Hyperplasia: A Propensity-Matched Analysis

<b><i>Background:</i></b> Holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy (RASP) have emerged as the two surgical treatments of medication-refractory benign prostatic hyperplasia (BPH). The comparative outcomes of en-bloc HoLEP with early apical release and RASP with modified Freyer's technique remain unexplored. <b><i>Methods:</i></b> Between 2018 and 2022, patients with medication-refractory BPH and prostate volume ≥80 g underwent HoLEP or RASP depending on clinical characteristics, patient choice, and surgeon preference. A 1:1 propensity-matched analysis was performed with prostate volume and preoperative International Prostate Symptom Score (IPSS) as the matching variables to eliminate selection bias. Trifecta outcome was defined as complete urinary continence, <i>Q</i>_max >15 mL/second, and no postoperative complications at 3 months. After an initial univariable analysis to predict factors associated with the trifecta outcome, variables with significance levels of ≤0.1 were included in a multivariable model. <b><i>Results:</i></b> Of 416 patients with medication-refractory BPH, 158 underwent HoLEP, whereas 258 underwent RASP. Following matching, 80 patients in each group were included in the analysis. There was no difference in the median postoperative IPSS score, median postoperative <i>Q</i>_max, and continence rate at 3 months. The percentage of patients who attained the trifecta outcome in the HoLEP and RASP groups was 71.25% and 63.75%, respectively (<i>p</i> = 0.4). Patients in the HoLEP group had shorter postoperative stay (HoLEP: 1 [IQR 1-2] <i>vs</i> RASP: 2 [IQR 1-2], <i>p</i> = 0.04) and catheterization time (HoLEP: 2 [IQR 1.75-3] <i>vs</i> RASP: 5 [IQR 5-5], <i>p</i> < 0.001). A multivariable regression did not identify any factors predictive of trifecta outcomes. <b><i>Conclusion:</i></b> Given its comparable efficacy to RASP, HoLEP is the preferred treatment for BPH in large prostates because of its shorter hospital stay and catheterization time. Future randomized controlled trials are required to solidify indications for these treatment modalities and standardize treatment protocols for patients with medication-refractory BPH.