Patients with Marked Prostatomegaly and Clinically Significant Prostate Cancer Have Inferior Perioperative Outcomes Following Radical Prostatectomy

<b>Background/Objectives</b>: While robot-assisted radical prostatectomy (RARP) is the standard surgical treatment for localized prostate cancer, patients with marked prostatomegaly may experience worse outcomes. The current literature lacks generalizable, multi-surgeon data examining surgical complications in this population. <b>Methods</b>: We conducted a retrospective cohort study of 2030 patients who underwent RARP at a tertiary academic referral center. Perioperative complications and oncologic outcomes were compared between patients with marked prostatomegaly (defined as a prostate volume >100 grams (g)) and those with average-sized glands (<100 g). Logistic regression was used to compare groups. <b>Results</b>: Patients with marked prostatomegaly had a lower PSA density (0.10 vs. 0.20, <i>p</i> < 0.001), but there were no significant differences in pathologic NCCN grade groups, margin status, or lymph node involvement between groups. Patients with marked prostatomegaly had 60% higher odds of experiencing perioperative complications (OR 1.60, 95% CI 1.25-2.07, <i>p</i> < 0.0003) and were over twice as likely to have an ED visit or hospital readmission following surgery (OR 2.16, 95% CI 1.79-2.61, <i>p</i> < 0.001). They were also 25% more likely to undergo non-nerve-sparing or unilateral nerve-sparing procedures (OR 1.25, 95% CI 1.11-1.42, <i>p</i> < 0.001). <b>Conclusions</b>: Marked prostatomegaly is associated with higher rates of perioperative complications following RARP, with more frequent emergency room visits and readmissions. While nerve-sparing procedures were less commonly performed, oncologic outcomes remained comparable. Further prospective, multicenter studies are warranted to validate these results, which impact preoperative counseling.