Impact of Prior Holmium Laser Enucleation of the Prostate on Robot-Assisted Radical Prostatectomy Outcomes: A Systematic Review and Meta-Analysis of Comparative Studies

Background: The prevalence of incidental prostate cancer (iPCa) after holmium laser enucleation of the prostate (HoLEP) ranges from 5% to 20%. The hypothesis is that prior HoLEP may complicate the treatment of such cancers with RARP and negatively impact post-RARP functional outcomes. Methods: In February 2025, PubMed®, Scopus®, and Web of Science™ were assessed to retrieve data of men with PCa undergoing RARP (P) after HoLEP (I), compared to those without prior HoLEP (C). The outcomes of interest included surgical results (O) from retrospective and prospective comparative studies (Studies). Surgical intra- (OT, EBL, number of nerve-sparing RARP and bladder neck reconstruction), and postoperative (LOS, time to catheter removal), pathological (PSM and tumor stage), oncological (BCR), and functional (postoperative continence and sexual function recovery) outcomes were meta-analyzed, using WMD for continuous variables and odd ratio (OR) for dichotomous variables. Results: After study selection, three comparative retrospective studies were included in the SR and MA, comprising 63 patients undergoing RARP after HoLEP and 322 patients who underwent RARP. Compared to patients who underwent RARP without prior HoLEP, patients undergoing RARP after HoLEP had a statistically significantly longer OT (WMD: 31.99 minutes, p < 0.001), higher likelihood of bladder neck reconstruction (OR: 9.90, p < 0.001), and longer time to catheter removal (WMD: 0.48 days, p = 0.003). However, no differences in terms of pathological, oncological, and functional outcomes were reported between the two groups. The main limitation relates to the inclusion of only three retrospective comparative studies and the small cohort of post-HoLEP patients, which limits the statistical power and generalizability of the findings. Conclusion: Prior HoLEP may introduce certain surgical challenges, reflected in longer OT, a greater need for bladder neck reconstruction, and a longer time to catheter removal. However, these procedural differences do not appear to affect oncological or functional outcomes after RARP.