There was no consensus about the management for large (> 80gm) or very large prostate based on guideline of European Association of Urology. Prostate enucleation and open prostatectomy was still the standard or the first choice for benign prostate hyperplasia.(1) With the popular of  minimal invasive surgery and robotic technology, robotic-assisted simple prostatectomy (RaSP) surgery became popular as an alternative for open prostatectomy now.(2) However, there was still no large scale randomized trials compared the efficacy and safety of robotic-assisted surgery and laser enucleation prostatectomy (LEP) in large prostate. 
     Our study aims to conducted a systematic review and meta-analysis for comparison of the efficacy and safety between laser enucleation and robotic-assisted simple prostatectomy for large prostate.

We conducted a systematic search using Embase, PubMed, and the Cochrane Library based on PRISMA principle. The search terms include: (robotic-assisted OR robot) AND prostatectomy AND laser enucleation AND benign prostate hyperplasia. 
     The primary outcome included resected adenoma, time of operation and length of hospital stay. The secondary outcomes included incidence of major complications (Clavien-Dindo Grade ≧ 3), decreased hemoglobin (Hgb) level,  blood transfusion rates and incidence of transient stress urinary incontinence (still stress urinary incontinence after operation 1 to 6 months). Data extraction and quality assessment were performed based Cochrane Guidance. The Cochrane Collaboration Review Manager software (RevMan Web) was used for statistical analysis.

There were 9 trials, 1478 patients met the inclusion criteria and included for meta-analysis. Totally, there were 374 and 1104 patients underwent RaSP and LEP, respectively. The results were showed in Figure 1 and Figure 2. The RaSP took similar operative time and resected adenoma as the LEP. (Resected adenoma: weighted mean difference: 5.35 gm, 95% CI: -7.00-17.70, p = 0.40; operation time: weighted mean difference: 55.86 minutes, 95% CI: -0.84- 112.57, p: 0.05 ) 
     RaSP has shorter catheterization time (weight mean difference: 6.31 days, 95% CI: 3.18-9.44, p:<0.00001) and hospital stay days  (weight mean difference: 1.30 days, 95% CI: 1.17-1.42, p:<0.00001).  LEP could have less decreased Hgb level and rate of blood transfusion but the result has no statistic significant difference. (Decreased Hgb level: weighted mean difference: 0.1 gm/dL, 95% CI: -0.01-0.22, p = 0.08; blood transfusion rate: Odds ratio: 2.5, 95% CI: 1.02-6.14 , p: 0.05 ) 
     The incidence of major complications  was higher among patients received RaSP (odds ratio: 2.43, 95% CI: 1.09-5.43 , p: 0.03) but LEP group has high incidence of post operation transient stress urinary incontinence (OR: 0.38, 95% CI: 0.17-0.88, p: 002).

All of the reported trials were surgeons with experienced hands in LEP or RASP. LEP and RASP has similar efficiency in adenoma resection. LEP has shorter catheterization time and hospital stay days. Although there was no statistic difference, LEP might have less decreased Hgb level and less rate of blood transfusion. The incidence of major complications were higher among patients received RaSP but the incidence of short-term stress urinary incontinence was higher in LEP group. 
     Lacking of long-term following up of function outcome result and limited prospective studies were the weak points of this study.

Current evidence indicates both LEP and RaSP provide similar efficiency (similar weight of resected adenoma and operation time) in experienced hands. LEP has significant shorter catheterization time and hospital stay days, but RaSP might have less blood loss and  rate of blood transfusion. 
     Although LEP has lower rate of major complication rate,  it comes with higher rate of post operation stress urinary incontinence. However, the long-term functional result was required.

EAU Guidelines. Edn. presented at the EAU Annual Congress Paris April 2024. ISBN 978-94-92671-23-3.
Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline amendment 2023. J Urol. 2023;10.1097/JU.0000000000003698.

Continence 12S (2024) 101406
DOI: 10.1016/j.cont.2024.101406