Robotic Assisted Simple Prostatectomy versus Holmium Laser Enucleation of the Prostate for Patients with Huge Benign Prostatic Hyperplasia

INTRODUCTION

Lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) commonly occur in aged men, often as a result of benign prostatic hyperplasia (BPH), the most common benign disease. Treatment options for LUTS/BPH include behavioral, pharmacologic, and surgical interventions, with treatment decisions based on symptom severity, patient goals, and clinician preference [1]. Surgical management is typically chosen for severe LUTS or refractory urinary retention, recurrent urinary tract infection, gross hematuria and bladder stones, and worse renal function impairment [2].

Over the past three decades, surgical management of BPH has evolved from open simple prostatectomy (OSP) to less invasive procedures such as transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), and laparoscopic or robot-assisted simple prostatectomy (RASP). While OSP is conventional, TURP has been proposed due to technological advances that reduce invasive-related complications. HoLEP, a type of transurethral approach, is characterized by less bleeding and less invasive procedures with less hospitalization, regardless of prostate size [3,4]. However, transurethral approaches may not always completely remove prostate tissues, which can result in a higher incidence of bladder injury, urinary sphincter injury, and urethral stenosis [3]. Urinary sphincter damage can lead to postoperative urinary incontinence, which can reduce the quality of life of patients. Urethral stenosis can occur due to the insertion of a large urethral scope of 26 French, and the longer the surgery takes, the worse it can become. The incidence of urethral stenosis and incontinence after HoLEP has been reported as 1.2% to 7.3% and 0% to 2.4%, respectively [5]. In a real clinical setting, the incidence of these complications may be higher depending on the size of the prostate.

To overcome the complications of endoscopic surgery, robot-assisted surgery has been proposed. A study by Umari et al [6] may be helpful in determining adequate surgical management for large prostate volumes exceeding 80 grams. During RASP, the field of view is widened, access is made easier, and sophisticated procedures can be performed. Because RASP is an antegrade approach to prostate tissues, the surgeon can identify the urethral sphincter. Additionally, it is possible to reduce complications related to urethral stenosis due to the absence of a large scope insertion, which is a disadvantage of the aforementioned transurethral approach. Therefore, we conducted a comparative review of RASP versus HoLEP in patients with huge BPH.

COMPARISON OF EFFICACY AND SAFETY BETWEEN RASP AND HOLEP: LITERATURE REVIEW

We compared the advantages and disadvantages of HoLEP and RASP. Both surgeries can be performed regardless of the prostate size, but HoLEP can be performed faster, with shorter hospitalization [7,8,9,10]. However, patients who underwent HoLEP occasionally experienced urinary incontinence or ureteral stenosis [11]. To avoid this, we used urethral sounding to dilate the urethra before inserting the cystoscope. RASP, on the other hand, is performed with laparoscopy, where the urethral sphincter can be identified in the field of view, preventing damage to the sphincter (Fig. 1). Additionally, some studies have shown that even if the noise level during HoLEP is within the hearing preservation level, some surgeons may feel uncomfortable [12]. Overall, we concluded that RASP is better in many aspects for surgeons than HoLEP.

Fig. 1. During robotic-assisted simple prostatectomy, urethral sphincter (yellow arrows) can be identified in the field of view.

Several studies have recorded parameters for each procedure, including post-voiding residual (PVR) volume, international prostate symptom score (IPSS), urinary flow rate (UFR), Hemoglobin change, postoperation complications, and operation time (Table 1, 2). Both HoLEP and RASP have been shown to improve symptoms by IPSS score and UFR improvement, although the improvement ratio may vary due to various factors.

Table 1. Holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy (RASP).

Study		Number	Mean PV	Preoperative		Postoperative
				IPSS	UFR	IPSS	UFR
HoLEP
	Kuntz et al [7]	60	114.6±21.6	22.1±3.3	3.8±3.6	2.3±2.0	27.4±9.7
	Piao et al [11]	579	73±57.5	19.7±7.5	9.0±4.4	5.8±5.9	20.45±10.5
	Tamalunas et al [12]	487	83.5	18.6	9.9	10.6	12.6
	Anan et al [13]	100	67.5±32	19.3±8.3	8.4±4.1	4.5±2.9	18.1±9.5
RASP
	Mourmouris et al [14]	26	NA	22.9	10.1	5.7	19.1
	Kim et al [15]	33	97.9	9.4	13.2	6.6±0.2	22±1.0
	Umari et al [6]	81	130	25	8	5	23

Values are presented as mean±standard deviation or mean only.

IPSS: international prostate symptom score, NA: not available, PV: prostate volume, UFR: urinary flow rate.

Table 2. Hemoglobin change, postoperative complication (urethral stenosis, incontinence), operation time.

Study		Number	Operation time (min)	Hospital day (day)	Catheterization (day)	Hemoglobin loss (mg/dL)	Complication (rate)
HoLEP
	Kuntz et al [7]	60	NA	3.3	1.5	-1.9	3.3%
	Piao et al [11]	579	62.1±34.1	2.5±0.9	2.1±2.7	TF 0%	1.2%
	Tamalunas et al [12]	487	85.1	3.0	2.0	-1.0
	Anan et al [13]	100	93±30	4±0.4	2.0	-1.3	3%
RASP
	Mourmouris et al [14]	26	133.6	3.4	3.0	TF 0%
	Umari et al [6]	81	105	4.0	3.0	-1.1	1.2%

Values are presented as mean±standard deviation or mean only.

HoLEP: holmium laser enucleation of the prostate, NA: not available, RASP: robot-assisted simple prostatectomy, TF: transfusion.

The study by Umari et al [6], which included a larger number of patients than the other studies, shows a clear decrease in IPSS and a clear increase in UFR from preoperative to postoperative, despite a larger average prostate volume than other studies. Several studies have also checked patient quality of life based on operation time, hospitalization, catheterization days, and the incidence rate of postoperative complications. When comparing several studies, the results were similar, although different operative times and different rates of postoperative complications could be attributed to operative factors such as the operator. In any case, RASP patients typically require more time for hospitalization and catheterization than HoLEP patients [13,14,15]. However, it can be seen that the incidence of complication after RASP was lower than in other studies after HoLEP, especially Umari et al [6]. In more advanced cases of BPH, where complications such as urethral stricture are considered, the prostate volume is larger, or there are multiple or large stones in the bladder due to BPH, robotic-assisted surgery may be indicated for safety reasons. Injuries to the urethra or urinary sphincter may be more pronounced in HoLEP. This fact has a huge impact on the quality of life of patients after surgery.

COMPARISON OF COST BETWEEN RASP AND HOLEP: LITERATURE REVIEW

When it comes to treating BPH, it is important for doctors to consider cost-effectiveness, but the net cost of the surgical procedure should also be taken into account from the patient's perspective. Several studies have attempted to evaluate the cost-effectiveness of procedures for BPH. One study found that the average cost of HoLEP compared to open surgery was $2,919 to $3,556 [16], which was attributed to shorter hospitalization in HoLEP. Another study found that the average cost per RASP, including hospitalization, was $11,878.

The Republic of Korea’s public healthcare system is referred to as the National Health Insurance (NHI). It is provided to all citizens to improve public health and promote social security by covering healthcare service costs, such as preventative treatment, diagnosis, treatment, rehabilitation, injuries, childbirth and death. In terms of the economic impact on NHI, HoLEP is covered by insurance, whereas RASP is not an option of insurance in Korea [17]. In the center where the study was conducted, HoLEP cost $877.57 with National insurance, while RASP cost $5,909.36. Ultimately, HoLEP may have more economic advantages in terms of the procedure and short hospitalization costs. Furthermore, private insurance as well as national insurance is an important criterion for patients to choose surgery. The rate of personal health medical insurance coverage by age in the Korean statistical information service portal was confirmed, and according to these statistics, the uninsured rate over the age of 60s is close to 50.1% (Table 3). In the 50s and below age groups, the uninsured rate was confirmed to be approximately 25.2%. The total cost of surgery has decreased a lot by personal insurance coverage; therefore, the cost gap between the two surgeries is narrowing. Although there are differences depending on the age group, having personal insurance can reduce the worries caused by the cost when patients choose surgery.

Table 3. Whether or not to subscribe to private health insurance (categorized by age).

	Random sampling	Insured rate (%)	Uninsured rate (%)
Under 29 yr	69	48.7	51.3
30–39 yr	331	72.1	27.9
40–49 yr	508	81.1	18.9
50–59 yr	586	77.3	22.7
Over 60 yr	505	49.9	50.1

Data from Life Insurance Association. Life insurance propensity survey [Internet]. KOSIS; c2015. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=367&tblId=DT_36701_15_A072&conn_path=I2

PREOPERATIVE ARTERIAL EMBOLIZATION FOR HUGE BPH

Prostate arterial embolization (PAE) is an interventional therapy for BPH that has recently been performed. This procedure leads to the shrinking of hyperplasia prostate tissue and reduces the volume of the prostate. Although HoLEP has a relatively low risk of bleeding compared to open prostatectomy, bleeding requiring transfusion has been reported in up to 6.7% of patients in case studies [18]. Some researchers have suggested that prostate size definitely plays a role in increasing the tendency to bleeding. Because the area and vascular density of the prostate capsule is increased in larger prostates. The study by Li et al [19] has demonstrated that combining HoLEP with PAE to treat extremely enlarged prostates resulted in improved outcomes in all monitoring functions after the procedure, including IPSS, Qmax, and PVR. These results indicate that HoLEP after PAE is an effective and safe treatment for patients with extremely enlarged prostate. At our center, we performed preoperative PAE on large size BPH patients to reduce volume [18,20]. Preoperative PAE has several advantages, including less bothersome LUTS, less bleeding, a low incidence of complications during and after surgery, and positive therapeutic effects [18,19,20,21]. We reviewed the outcomes of preoperative PAE in patients and found that it resulted in reduced hemoglobin loss and reduced surgical time, which ultimately contributed to the rapid recovery of the patient. In addition, patients experienced improved IPSS, UFR, clinical symptoms, while their prostate volume and prostate-specific-antigen levels were reduced. However, PAE is a procedure that requires an understanding of various pelvic artery anatomy and should be performed by a skilled professional.

COMPARING SINGLE PORT VERSUS MULTI-PORT RASP

The United States approved the first da Vinci surgical robot in 2000, and RASP was first performed in 2001. This allowed for minimally invasive urology by using rigid instrument arms through multiple trocars to access surgical targets. The robot has advantages such as high definition three-dimensional visualization cameras, fine handling, tremor reduction, and accessing all around angles to enable complex operations. RASP allows identification of the urethra area, preserving antegrade ejaculation and reducing adverse effects such as postoperative incontinence. Numerous studies show us safe and practical ways to perform da Vinci assisted operations for prostatectomy, such as the study by Dobbs et al [22]. Additionally, several recent studies propose that single port methods have advantages such as better cosmesis, shorter hospitalization, and less catheterization compared to existing multiport systems [23,24,25]. However, these results have only been demonstrated by expert surgeons [25], and there are disadvantages of all robot arms being located closely in a single port, which reduces the visualized field and decreases the rotation angle of robot arms and movement extent. On the contrary, multiport systems are free of these limitations and allow surgeons to feel more comfortable during surgery. However, it should be noted that multiport systems have been mainly used thus far, and this can affect study results, as it may be more convenient for surgeons. While comparative studies on single port and multiport systems have been conducted recently, it is difficult to make conclusive comparisons due to the lack of available cases by single port systems and sophisticated statistical methods [25]. Therefore, it is challenging to state definitively whether single port robot surgery is better than multiport systems.

CONCLUSIONS

Our study reviewed other studies and compared RASP versus HoLEP postoperative complications in our center. Both techniques showed excellent outcomes in improving LUTS/BPH. However, RASP costs are high, which puts a burden on the patient. Moreover, the operation time and hospitalization are longer than HoLEP. But considering the operative way, postoperative complications such as urethral stenosis and incontinence occur less in RASP. In RASP, urethral sphincters are visible during the procedure, which can be anatomically distinguished from others. And it can cause fatigue and hearing problems when a surgeon performs HoLEP. We perceive that RASP is expensive, but it cannot be counted as a price because it improves postoperative results by reducing complications and contributes to making the surgeon's hearing safety. It is important to consider several factors that we have dealt with to determine the surgical procedure for large BPH patients.