Robot-assisted simple prostatectomy vs. laser enucleation of the prostate for large-volume benign prostatic hyperplasia (BPH, ≥80 mL): a systematic review and meta-analysis

Background Robot-assisted simple prostatectomy (RASP) and laser enucleation of the prostate (LEP) are established surgical options for the treatment of large-volume benign prostatic hyperplasia (BPH); however, consensus regarding the superiority of one technique over the other has not been established. This study aimed to comprehensively compare the perioperative efficiency, safety, and functional outcomes of RASP and LEP. Methods We conducted a comprehensive search of four databases (PubMed, Embase, Web of Science, and Scopus) to identify studies comparing RASP and LEP in large-volume BPH. Pooled and subgroup analyses were performed using Stata MP 18 and Review Manager 5.4.0. Results Fifteen studies (2,231 patients, 763 RASP and 1,468 LEP) were included in the analysis. LEP was associated with shorter operative time and catheterization duration than RASP. Hospital stay was reduced with thulium fiber laser enucleation of the prostate (ThuLEP; mean difference MD 2.43, 95% confidence interval CI 1.52–3.34, p 0.001), but not with holmium fiber laser enucleation of the prostate (HoLEP). Specimen weights were comparable overall (MD 3.61, 95% CI −11.29–18.51, p = 0.60), although ThuLEP yielded smaller specimens (MD 28.44, 95% CI 12.17–44.71, p = 0.01). Low- and high-grade Clavien–Dindo complications were comparable between groups, while RASP was associated with incidence of lower urinary incontinence (OR 0.48, 95% CI 0.27–0.85, p = 0.01) and superior improvements in International Prostate Symptom Score (MD −1.33, 95% CI −2.41–−0.26, p = 0.015) and post-void residual (MD −3.95, 95% CI −7.28–−0.61, p = 0.020), with International Prostate Symptom Score benefit observed primarily at long-term follow-up (≥12 months, MD −1.45, 95% CI −2.24–−0.67, p = 0.012). Maximum urinary flow rate and quality of life were comparable across groups. Conclusion Both RASP and LEP may be safe and effective surgical options for large-volume BPH. LEP may be associated with faster perioperative recovery, whereas RASP may reduce the incidence of UI and potentially improve long-term symptom control. Given the observational design of included studies, heterogeneity across cohorts, and limitations of retrospective evidence, these findings should be interpreted with caution, and tailored surgical strategies are recommended.