Holmium Laser Enucleation of the Prostate Versus Robot-Assisted Simple Prostatectomy for Benign Prostatic Obstruction: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as an alternative for benign prostatic obstruction (BPO), with fewer perioperative and functional complications. However, its comparative performance relative to robot-assisted simple prostatectomy (RASP) remains debated, requiring updated evaluation. Methods: A systematic review and meta-analysis of studies comparing HoLEP and RASP was performed using PubMed, Scopus, and Cochrane databases through August 2025. Outcomes were pooled using mean differences (MDs) and odds ratios (ORs) with random-effects models. Risk of bias assessment and trial sequential analysis were conducted to evaluate the robustness of evidence. Results: Thirteen studies, including 1993 patients, were analyzed. HoLEP was associated with shorter operative time (MD = −32.05 minutes), lower transfusion rates (OR = 0.34), fewer Clavien–Dindo grades III and IV complications (OR = 0.39), and earlier catheter removal (MD = −3.84 days). Postoperative International Prostate Symptom Score modestly favored RASP (MD = 0.96). No significant differences were observed in quality of life, maximum urinary flow rate, International Index of Erectile Function, prostate-specific antigen reduction, postvoid residual volume, estimated blood loss, specimen weight, hospital stay, minor complications, trifecta achievement, or postoperative urge and stress incontinence. Conclusion: HoLEP provides improved perioperative safety with largely comparable functional outcomes compared with RASP. Further high-quality comparative studies are needed to confirm long-term effectiveness.