Comparative Outcomes of Holmium Laser Enucleation of the Prostate (HoLEP) versus Robotic- Assisted Simple Prostatectomy (RASP) for Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

With the rising prevalence of benign prostatic hyperplasia (BPH), there is an increasing demand for surgical interventions that optimize patient outcomes while minimizing complications. This systematic review aims to critically evaluate and contrast the clinical outcomes, surgical efficiency, and safety profiles during the perioperative period for holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy (RASP) in patients diagnosed with BPH exhibiting a prostate volume of ≥80 mL, providing evidence-based insights for BPH management. Adhering to the EAU Guidelines Office and PRISMA guidelines, the study protocol was registered with Prospero [CRD420251059418]. A comprehensive literature search was conducted in Web of Science, Embase, PubMed and Scopus up to May 10, 2025, to identify comparative studies of HoLEP and RASP in BPH patients. The methodological quality of the included studies was systematically evaluated using the Newcastle-Ottawa Scale (NOS), a validated tool specifically designed to assess the risk of bias in observational studies. Eleven studies involving 1,772 patients (1,247 HoLEP; 525 RASP) met inclusion criteria. Both techniques demonstrated comparable efficacy in functional outcomes, including maximum urinary flow rate, post-void residual volume, International Prostate Symptom Score (IPSS), and quality of life (QoL). However, HoLEP exhibited superior efficiency metrics: Reduced estimated blood loss : 105.01 mL (p < 0.005); Shorter catheterization time : 4.36 days (p < 0.00001); Lower transfusion risk : 32% reduction (p = 0.02) Operative time and postoperative complications showed no significant differences between groups. HoLEP and RASP are equally effective for managing large prostates. HoLEP offers advantages in minimizing blood loss, catheter duration, and transfusion rates, while RASP benefits from procedural ease in robotic-equipped facilities. Optimizing outcomes requires addressing disparities in technique adoption, enhancing surgical training, and aligning with evidence-based guidelines. Future high-quality randomized trials are warranted to refine personalized decision-making for clinicians and patients.