Current Urology Reports (2018) 19: 71

https://doi.org/10.1007/s11934-018-0820-1

BENIGN PROSTATIC HYPERPLASIA (K MCVARY, SECTION EDITOR)

Comparison of Robot-Assisted Versus Open Simple

Prostatectomy for Benign Prostatic Hyperplasia
Ankur A. Shah1 & Jeffrey C. Gahan2 & Igor Sorokin3

Published online: 12 July 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review Recent advancements in minimally invasive approaches for prostate surgery have provided numerous
options for surgical management of benign prostatic hyperplasia (BPH). In the setting of a large prostate, an open simple
prostatectomy was previously considered the gold standard surgical treatment. However, the recently updated American
Urological Association (AUA) guidelines on surgical management of BPH now consider both open and minimally
invasive approaches to simple prostatectomy viable alternatives for treating large glands, depending on expertise with the
techniques. The purpose of our review is to discuss the minimally invasive robot-assisted approach and compare it to the
classic open approach to simple prostatectomy.
Recent Findings Despite longer operative times, the robotic approach is associated with shorter hospital stay and lower
morbidity profile. The morbidity of an open approach remains significant. Blood transfusions are 3–4 times as likely
compared to a robotic approach and major complications are twice as likely. Consistent with previous literature, our
review shows functional outcome improvements like flow rate and symptom score to be comparable between the robotic
and open approach. The amount of adenoma resected and PSA decline is also similar among robotic and open cases.
Summary Robot-assisted simple prostatectomy is a safe and effective procedure for BPH secondary to a large prostate
gland. Appropriately, it is no longer deemed “investigational” by the latest AUA guidelines on BPH and recommended as
an alternative to the open approach.

. . . .
Keywords RASP OSP Simple prostatectomy Robotic simple prostatectomy BPH

Introduction urgency, daytime frequency, and sensation of incomplete

emptying. Because of the increasing prevalence of these
Benign prostatic hyperplasia (BPH) adversely affects the symptoms in the aging population due to BPH, the
qual-ity of life in men throughout the world. An estimated 1.1 American Urological Association (AUA) has guidelines
billion men suffer from BPH and its associated symptoms. [1] for both medical and recently updated surgical
The proliferation of prostatic smooth muscle and epithelial management of BPH. [2, 3••]
cells can lead to lower urinary tract symptoms (LUTS), which Medical management of BPH primarily revolves around
include storage and voiding symptoms such as nocturia, alpha-blockers and 5α-reductase inhibitors, whether it be
single-drug therapy or the combination. [2] Clinicians should
This article is part of the Topical Collection on Benign Prostatic consider surgical intervention when patients complain of
Hyperplasia moderate-to-severe LUTS not sufficiently treated by medica-
tion or any BPH-related structural changes in the urinary sys-
* Igor Sorokin
tem. Recommendations for surgery, as stated by the AUA
igsorokin@gmail.com
guidelines, include renal insufficiency, refractory urinary re-
1 tention, recurrent urinary tract infections (UTIs), recurrent
Division of Urology, Albany Medical Center, Albany, NY, USA
2 bladder stones or gross hematuria, and/or LUTS refractory to
Department of Urology, UT Southwestern Medical
Center, Dallas, TX, USA medical therapies. [3••]
3 Recent advancements in minimally invasive approaches
Department of Urology, University of Massachusetts, 119
Belmont St, Worcester, MA 01605, USA for prostate surgery have provided numerous options for
71 Page 2 of 8
surgical intervention. Prostate size is typically the determinant
factor for the type of treatment patients receive. [3••]
Transurethral resection of the prostate (TURP) remains the
historical standard for comparison of treatments for BPH and
is recommended for small and average size glands. Surgeons
versed in bipolar TURP have shown excellent re-sults in
prostates > 60 grams (g). Newer laser therapies such as
holmium laser enucleation of the prostate (HoLEP) or thulium
laser enucleation of the prostate (ThuLEP) are now considered
prostate size-independent options. However, not all providers
have access to or are sufficiently trained in these modalities.
Therefore, simple prostatectomy is still a proven and recom-
mended option in patients with large glands. The classic min-
imal size to recommend a simple prostatectomy has been > 80
g [2]; however, the updated AUA guidelines no longer
recommend a specific size cutoff for large glands as large is a
relative term. [3••]
The open approach to simple prostatectomy (OSP) has
classically been regarded as the standard of care for large
glands due to the beneficial long-term functional out-
comes after surgery and greater volume of adenoma re-
moved. [2, 4, 5] However, because OSP is often cited to
have higher estimated blood loss (EBL), higher rates of
transfusions, and longer length of stay (LOS), minimally
invasive prostatectomy has increasingly been pursued, and
notably, OSP cases have been decreasing as reflected by
national trends. [6, 7] Laparoscopic simple prostatec-tomy
(LSP) is considered equivalent to OSP in terms of
functional outcomes [8, 9], but a purely laparoscopic
approach is considered technically difficult and the steep
learning curve has prevented wider acceptance among
urologists. [10] On the other hand, robot-assisted simple
prostatectomy (RASP) has become a common substitu-tion
for OSP in urologic patients due to the routine use of
robot-assisted surgery for radical prostatectomy. The
increased comfort of urologic surgeons in performing
robot-assisted prostate surgery coupled with the de-creased
transfusion rates in RASP, makes the transition to robotic
surgery the expected next step in treating large volume
BPH [11•].
The previous AUA guidelines on management of BPH
published in 2011 considered RASP as investigational
owing to the relative lack of evidence supporting this
surgical approach. [2] The updated surgical management
guidelines recently published in 2018 now recommend all
approaches (open, laparoscopic, and robotic) to simple
prostatectomy, depending on the surgeon’s expertise with
the technique. [3••] Hence, there is no longer a true single
gold standard to managing bothersome LUTS in large
glands. However, the guidelines do not go into further
details on comparing the techniques, specifically the ro-
botic compared to the open approach. The goal of this
report is to provide a review of the literature on both
Curr Urol Rep (2018) 19: 71
RASP and OSP so that their functional peri- and post-
operative outcomes may be compared. While there are
certainly other effective minimally invasive treatments for
large glands such as HoLEP that have been directly
compared to RASP [12, 13], our intent was to narrow the
focus to simple prostatectomy in this era of expansion of
robotic surgery.
Comparison of Surgical Approaches
Open simple prostatectomy is classically performed by either
the retropubic or suprapubic approach. The suprapubic pros-
tatectomy, described by Eugene Fuller in 1894 and popular-
ized by Peter Freyer in 1900, is performed either by a
vesicocapsular incision (Freyer’s procedure) or only with a
longitudinal bladder incision (modified Freyer’s proce-dure).
[14] Direct vision of the bladder and bladder neck are
afforded by this approach but the prostatic apex is difficult to
visualize. The retropubic OSP described in 1945 is performed
by a transverse capsular incision referred to as the Millin pro-
cedure and avoids entering the bladder. [15] While this tech-
nique has the advantage of better control of bleeding and
visualization of adenoma, concomitant bladder lithiasis or di-
verticula cannot be addressed.
Robotic simple prostatectomy can also be classified as ei-
ther involving a transcapsular or transvesical approach. The
first technical description of RASP was published by Sotelo
and colleagues in 2008. [16] They described a transperitoneal
approach that involved mobilizing the bladder to get to the
space of Retzius, followed by a horizontal cystotomy on the
anterior surface of the bladder to get to the prostate adenoma.
Several series have gone on to replicate this technique with
slight modifications. [17, 18] Other series have described a
transperitoneal, transvesical approach that does not require
mobilizing the bladder [10, 11•]. The transvesical approach
involves making a posterior cystotomy and using stay sutures
on the hemibladder for retraction. The extraperitoneal ap-
proach is an alternative method for performing RASP and
adopted from the approach to laparoscopic radical prostatec-
tomy. [19, 20] Although no comparative series between vari-
ous approaches have been reported, benefits of the
extraperitoneal approach include avoiding intra-abdominal
adhesions and compartmentalizing any potential hematoma or
urinoma.
Comparative Outcomes
Previous literature has combined laparoscopic and robotic
approaches into minimally invasive simple prostatectomy
(MISP) to compare to OSP. The largest comparative study
by Lucca et al. [21] was a meta-analysis which looked at
Curr Urol Rep (2018) 19: 71
27 studies that included 764 patients. After an extensive
analysis, the authors concluded that MISP, while taking
longer, offered similar improvements in maximum flow
rate (Qmax) and International Prostate Symptom Score
(IPSS) as the open approach. However, MISP was noted to
have less blood loss and shorter hospital stay. Parsons et al.
[6] looked at the nationwide inpatient sample (NIS) from
1998 to 2010 and compared 6027 patients that underwent
OSP to 193 MISP cases. While some non-significant
trends were noted, the overall results showed MISP
showed no difference compared to OSP.
Only two studies in the literature provide a direct compar-
ison of RASP versus OSP. Hoy et al. [22] were the first to
retrospectively describe four cases of RASP compared to 28
OSP cases from 2011 to 2013 in a Canadian academic center.
While limited by a small sample size, the authors found that
RASP was associated with a shorter hospital stay (2.3 vs.
5.5 days, p < 0.001), lower EBL (218.8 vs. 835.7 mL, p <
0.001), but a higher operative time (161 vs. 79 mins, p <
0.008) compared to OSP. The authors concluded that RASP
deserved further investigation and consideration at Canadian
centers performing robotic prostatectomies. Sorokin et al.
[11•] retrospectively reviewed 167 simple prostatectomy
cases over a 5-year period at a single institution. After 1:1
propensity score matching to reduce selection bias, 59 RASP
cases were compared to 59 OSP cases. Similar to the
comparative study described earlier, these authors found
shorter hospital stay (1.5 vs. 2.6 days, p < 0.001), lower EBL
(339 vs. 587 mL, p < 0.001), but longer operative times (161
vs. 93 mins, p < 0.001) compared to OSP, respectively.
Functional outcomes were no different between the two tech-
niques and the authors concluded that RASP offers several
advantages over the open approach.
Despite the paucity of studies directly comparing the open and
robotic approach, there is an abundance of individual series on
RASP and OSP, respectively. Selected contemporary series [23–
30] with respect to peri- and post-operative out-comes are
described (Tables 1 and 2). We further explore the various
parameters to compare both approaches.
Operative Times
One of the most criticized aspects of the robotic approach is
the operative time. One RASP series reported a mean opera-
tive time of 274 min in 32 cases [13]. Compared to the longest
OSP series which reported a mean operative time of 126 min
[31], this is a significant downside to the robotic approach.
While the overall data demonstrate OSP has shorter operative
times on the order of 30 min to an hour, the increasing use of
robotic surgery in urology may continue to decrease the dis-
parity in operative times between RASP and the previously
established standard of OSP.
Page 3 of 8 71
Blood Loss and Transfusions
An important critique of OSP, as previously mentioned, is the
elevated blood loss for patients who undergo this procedure.
When looking at large national datasets [NIS], transfusion
rates after OSP were found to be 20.9% compared with 10.8%
for MISP. [6] That is, one in five patients that underwent OSP
received a transfusion. However, this 50% reduction for the
minimally invasive approach did not reach statistical
significance. Our review also found a disparity in transfusion
rates demonstrating that patients undergoing OSP were more
than three to four times as likely to receive a blood transfusion
as patients who underwent RASP. It is also impor-tant to note
that transfusion rates can vary among institutions, surgeons,
and patients based on local guidelines, personal preference,
and comorbidities. [22] Without predetermined criteria for
transfusion controlled in all patients in a given sample,
transfusion rates are variable. Regardless, the general trend
that OSP results in more perioperative blood loss is widely
accepted and consistent with our review of the litera-ture,
which suggests that RASP is likely superior with respect to
blood loss.
Hospital Length of Stay and
Length of Catheterization
One of the main advantages of a minimally invasive approach is a
decreased LOS. The NIS database comparing OSP and MISP
noted a median 2 days shorter LOS for MISP, but this difference
was not statistically significant. [6] Our review of the literature
demonstrates that the average LOS in the hospi-tal after RASP
was at least half that of patients who underwent OSP. While LOS
is certainly influenced by nonmedical factors such as local
practice patterns and patients’ social situations, operative
technique likely plays a major role. Although LOS was shorter,
length of catheterization (LOC) was similar in both RASP and
OSP. However, as Sorokin et al. [11•] suggest, RASP may, in
fact, have shorter LOC but patients’ hospital stays are too short to
remove the catheter at discharge, and thus, these patients have
their catheters removed at their out-patient follow-up visit,
increasing the LOC artificially. In con-trast, patients undergoing
OSP are typically in the hospital long enough to have their
catheters removed before discharge. Again, while LOC is
dependent to local practice patterns, it seems to be unaffected by
the type of procedure patients are undergoing based on our
review.
Adenoma Removal
All series included used a pre-operative criteria of
transrectal ultrasound-based (TRUS) prostate volume >
 71 Page 4 of 8
Table 1 Perioperative and postoperative patient outcomes among RASP vs. OSP series

Study Technique No. of cases Operative time (min) EBL (mL) Transfusion rate (%) LOS (days) LOC (days) TRUS volume (mL) Specimen Weight (g)

Sorokin et al. (2017) [11•] RASP 64 160.9 ± 32.4 327.9 ± 192.5 3.1% 1.5 ± 2 5.7 ± 2.6 136.2 ± 46.6 81.3 ± 36
Zhang et al. (2017) [13] RASP 32 274 ± 49 NR 9.4% 2.3 ± 2.3 8±2 NR 110 ± 44
Castillo et al. (2016) [18] RASP 34 96 (78–126) 200 (100–300) 5.8% 2 (1–4) 5 (4–6) 117 (99–146) 76 (58–100)
Pavan et al. (2016) [23] RASP 130 150 (98–180) 250 (127–450) NR 5 (5–6) 5 (4–6) 118.5 (100–140) 77 (58–101)
Umari et al. (2016) [12] RASP 81 105 (85–150) 250* 1.2% 4 (3–5) 3 (2–4) 130 (111–190) 89 (70–122)
Autorino et al. (2015) [24] RASP 487 154.5 (100–180) 200 (150–300) 1.0% 2 (1–4) 7 (5–9) 110 (86–140) 75 (52–101)
Pokorny et al. (2015) [25] RASP 68 97 (80–127) 200 (115–360) 1.5% 4 (3–5) 3 (2–4) 129 (104–280) 84 (65–114)
b
Leslie et al. (2013) [10] RASP 25 214 (165–345) 143 4.0% 4 (2–16) 9 (7–23) 149.6 (91–260) 88 (50–172)
Matei et al. (2012) [33] RASP 35 186 ± 38 121 ± 144 0.0% 3.2 ± 1.7 7.4 ± 2 106.6 ± 40.9 87 ± 38.5

Misrai et al. (2018) [26] OSP 204 67 (60–80) NR 8.3% 7 (6–7) 5 (5–6) 90 (80–120) 70 (50–90)
Sorokin et al. (2017) [11•] OSP 103 94.5 ± 16.7 596.7 ± 292.6 8.7% 2.7 ± 1.5 3.3 ± 3.5 147.3 ± 50.1 103.8 ± 49.1
Demir et al. (2016) [27] OSP 26 106.9 ± 29.9 531.5 ± 191.1 38.4% 7.2 ± 2.8 9.8 ± 2.6 140 ± 38.1 103.2 ± 33.7
Carneiro et al. (2016) [31] OSP 65 126.5 ± 36.1 1044.3 ± 619.7 3.9% 4.6 ± 2.2 NR 118.7 ± 52.1 NR
Ou et al. (2010) [28] OSP 34 109.5 ± 27.1 NR 11.8% 9.2 ± 3.4 7.5 ± 1.6 138.4 ± 35.3 116.8 ± 33.2
McCullough et al. (2009) [8] OSP 184 54.7 ± 19.7 400 (300–600) 10.2% 7.7 ± 2.4 6.4 ± 2.9 117.2 ± 42.2 NR
a
Alivizatos et al. (2008) [29] OSP 60 50 (45–60) NR 13.3% 6 (5–6) 5 (4–6) NR 73.5
Varkarakis et al. (2004) [5] OSP 232 NR NR 6.8% 6.0 ± 0.9 5.0 ± 0.9 104.5 ± 32.4 NR
Kuntz et al. (2002) [30] OSP 60 90.6 ± 19.5 NR 13.3% 10.5 ± 1.9 8.1 ± 0.8 113 ± 19.2 96.4 ± 36.4

Data are presented as mean ± SD or median (IQR)

RASP robot-assisted simple prostatectomy, OSP open simple prostatectomy, EBL estimated blood loss, LOS length of stay, LOC length of catheterization, TRUS transrectal ultrasound-based,
a b
NR not recorded; median; mean

Curr Urol Rep (2018) 19: 71

 Curr Urol Rep (2018) 19: 71
Table 2 Functional, PSA, and complications among the selected RASP vs. OSP series

Study Technique Pre-op Qmax (mL/s) Post-op Qmax (mL/s) IPSS pre-op IPSS post-op Pre-op PSA (ng/mL) Post-op PSA (ng/mL) Complications
(Clavien ≥ 3)

Sorokin et al. (2017) [11•] RASP 10.1 ± 6.8 22.4 ± 9.9 18.4 ± 8.1 7.3 ± 5.7 7.2 ± 5.8 0.9 ± 0.8 3.4%
Zhang et al. (2017) [13] RASP NR NR 24 ± 4* NR NR NR 3.1%
a a a
Castillo et al. (2016) [18] RASP 10.4 23.1 23.5 (22–27) 8 7.3 ± 9.5 NR 2.9%
Pavan et al. (2016) [23] RASP 9 (7–12) 22 (18–28) 23 (19–27) 5 (4–10) 6.1 (3.6–9.7) 2 (0.5–3.1) 2.3%
Umari et al. (2016) [12] RASP 8 (5–11) 23 (16–30) 25 (20–28) 5 (2–8) 7.05 (4.4–12.8) 1.09 (0.62–1.79) 10.0%
Pokorny et al. (2015) [25] RASP 7 (5–11) 23 (16–35) 25 (20.5–28) 3 (0–8) 6.5 (3.8–12) 0.6 (0–1.3) 9.0%
Autorino et al. (2014) [24] RASP 8 (5–11) 25 (20–33) 23 (18–27) 7 (4–9) 6.2 (3.7–11) 1.1 (0.6–1.9) 2.5%
b b
Leslie et al. (2013) [10] RASP 11.3 (4–20) 20 (12–35) 23.9 (9–35) 3.6 (0–6) 9.4 1.5 12.0%
Matei et al. (2012) [33] RASP 6.6 ± 4.6 18.9 ± 4.7 28 ± 7 7±2 5.44 ± 4.68 NR NR

Misrai et al. (2018) [26] OSP NR 27 (25–29) NR 6 (3.6–7) 5.9 (3.7–9) 0.5 (0.3–1.2) 11.2%
Sorokin et al. (2017) [11•] OSP 8.9 ± 5.0 20.7 ± 10.6 18.2 ± 6.5 6.9 ± 5.1 7.4 ± 4.8 0.7 ± 1.1 10.0%
Demir et al. (2016) [27] OSP 6.5 ± 2.4 21.6 ± 3.9 19.9 ± 5.5 7.1 ± 2.1 NR NR 0.0%
Carneiro et al. (2016) [31] OSP 4.3 ± 17 19.8 ± 11.2 25.1 ± 14.0 5.6 ± 5.4 NR NR 26.0%
Ou et al. (2010) [28] OSP 5.0 ± 2.7 14.5 ± 2.6 23.1 ± 5.4 6.2 ± 1.0 NR NR NR
McCullough et al. (2009) [8] OSP NR NR NR NR NR NR 1.2%
Alivizatos et al. (2008) [29] OSP 8 (5.8–10.2) 15.6 (12.8–17.1) 21 (16.2–23.7) 9 (7–12) 6.3 (2.9–8.6) 2 (1.2–2.6) 5.0%
Varkarakis et al. (2004) [5] OSP 7.2 ± 1.8 24.2 ± 3.7 24.9 ± 4.8 1.7 ± 1.7 5.4 ± 3.9 NR NR
Kuntz et al. (2002) [30] OSP 3.6 ± 3.8 26.6 ± 6.1 21 ± 3.6 5.0 ± 2.3 NR NR 10%

Data are presented as mean ± SD or median (IQR)

RASP obot-assisted simple prostatectomy, OSP open simple prostatectomy, Qmax maximum flow rate, IPSS International Prostate Symptom Score, PSA prostate-specific antigen, NR not
a b
recorded; median; mean

Page 5 of 8 71
71 Page 6 of 8
80 mL for both OSP and RASP cohorts and therefore are
appropriately comparable. Likewise, pre-operative PSA
values ranged from 5 to 7 ng/mL in both approaches. Post-
operative specimen weights were about equal in both
approaches, ranging from 75 to 110 g in RASP series and
70–117 g in OSP series. Specimen weight of course de-
pends on the timing of weighing the specimen and may
differ if weighed immediately after specimen removal or
by pathology report. Post-operative prostate-specific anti-
gen (PSA) may be used as a surrogate of adenoma remov-
al, and by this criteria, RASP and OSP are equally com-
parable with similar ranges of PSA decline seen in both
approaches. As most of the RASP series were published in
the last few years, it is premature to compare retreatment
rates, although this will be an interesting var-iable in long-
term studies.
Functional Outcomes
Functional outcomes are comparable between both ap-
proaches. Maximum flow rate (Qmax) showed a median
14 mL/s for RASP vs. a mean improvement of 15 mL/s for
OSP post-operatively. Very rare reports of incontinence
post-operatively are also noted in both approaches. IPSS
also showed similar improvements among both robotic and
open approaches with average reporting of mild symptoms
after surgery compared to severe pre-operatively. These
findings are consistent with the previous literature
comparing the two approaches.
Complications
The morbidity associated with OSP was a major catalyst that
spurred the search for alternative procedures to treat large
gland BPH, such as RASP. In our review, major
complications (Clavien ≥ 3) were almost double in OSP
(10.6%) compared to RASP (5.6%). Series that report detailed
complications of-ten report severe bleeding, clots requiring
intervention, and bladder neck/urethral stricture as the most
common types of complications after simple prostatectomy.
Parons et al. [6] performed a unique comparison of mor-
bidity among OSP and MISP by looking at patient safety
indicators (PSIs) as established by the Agency for
Healthcare Research and Quality (AHRQ). These quality
measures assess complications of anesthesia, postoperative
respiratory failure, and pulmonary embolus, among others.
Their review showed that both approaches were safe as
they showed relatively a low incidence of preventable
adverse safe-ty events. Despite the low frequency, room
for improvement still remains in simple prostatectomy
especially in improving processes for post-operative care.
Curr Urol Rep (2018) 19: 71
Cost
Cost is another controversial topic when discussing robotic
approaches to established urologic procedures such as OSP.
Sutherland et al. [32] noted that RASP added an additional
$2797 to the operating charges compared to OSP. However,
Matei et al. [33] have shown RASP can be cheaper overall
when factoring in the cost of hospitalization, transfusion rates,
and need for continuous bladder irrigation (CBI). The addi-
tional social impact (i.e., savings from convalescence and
back-to-work time) of robotics may be superior as well but
cannot be quantified. Furthermore, Pariser et al. [7] noted
significantly higher mean inflation-adjusted hospital charges
if patients experienced a complication ($51,295) vs. those
who did not ($32,305) after simple prostatectomy using the
NIS database.
Robotic surgical instruments represent an essentially
fixed cost that contributes to a significant portion of
operative costs. [34] Innovative instrument use can be
utilized in robotic sur-gery to drive down costs such as
using one instrument for dual purposes (i.e., a mega needle
driver can be used as both a needle driver and a retractor in
RASP). Since most instru-ments have 10 lives and cost
$2500, a savings of $250 per case can be estimated if a
dedicated grasper/retractor is not additionally used. Future
studies directly comparing costs are warranted.
Learning Curve
The learning curve for OSP has not been previously compared
to RASP. Recently, a prospective, randomized series from
Brazil comparing 65 consecutive patients undergoing
suprapubic or retropubic prostatectomy during a resident’s
learning curve was described. [31] The two techniques were
all performed by first- or second-year residents but supervised
by senior surgeons and compared in terms of surgical morbid-
ity and functional outcomes. The mean EBL for the series was
1044 mL, higher than most OSP series and explained by the
fact that residents performed the procedures at the beginning
of their learning curve. There was also a high major compli-
cation rate with 26% being Clavien 3–4. Furthermore, 15.4%
of patients required some re-endoscopic surgical intervention,
50% for clot evacuation. Functional outcomes, which includ-
ed IPSS (5.56) and Qmax (19.8 mL/s), are comparable to
other OSP series. Although a specific number for learning
curve was not described, OSP is associated with higher mor-
bidity in one’s early experience.
RASP has been growing in popularity as it is considered
easier to adopt because of the familiarity with robotic surgery,
especially radical prostatectomy. [35] An abstract presented at
the 2017 World Congress of Endourology in Vancouver, BC,
attempted to describe the learning curve for RASP among two
Curr Urol Rep (2018) 19: 71
surgeons. [36] Variables of interest, which included EBL, op-
erative times, PSA reduction, and percentage tissue yield were
plotted along their respective, consecutive cases and a loga-
rithmic best-fit line was used to analyze the learning curve.
All factors considered together, a learning curve of 5–10 cases
was observed graphically. This is of course data from two
highly experienced robotic surgeons commonly performing
radical prostatectomies. The learning curve for novice robotic
surgeons would be intriguing and desirable for future studies.
Conclusion
For men with large prostates, RASP is a valuable alternative
to OSP. Men undergoing RASP have similar functional out-
comes such as flow rates and symptom score improvement
when compared to OSP. Despite longer operative times, pa-
tients undergoing RASP are shown to have a shorter hospital
stay and lower morbidity profile. This is evidenced by both
direct comparative studies and a number of individual RASP
series that have been published after the older AUA
guidelines in 2011. Therefore, RASP is a safe and effective
alternative to OSP and appropriately no longer deemed
“investigational” by the latest AUA guidelines on BPH. While
further studies are needed on cost analysis and learning curve,
it is evident that RASP will be increasingly implemented over
OSP in centers with established robotic programs. Still,
surgical management of large prostates should be
individualized based on surgeon’s expertise, patient’s
comorbidities, and availability of the technology.
Compliance with Ethical Standards
Conflict of Interest Ankur A. Shah, Jeffrey C. Gahan, and Igor
Sorokin each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects
performed by any of the authors.
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