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Simple Prostatectomy (Open / Laparoscopic / Robotic)

Simple prostatectomy is the surgical enucleation of the prostatic adenoma — the most durable BPH operation, typically reserved for large prostates (> 80 g). Approaches include open transvesical (Freyer), open retropubic (Millin), laparoscopic, and robotic-assisted (transvesical / transcapsular / urethra-sparing Madigan; multiport or single-port). It produces the greatest magnitude of symptom improvement (IPSS reduction 14–22 points) and the lowest long-term retreatment rate (~ 1.3% at 1 yr, ~ 4.4% at 5 yr) of any BPH operation.[1][2][3]

For positioning vs HoLEP, MISTs, and TURP, see BPH & Male LUTS — chooser.

Indications​

Generally > 80 mL (some guidelines > 80–100 mL).[4][1][5] Specific indications:

  • Bothersome LUTS refractory to medical management
  • Urinary retention from prostatic obstruction
  • Recurrent UTI from incomplete bladder emptying
  • Bladder stones or large diverticula (can be addressed concomitantly — favors transvesical)
  • Renal insufficiency from BOO
  • Recurrent gross hematuria from BPH[1][6]

The AUA recommends simple prostatectomy or endoscopic enucleation (HoLEP / ThuLEP) as the treatment of choice for BPO from large glands.[7][5]

Open techniques — Freyer vs Millin​

Transvesical (Freyer, 1900)Retropubic (Millin, late 1940s)
ApproachBladder opened; finger enucleation through bladder neckCapsular incision (transcapsular); direct adenoma exposure
Best whenConcomitant bladder pathology (diverticula, stones)Standard adenoma without intravesical pathology
BleedingMore — median EBL 640 mL vs 362 mL (p = 0.007)Less — improved visualization of bleeding points[8]
Stress UIHigherLower
Urethral divisionLess preciseMore accurate

Modern minimally invasive​

  • Laparoscopic simple prostatectomy (LSP) — extraperitoneal Millin or transvesical. Reduced blood loss, shorter catheter and LOS vs open; advanced laparoscopic skills required.[9][10][11]
  • Robot-assisted simple prostatectomy (RASP) — most rapidly growing approach. Available with multiport and single-port (SP) platforms. RASP grew from near-zero to a meaningful share of simple prostatectomies in Germany 2013–2023 while open declined.[12][13][14][15]

Modern RASP techniques — step by step​

1. Transvesical (Freyer) RASP — multiport​

Most widely described multiport technique.[29][30][31]

  • Positioning / ports — steep Trendelenburg, transperitoneal access. "W"-configuration ports (4 × 8-mm robotic + 1–2 assistant). da Vinci Si / Xi docked four-arm.
  • Bladder detachment + cystotomy — bladder mobilized off anterior abdominal wall; longitudinal anterior cystotomy exposes bladder neck and adenoma. Keith needles through abdominal wall can retract bladder edges.[29]
  • Adenoma enucleation — circumferential mucosal incision around adenoma; sharp + blunt dissection in the plane between adenoma and surgical capsule, bladder neck → apex; urethra divided at apex.
  • Hemostasis — selective coagulation of bladder-neck vessels at 5 and 7 o'clock.
  • Trigonization + closure — running 2-0 Polysorb or barbed suture advances bladder mucosa over the prostatic fossa to reduce raw surface area; cystotomy closed in 2 layers; Foley + water-tightness test.[29]
  • Specimen retrieval — through optical-port incision or Endo Catch.

2. Transcapsular (Millin) RASP — multiport​

Mirrors the open Millin; avoids entering the bladder.[31][16][30]

  • Retropubic-space development — Retzius space developed and endopelvic fascia exposed, mirroring radical-prostatectomy initial steps (key advantage for surgeons experienced in robotic RP).[31]
  • Capsulotomy — transverse incision on the anterior prostatic capsule, distal to the bladder neck.
  • Adenoma enucleation — sharp + blunt dissection within the capsule from capsulotomy → apex.
  • Closure — capsulotomy closed with running suture; some surgeons perform a vesicourethral anastomosis as in radical RP.

3. Urethra-sparing (Madigan) RASP — designed for ejaculatory-function preservation​

Most technically innovative variant.[32][33]

  • Transcapsular access.
  • Urethral identification with ICG + near-infrared fluorescence — Simone / Misuraca 2019 retrograde injection of indocyanine green through the Foley illuminates the prostatic urethra under da Vinci Firefly; the surgeon dissects around the fluorescent urethral tube.[32]
  • Selective lobe enucleation rather than en-bloc — each lobe peeled off the urethra circumferentially while preserving the urethra and ejaculatory ducts.
  • Porpiglia 2021 Eur Urol larger series (n = 92): full urethral sparing 61%, partial 23%, conversion to standard Millin 16%. 81% maintained anterograde ejaculation at 12 mo in patients with preoperative ejaculation.[33]
  • Original Simone ICG-guided cohort: 66% satisfactory anterograde ejaculation at 12 mo.[32]

4. Single-port (SP) transvesical RASP​

The da Vinci SP platform enables a truly intravesical approach through a single small incision.[34][14]

  • Access — 3-cm suprapubic incision; bladder entered; SP arm docked directly into the bladder lumen; camera + 3 articulating instruments emerge from a single cannula.
  • Enucleation — adenoma enucleated from within the bladder under direct visualization of the bladder neck and prostatic fossa.
  • 360° mucosal flap reconstruction — bladder mucosa advanced and sutured circumferentially to the urethral stump, covering the entire raw fossa. Eliminates need for continuous bladder irrigation and reduces postoperative bleeding and irritative symptoms.[34][35]
  • Ramos 2024 Eur Urol (n = 117, 1-yr FU): median console 107 min, EBL 100 mL, 0% transfusion, 95.8% discharged within 24 h (median LOS 5 h), no major complications, median catheter 5 d, durable IPSS / Qmax at 1 yr.[34]

5. Novel approaches​

  • Trans-Douglas (Retzius-sparing) RASP — De Concilio 2018: posterior peritoneal approach preserving the bladder neck; case series with 80 mL EBL, catheter d4, IPSS 30 → 8.[36]
  • Intrafascial RASP — Poncel 2023: dissection between prostatic capsule and surrounding fascia preserving NVBs; successfully applied to a 470 g prostate with IPSS 34 → 3 and preserved EF (SHIM 23).[37]
  • Hugo RAS platform — Piro 2023 first large series (n = 20): median OR 165 min, catheter removal POD1 in 80%, median LOS 3 d.[38]

RASP technique comparison​

ParameterTransvesical (MP)Transcapsular (MP)Madigan (urethra-sparing)Single-port TV
Console time (min)91–16071150107
EBL (mL)100–200200250100
Transfusion rate0–2.5%0–2.5%—0%
Catheter duration (d)6.7–84.375
LOS (d)4–6535 hours
Same-day dischargeRareRareRare48–96%
Ejaculation preservation~ 10%~ 10%66–81%—
Major complications4.5–12.5%3.3%2%0%
Best fitBladder pathologySurgeon familiarity (robotic-RP background)Sexually active menEnhanced recovery / same-day pathway

References: transvesical / multiport general[29][30][31]; transvesical-vs-transcapsular[16]; Madigan[13][32][33]; SP transvesical[14][34].

360° Circumferential Mucosal Flap Reconstruction​

The 360° circumferential mucosal flap reconstruction is a key technical innovation in transvesical RASP that covers the entire raw prostatic fossa with bladder mucosa, eliminating exposed capsular surface area and thereby reducing postoperative bleeding, the need for continuous bladder irrigation (CBI), and irritative symptoms.[35][34] It is an evolution beyond traditional "trigonization" and has become the standard reconstruction in single-port transvesical RASP.

Concept and rationale​

After enucleation, the prostatic fossa is a large, raw, vascularized cavity lined by the surgical capsule. Two reconstruction strategies have been used historically:

ApproachWhat it doesTrade-off
Trigonization (traditional)Bladder mucosa advanced and sutured only at the posterior bladder neck (trigone area), covering a limited portion of the fossaRaw capsular surface remains exposed → managed with electrocautery + postop CBI[29]
360° mucosal flap reconstructionBladder mucosa circumferentially advanced and sutured to the distal urethral stump, completely covering the entire prostatic fossaEliminates raw surface, minimizes electrocautery, removes need for CBI[35]

The rationale: exposed raw capsular surface drives postoperative bleeding and irritative symptoms. Covering it entirely with mucosa addresses both problems simultaneously.[35][46]

Step-by-step technique (Cacciamani 2018)​

The original 23-patient description:[35]

  1. Adenoma enucleation — standard transperitoneal transvesical approach; sharp + blunt dissection from bladder neck → apex.
  2. Hemostasis of the fossa — selective coagulation of active bleeders only; minimize cautery (excessive cautery contributes to postop irritative symptoms and delayed healing).
  3. Initiation of the mucosal flap — first suture at the 9 o'clock position on the prostatic fossa using 2-0 barbed (V-Loc) suture to approximate bladder-mucosa edge to urethral stump.
  4. Counter-clockwise circumferential closure — running suture from 9 o'clock → 6 o'clock (posterior) → 3 o'clock (contralateral) → 12 o'clock (anterior). At each point bladder mucosa is advanced and approximated to the corresponding urethral edge.
  5. Completion — full mucosal-to-mucosal anastomosis encircling the entire fossa, analogous to a vesicourethral anastomosis in radical prostatectomy. Raw capsular surface entirely covered.
  6. Cystotomy closure — anterior cystotomy closed in 2 layers; Foley + water-tightness test.

Modified vesicourethral anastomosis (Coelho 2012)​

An earlier related technique combined three reconstructive steps:[46]

  1. Posterior capsular plication — running suture to reduce dead space and approximate posterior bladder neck to the urethra.
  2. Modified van Velthoven vesicourethral anastomosis — continuous running suture circumferentially.
  3. Anterior capsular closure — anterior prostatic capsule sutured to anterior bladder wall.

Initial 6-patient series: 0% transfusion, 0% CBI, mean EBL 208 mL, all discharged POD 1.[46]

Application in single-port transvesical RASP​

The 360° mucosal flap is the defining reconstructive step of SP-RASP — the SP platform's articulating instruments working within the bladder provide ideal visualization for this reconstruction:[34][47][48]

  • After enucleation, bladder-mucosal edges mobilized circumferentially; mucosa advanced as a vesicourethral mucosal advancement flap sutured to the urethral stump using barbed suture.
  • Abou Zeinab 2022 J Endourol — refined flap technique reduced median catheter from 7 d → 3 d in the last 19 consecutive patients.[47]
  • Ramos 2024 Eur Urol (n = 117): 360° reconstruction in all cases; no routine CBI or drains; 0% transfusion, 95.8% discharged within 24 h (median LOS 5 h), no major postoperative complications.[34]

360° reconstruction vs traditional trigonization​

No head-to-head RCT exists, but the available data show meaningful differences:

Parameter360° mucosal flapTraditional trigonization
CBI requiredNoYes (typically)
EBL (mL)99–100200
Transfusion rate0%0–2.5%
LOS2.1 d / 5 h (SP)4–6 d
Catheter duration (d)3–5 (SP)7–8
Same-day discharge92–96% (SP)Rare
Postoperative hematuriaMinimalMore common
Irritative symptomsReducedMore common

References: Cacciamani 2018[35], Ramos 2024[34], Chavali 2018[29], Coelho 2012[46], Abou Zeinab 2022 J Endourol[47], Abou Zeinab 2022 J Urol[14].

Cockrell / Lee bladder-edge-to-apical-margin variant​

A related but distinct approach in transcapsular RASP — bladder edge sutured to the distal apical prostate margin (rather than the urethral stump), mirroring the radical-prostatectomy anastomosis. Reported to greatly reduce postoperative hematuria without requiring full 360° mucosal advancement.[31]

Open-surgery parallel — modified bladder-neck repair without CBI​

The mucosal-coverage concept has been validated in open simple prostatectomy. Okorie 2010 — n = 43 standard hemostasis + CBI vs n = 39 modified bladder-neck repair without CBI: significantly fewer clot-retention events (2 vs 11, p = 0.01) and no bladder-wall disruptions, confirming that meticulous mucosal reconstruction can safely eliminate CBI even in the open setting.[49]

Technical pearls and pitfalls​

  • Barbed suture (2-0 V-Loc or similar) maintains tension without knot-tying — essential for continuous running closure in a confined space.[35]
  • Mucosal mobility — bladder mucosa must be adequately mobilized from the underlying detrusor for tension-free advancement to the urethral stump; insufficient mobilization risks pull-through or incomplete coverage.
  • Urethral stump identification — clear identification of the distal urethral stump is critical; in SP-RASP, the intravesical vantage gives excellent apical visualization.
  • Posterior wall first — some surgeons start at 6 o'clock where the mucosa is thickest and the trigone is a robust anchor, then proceed anteriorly.
  • Avoiding the ureteral orifices — care during posterior mucosal advancement to avoid incorporating or kinking the orifices, particularly with intravesical prostatic protrusion that distorts the trigone.

The 360° mucosal flap transforms the prostatic fossa from a raw bleeding cavity into a mucosal-lined channel — eliminating CBI, reducing bleeding and irritative symptoms, enabling same-day discharge, and shortening catheterization. It is the single most recovery-optimizing technical refinement in modern simple prostatectomy.[35][34][47][46]

Comparative outcomes — RASP vs OSP / LSP / HoLEP​

Pandolfo 2023 SR/meta of 6,659 patients across 15 studies:[7]

ParameterRASP vs OSPRASP vs LSPRASP vs Laser EEP
OR timeLongerSimilarSimilar (ThuLEP shorter)
EBLLowerSimilarSimilar
Transfusion rateLowerSimilarHigher
LOSShorterShorter for LSPLonger
Catheter durationShorterSimilarLonger
ComplicationsLowerSimilarSimilar
IPSS / QmaxEquivalentEquivalentEquivalent

Pyrgidis 2025 German nationwide analysis (n = 46,234) — RASP and LSP had transfusion rates of 6.5–7.3% vs OSP 13%, lower urinary retention rates, and shorter LOS than open.[15]

Benarroche 2022 single-center RASP vs OSP: blood loss 200 vs 400 mL, LOS 5 vs 10 d, catheter 4 vs 9 d, Grade ≥ 2 complications 4.3% vs 23.2% (p = 0.005) — identical functional outcomes at 12 mo.[17]

vs HoLEP for prostates > 80 cc​

The most clinically relevant comparison since both are guideline-recommended for large glands.

Lee 2023 head-to-head:[18]

HoLEPOSPRASP
OR time (h)1.42.73.8
LOS (d)0.654.22.6
Catheter (d)0.389.911.2
EBL (mL)66795326

Benzouak 2025 SR/meta + Grosso 2024 propensity-matched + Palacios 2023 SP-RASP-vs-HoLEP + Glucksman 2026 single-center MP-vs-SP-vs-HoLEP synthesis:[39][40][41][42]

ParameterRASPHoLEPp
OR time~ 50 min longershorter0.001
EBL (mL)200–326660.001
Transfusion ratehigher (1.87× risk)75% lowersig
Catheter duration (d)5–110.4–30.001
LOS (d)2.6–50.65–4variable
Same-day discharge (SP-RASP vs HoLEP)48%8%0.01
IPSS / QmaxequivalentequivalentNS
Transient stress incontinence5–8% (SP-RASP)20–30%0.01
Antegrade ejaculation (propensity-matched)55%7%0.05
Trifecta rate83%76%NS
Grade ≥ 3 complications3.41× higher (RASP)lowersig
% adenoma removed57%51%NS

Key takeaways:

  • Functional outcomes (IPSS / Qmax / PVR) are equivalent across all studies and meta-analyses.[39][43]
  • HoLEP advantages — ~ 50 min shorter OR time, ~ 3.8 d shorter catheter, ~ 1.5 d shorter LOS, lower EBL, 75% lower transfusion risk, lower complication rate.[39]
  • RASP advantages — significantly lower transient SUI (5–8% vs 20–30%), significantly better ejaculatory preservation (55% vs 7% antegrade in propensity-matched data), and higher same-day-discharge rates with SP-RASP.[40][41]
  • Learning curve — RASP has a shorter learning curve (steps mirror robotic radical prostatectomy, which most robotic surgeons already perform). HoLEP has a notoriously steep learning curve (50–100+ cases for proficiency), which limits its adoption.[7][39]
  • SP-RASP specifically — preferred for unfavorable urethral access, large bladder-stone burden, or bladder diverticula requiring concomitant repair.[41]

The Hinojosa-Gonzalez 2026 Bayesian network meta comparing all RASP variants vs enucleation found no significant differences in overall complication rates and similar improvements in flow rates. SP-TV-RASP had the highest ranking for IPSS improvement and lowest incontinence rates, though the differences were not statistically significant.[43]

RASP vs Aquablation​

Single-institution comparison of n = 172 (111 Aquablation, 61 SP-RASP) for prostates > 80 mL — Gangwish 2025:[44]

  • Aquablation advantages — lower transfusion rates (OR 4.22 favoring Aquablation), shorter LOS (by 1.7 d), shorter OR time (by ~ 119 min).
  • Simple prostatectomy advantages — better 1-yr IPSS (β = −3.4, p = 0.005), lower retreatment rates (OR 0.46, p = 0.019), less postoperative alpha-blocker use (p = 0.001).
  • QoL and adverse-event rates comparable.

The WATER II 5-yr trial (Aquablation for 80–150 mL prostates) showed freedom from retreatment 96.3%, IPSS reduction 15.9 points, Qmax improvement 9.2 mL/s.[45] Aquablation is currently limited to prostates ≤ 150 mL, whereas RASP has no upper size limit — cases up to 470 g have been reported.[37]

Clinical efficacy​

OutcomeSimple prostatectomy
IPSS improvement−14 to −22 points at 8–40 mo
Qmax improvement+12 to +22 mL/s at 8–40 mo
Postop IPSS (RASP)Median 3–5
Postop Qmax (RASP)21–23 mL/s
Time to maximal improvement~ 3 mo, stable through ≥ 36 mo

In Lee 2020 (n = 150 RASP, 31-mo mean), IPSS and QoL maximal by 3 mo and stable through ≥ 36 mo, with no bladder neck contractures and no reoperations for LUTS.[19]

Durability and retreatment​

Simple prostatectomy has the lowest retreatment rate of any BPH procedure.

  • Gilfrich 2021 (German n > 43,000, 5-yr FU): open simple prostatectomy HR 0.43 for reintervention vs TURP.[2][3]
  • Eredics 2018 Austrian nationwide — 8-yr re-TURP rate 4.3% after open prostatectomy vs 8.3% after primary TURP.[20]
  • At 5 years, 95% of simple prostatectomy patients remain non-obstructed and subjectively satisfied.[21]

Complications​

Perioperative

  • Blood loss / transfusion — the dominant concern with open. OSP EBL 400–800 mL, transfusion 11–16%; RASP EBL 100–200 mL, transfusion 0–7%.[15][17][22][23]
  • Mortality — < 1%.[6][20]
  • Overall complication rate — 30% with RASP (mostly Clavien I–II); 4.5% Clavien IIIb in one series.[12]
  • DVT / PE — rare but reported.[23]

Postoperative

  • Bladder neck contracture — 0–3.3%.[19][24]
  • Urethral stricture — 0.6–1.3%.[24]
  • Stress urinary incontinence — 0–20% transient; 3–8% persistent.[1][23]
  • UTI — variable.

Sexual function​

  • Retrograde ejaculation 80–90% — most common sexual side effect; similar to TURP.[1]
  • De novo ED 3–5%.[1]
  • Madigan urethra-sparing RASP preserves sexual function significantly better than Millin or Freyer (IIEF + MSHQ at 1 yr) — likely from avoiding bladder-neck and ejaculatory-duct manipulation.[13]
  • Sexual desire and overall satisfaction generally preserved; orgasm and ejaculation commonly affected.[25]

Impact on subsequent radical prostatectomy​

Creta 2024 SR/meta (n = 11,101) — prior BPH surgery (including simple prostatectomy) is associated with:[26]

  • Higher positive surgical margin rate (OR 1.39)
  • Lower continence at 3 mo and 1 yr (OR 0.48 and 0.44)
  • Lower erectile function recovery at 1 yr (OR 0.60)

after subsequent radical prostatectomy for prostate cancer. Counsel the patient.

Salvage simple prostatectomy after failed prior procedures​

RASP works in the salvage setting after failed transurethral procedures. Pathak 2023 — n = 520 (87 / 16.7% with prior TURP, PVP, TUMT, UroLift, or Rezūm) — perioperative outcomes and functional improvement equivalent between primary and salvage RASP.[27][28]

Advantages and limitations​

Advantages

  • Most durable BPH operation; lowest retreatment rate
  • Greatest magnitude of symptom and flow improvement
  • Size-independent — no upper limit on prostate volume
  • Can address concomitant bladder pathology (stones, diverticula)
  • RASP offers minimally invasive benefits with shorter learning curve than HoLEP
  • Effective as salvage after failed prior procedures

Limitations

  • Requires general / regional anesthesia and hospitalization
  • Higher retrograde ejaculation rate (80–90%)
  • Longer catheterization (4–11 d) and LOS than endoscopic alternatives
  • Open approach carries significant blood-loss / transfusion risk
  • Robotic approach requires capital equipment and longer OR time

See Also​

References​

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2. Gilfrich C, May M, Fahlenbrach C, et al. Surgical reintervention rates after invasive treatment for lower urinary tract symptoms due to benign prostatic syndrome: a comparative study of more than 43,000 patients with long-term followup. J Urol. 2021;205(3):855–863. doi:10.1097/JU.0000000000001463

3. He W, Ding T, Niu Z, et al. Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review. Front Endocrinol. 2023;14:1287212. doi:10.3389/fendo.2023.1287212

4. Arnold MJ, Gaillardetz A, Ohiokpehai J. Benign prostatic hyperplasia: rapid evidence review. Am Fam Physician. 2023;107(6):613–622.

5. Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. J Urol. 2024;211(1):11–19. doi:10.1097/JU.0000000000003698

6. Thorpe A, Neal D. Benign prostatic hyperplasia. Lancet. 2003;361(9366):1359–1367. doi:10.1016/S0140-6736(03)13073-5

7. Pandolfo SD, Del Giudice F, Chung BI, et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis. 2023;26(3):495–510. doi:10.1038/s41391-022-00616-4

8. Dall'Oglio MF, Srougi M, Antunes AA, Crippa A, Cury J. An improved technique for controlling bleeding during simple retropubic prostatectomy: a randomized controlled study. BJU Int. 2006;98(2):384–387. doi:10.1111/j.1464-410X.2006.06236.x

9. Rehman J, Khan SA, Sukkarieh T, Chughtai B, Waltzer WC. Extraperitoneal laparoscopic prostatectomy (adenomectomy) for obstructing benign prostatic hyperplasia: transvesical and transcapsular (Millin) techniques. J Endourol. 2005;19(4):491–496. doi:10.1089/end.2005.19.491

10. Baumert H, Ballaro A, Dugardin F, Kaisary AV. Laparoscopic versus open simple prostatectomy: a comparative study. J Urol. 2006;175(5):1691–1694. doi:10.1016/S0022-5347(05)00986-9

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12. Pokorny M, Novara G, Geurts N, et al. Robot-assisted simple prostatectomy for treatment of lower urinary tract symptoms secondary to benign prostatic enlargement: surgical technique and outcomes in a high-volume robotic centre. Eur Urol. 2015;68(3):451–457. doi:10.1016/j.eururo.2015.03.003

13. Bove AM, Anceschi U, Ferriero M, et al. Perioperative and 1-year patient-reported outcomes of Freyer versus Millin versus Madigan robot-assisted simple prostatectomy. World J Urol. 2021;39(6):2005–2010. doi:10.1007/s00345-020-03391-w

14. Abou Zeinab M, Beksac AT, Corse T, et al. The multi-institutional experience in single-port robotic transvesical simple prostatectomy for benign prostatic hyperplasia management. J Urol. 2022;208(2):369–378. doi:10.1097/JU.0000000000002692

15. Pyrgidis N, Weinhold P, Schulz GB, et al. Peri-operative outcomes of open, laparoscopic and robotic simple prostatectomy. BJU Int. 2025. doi:10.1111/bju.16928

16. Farzat M, Wagenlehner FM. Transvesical vs transcapsular robot-assisted multiport simple prostatectomy: a comparative analysis of perioperative outcomes. J Endourol. 2025. doi:10.1177/08927790251387347

17. Benarroche D, Paladini A, Grobet-Jeandin E, et al. Robotic versus open simple prostatectomy for benign prostatic hyperplasia in large glands: single-centre study. World J Urol. 2022;40(12):3001–3006. doi:10.1007/s00345-022-04176-z

18. Lee MS, Assmus MA, Ganesh M, et al. An outcomes comparison between holmium laser enucleation of the prostate, open simple prostatectomy, and robotic simple prostatectomy for large gland benign prostatic hypertrophy. Urology. 2023;173:180–186. doi:10.1016/j.urology.2022.12.018

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23. Shaheen A, Quinlan D. Feasibility of open simple prostatectomy with early vascular control. BJU Int. 2004;93(3):349–352. doi:10.1111/j.1464-410x.2003.04614.x

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25. Gacci M, Bartoletti R, Figlioli S, et al. Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study. BJU Int. 2003;91(3):196–200. doi:10.1046/j.1464-410x.2003.04072.x

26. Creta M, Manfredi C, Arcaniolo D, et al. Functional and oncological outcomes after radical prostatectomy in patients with history of surgery for lower urinary tract symptoms related to benign prostatic enlargement: a systematic review with meta-analysis. Prostate Cancer Prostatic Dis. 2024;27(3):367–384. doi:10.1038/s41391-023-00678-y

27. Pathak RA, Krol BC, Crain NA, Hemal AK. Robot-assisted simple prostatectomy: a comparison of primary simple prostatectomy vs salvage simple prostatectomy in treatment of lower urinary tract symptoms. J Endourol. 2023;37(4):414–421. doi:10.1089/end.2022.0588

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30. Cardi A, Palleschi G, Patruno G, et al. Robot-assisted simple prostatectomy for treatment of large prostatic adenomas: surgical technique and outcomes from a high-volume robotic centre. World J Urol. 2023;41(2):515–520. doi:10.1007/s00345-022-04262-2

31. Cockrell R, Bonzo J, Lee D. Robot-assisted simple prostatectomy. J Endourol. 2018;32(S1):S33–S38. doi:10.1089/end.2017.0715

32. Simone G, Misuraca L, Anceschi U, et al. Urethra and ejaculation preserving robot-assisted simple prostatectomy: near-infrared fluorescence imaging-guided Madigan technique. Eur Urol. 2019;75(3):492–497. doi:10.1016/j.eururo.2018.11.051

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