In the past years, minimally invasive surgical  techniques for the treatment fo benign prostatic hyperplasia have been introduced. Open prostatectomy (OP) is still the most effective treatment for BPH, however it is as well the most invasive. To overcome the limitations of OP, robotic/laparoscopic simple prostatectomy has been recently inroduced.  Aim of our study is to analyse outcomes and safety of open, laparoscopic and robotic simple prostatectomy.

A consecutive series of men with lower urinary tract symptoms  and large prostates (>80cc) undergoing laparoscopic (LSP), robotic (RASP) or open simple prostatectomy (OSP) were enrolled between January and Semptember 2018 in three centers. Outcomes were evaluated considering the trifecta favourable outcome which was defined as reported in the literature as a combination of the following items: (1) no perioperative complications, (2) postoperative IPSS <8, and postoperative Qmax >15 ml/s.  Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. Predictive accuracy was assessed with L-ROC.

Overall 159 patients were prospectively enrolled (32 Robotic, 66 Laparoscopic, 61 open). Preoperative characteristics are described in table 1. IPSS, Qmax significantly improved in all the three groups (table 1) when compared to baseline (p<0.001). The overall complication rate was 10/61 (16 %) for OSP, 6/66 (9%) for LSP and 3/32 (9%) for RSP, however most of the complications were low grade complications according to modified Claviend-dindo classification (Grade ≤2).

Overall, 51/66 (77%) of the patients presented a positive trifecta outcome after LSP, 24/32 (75%) after a RASP and 49/61 (80%) after OSP; p= 0.517. On multivariate analysis, adjusted for ASA score, only Age (OR: 0.88; CI:0.79-0.97, p=0.014), and preoperative symptoms (OR:0.86, CI:0,75-0.98, p= 0.028) were independent predictors of positive trifecta outcome. The multivariable model has a predictive accuracy of 0.84.

Simple prostatectomy represents a safe and effective procedure in the treatment of large adenomas.  Although RCTs are needed before reaching definitive conclusions, Laparoscopic and robotic surgical approach seems to be less invasive with similar trifecta outcomes when compared to open procedures.