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Simple Prostatectomy (Open / Laparoscopic / Robotic)

Simple prostatectomy is the surgical enucleation of the prostatic adenoma, typically reserved for large prostates (> 80 g). Approaches include open transvesical (Freyer), open retropubic (Millin), laparoscopic, and robotic-assisted (transvesical, transcapsular or urethra-sparing Madigan; multiport or single-port). Series report IPSS reductions of 14–22 points. A pooled analysis of reoperation rates after open prostatectomy gave 1.3% at 1 yr and 4.4% at 5 yr, among the lowest of the procedures in that review, and a German claims analysis found a lower 5-yr reintervention hazard than TURP for open simple prostatectomy (HR 0.43).[1][2][3]

For positioning versus HoLEP, MISTs, and TURP, see the BPH & Male LUTS chooser.

Indications​

Generally > 80 mL (the 2022 CUA guideline describes >80–100 mL for laparoscopic or robotic simple prostatectomy).[4][1][5][63] 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, for example with bladder diverticulectomy; favors transvesical)
  • Renal insufficiency from BOO
  • Recurrent gross hematuria from BPH[1][6]

Simple prostatectomy has been cautioned against in patients with a prior bladder augmentation, because of the risk of injury to the reconstructed bladder; in that setting, medical therapy, endoscopic outlet procedures, or a catheterizable channel are the alternatives discussed for patients who wish to continue catheterization.[54]

The AUA 2026 guideline states that clinicians should offer simple prostatectomy (open, laparoscopic or robotic) as an option for prostates larger than 80 cc , and should offer laser enucleation (HoLEP / ThuLEP) as an option for LUTS/BPH .[50] Earlier guidance and the Pandolfo review describe both as treatments of choice for large glands.[7][5] EAU 2026 strongly recommends open prostatectomy for prostates above 80 mL when endoscopic enucleation is not available, and HoLEP as an alternative to TURP or open prostatectomy.[51] EAU reports that open prostatectomy has similar short- and mid-term efficacy to HoLEP and bipolar enucleation in large glands (level 1a), with longer catheterization and hospital stay, more transfusions and a less favorable perioperative safety profile.[51]

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) in a randomized study of 62 men that used a modified Millin techniqueLess, with improved visualization of bleeding points[8]
Stress UIComparative risk unquantifiedComparative risk unquantified
Urethral divisionLess preciseMore accurate

In Rohiem et al.'s endoscopically assisted open transvesical approach for large glands with bladder stones, the bladder was opened and stones removed; the ureteral orifices were identified before mucosal incision, finger enucleation followed the adenoma–capsule plane with care to avoid apical sphincter traction, and hemostatic sutures were placed at 5 and 7 o'clock when accessible. Their technique used a three-way urethral catheter, suprapubic drainage, two-layer cystotomy closure, and irrigation.[60]

The open Millin sequence has been described as follows: deep 0-chromic capsular sutures are placed transversely near the bladder neck and near the apex before the capsule is opened between them, and the adenoma is enucleated in the plane between capsule and adenoma; under direct vision the adenoma is divided just proximal to the membranous urethra to protect the sphincter. Figure-of-eight hemostatic sutures at the 5- and 7-o'clock positions control urethral branches of the prostatic arteries, and the posterior bladder-neck lip is then sutured to the posterior prostatic capsule, with excess neck tissue trimmed to leave a wide junction (bladder-neck trigonization). The chapter authors attribute reduced postadenectomy urethral stricture and a shorter catheter duration to this step, without a comparative study. Closure uses a large-bore (22–24 Fr) three-way catheter with the balloon tamponading the fossa, continuous bladder irrigation, and a Retzius-space drain.[52]

Modern minimally invasive​

  • Laparoscopic simple prostatectomy (LSP). Extraperitoneal Millin or transvesical. Reduced blood loss, shorter catheter and LOS versus open; advanced laparoscopic skills required.[9][10][11]
  • Robot-assisted simple prostatectomy (RASP). Available with multiport and single-port (SP) platforms. In German nationwide inpatient data for 2013–2023 excluding concomitant bladder stones, robotic simple prostatectomy rose steeply and open declined, but open still accounted for 96% of 46,234 procedures.[12][13][14][15]

Modern RASP techniques — step by step​

1. Transvesical (Freyer) RASP — multiport​

This is the most widely described multiport technique.[29][30][31]

  • Positioning and ports. Steep Trendelenburg, transperitoneal access. "W"-configuration ports (4 × 8-mm robotic plus 1–2 assistant). da Vinci Si / Xi docked four-arm.
  • Bladder detachment and 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. Identify the trigone and both ureteral orifices before a mucosal incision around the adenoma, keeping the incision clear of the orifices.[59] Use sharp and blunt dissection in the plane between adenoma and surgical capsule from bladder neck to apex; divide the urethra at the apex.
  • Hemostasis. Selective coagulation of bladder-neck vessels at 5 and 7 o'clock.
  • Trigonization and 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 and water-tightness test.[29]
  • Specimen retrieval. Remove the adenoma through the optical-port incision or an Endo Catch bag and submit it for histopathology. A six-center SP-RASP series found incidental cancer in 11/235 specimens (4.6%), including clinically significant cancer in 2.1%; arrange grade-appropriate follow-up when found.[61]

Robotic transvesical simple prostatectomy: prostatic fossa before and after trigonization with a barbed suture

Trigonization during robot-assisted transvesical simple prostatectomy after adenoma removal. (a) Bleeding from the prostatic fossa obscures the operative field. (b) Approximating the bladder neck to the urethra with a unidirectional barbed suture substantially improves hemostasis. From Larsen M, et al. BMC Urol. 2024;24(1):221, Fig. 2 (CC BY 4.0).[55]

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 (an advantage for surgeons experienced in robotic RP).[31]
  • Capsulotomy. Transverse incision on the anterior prostatic capsule, distal to the bladder neck.
  • Adenoma enucleation. Sharp and blunt dissection within the capsule from capsulotomy to 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​

This variant has been described in small series.[32][33] A 2025 meta-analysis of five retrospective comparisons reported that urethra-sparing RASP was associated with an 8.09-point higher postoperative-minus-preoperative change in MSHQ-EjD score than conventional RASP across four reporting studies (95% CI 5.92–10.26; I² = 68%).[58]

  • Transcapsular access.
  • Urethral identification with ICG and 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 replaces en-bloc removal: each lobe is peeled off the urethra circumferentially while the urethra and ejaculatory ducts are preserved.
  • Porpiglia 2021 Eur Urol (prospective, n = 92, with a retrospective Millin control group; small sample and short follow-up): full urethral sparing 61%, partial 23%, conversion to standard RASP 16%. Of 70 patients with preoperative ejaculation, 81% maintained anterograde ejaculation at 12 mo.[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 allows an intravesical approach through a single small incision.[34][14]

  • Access. Through a 3-cm suprapubic incision, enter the bladder and dock the SP arm directly into the bladder lumen; the camera and 3 articulating instruments emerge from a single cannula. Use controlled intravesical insufflation; abrupt hypotension or desaturation warrants evaluation for possible gas embolism. Suspected events were reported in early SP series and attributed to high insufflation pressure in a 117-case series.[14][34]
  • Enucleation. Adenoma enucleated from within the bladder under direct visualization of the bladder neck and prostatic fossa.
  • 360° mucosal flap reconstruction. Bladder mucosa is advanced and sutured circumferentially to the urethral stump, separating the residual raw fossa from the urinary lumen. In the reported series, routine continuous bladder irrigation was avoided; reduced postoperative bleeding and irritative symptoms remain proposed benefits.[34][35]
  • Ramos 2024 Eur Urol (retrospective, 117 cases; 1-yr functional outcomes analyzed among patients with at least 12 mo of follow-up): median console 107 min, EBL 100 mL, 0% transfusion, 95.8% discharged within 24 h (median LOS 5 h), no major postoperative complications, median catheter 5 d, and persistent IPSS and flow-rate improvement at 1 yr. Two intraoperative suspected air emboli were attributed to high insufflation pressure.[34]

5. Novel approaches​

  • Trans-Douglas (Retzius-sparing) RASP. De Concilio 2018: posterior peritoneal approach preserving the bladder neck; one reported patient had 80 mL blood loss, catheter removal on day 4, and IPSS improvement from 30 to 8 at 60 days.[36]
  • Intrafascial RASP. Poncel 2023: dissection between prostatic capsule and surrounding fascia preserving NVBs; successfully applied to a 470 g prostate with IPSS 34 to 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 rate5% (2/40) in MP comparison[16]0% (0/60) in MP comparison[16]—1.1% (1/91) in multicenter series; 0% (0/117) in Ramos series[14][34]
Catheter duration (d)6.7–84.375
LOS (d)4–6535 hours
Same-day dischargeNo transvesical-specific rate reportedNo transcapsular-specific rate reportedNot quantified for Madigan42% in a 91-patient multicenter series; 48% in a HoLEP comparison; 92% of 23 after excluding planned admissions[14][41][47]
Ejaculation preservation——8/12 (66%) at 12 mo in Simone; 57/70 (81%) at 12 mo in Porpiglia[32][33]—
Major complications12.5% (5/40) in MP comparison[16]3.3% (2/60) in MP comparison[16]2/92 (2%) grade ≥3 in attempted urethra-sparing cohort[33]0/117 major postoperative complications in Ramos series[34]
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 approximates bladder mucosa circumferentially to the urethral edge to reduce exposed capsular surface. Cacciamani's 23-patient technical series proposed that circumferential reconstruction might lessen bleeding and irritative symptoms, without a trigonization comparator.[35] Ramos's 117-patient single-port series used no routine CBI.[34] In a 2025 single-surgeon multiport series of 292 men undergoing circumferential anastomosis, postoperative CBI was not used and no bladder-neck contracture or LUTS reoperation was observed (mean clinical follow-up 22.6 months). Among 198/288 contacted survey respondents at mean 66 months, mean IPSS was 2.1.[59] It extends traditional "trigonization" and is the reconstruction used in the single-port transvesical RASP series cited here.

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 and is managed with electrocautery and postoperative CBI[29]
360° mucosal flap reconstructionBladder mucosa circumferentially advanced and sutured to the distal urethral stump, separating the residual prostatic fossa from the urinary lumenReduces exposed raw capsular area and aims to minimize electrocautery; routine CBI was avoided in the cited uncontrolled series, but comparative hemostatic benefit remains unproven.[35][59]

The proposed rationale is that exposed raw capsular surface contributes to postoperative bleeding and irritative symptoms, and that covering it with mucosa reduces both.[35][46]

Step-by-step technique (Cacciamani 2018)​

The original 23-patient description:[35]

  1. Adenoma enucleation. Standard transperitoneal transvesical approach; sharp and blunt dissection from bladder neck to 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 to 6 o'clock (posterior) to 3 o'clock (contralateral) to 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. The mucosa-to-mucosa anastomosis separates the raw capsular fossa from the urinary lumen; residual fossa dead space remains.[35][59]
  6. Cystotomy closure. Anterior cystotomy closed in 2 layers; Foley and 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 reconstructive step of SP-RASP; the articulating SP instruments working within the bladder give visualization of the fossa 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 to 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. The columns below compare separate, non-randomized series:

Parameter360° mucosal flapTraditional trigonization
CBI use in cited seriesNot routine in 117 single-port cases[34]Not quantified in the 28-case traditional transvesical report[29]
EBL (mL)99–100200
Transfusion rate0/23 in the 360° series[35]Not established in the cited series
LOS2.1 d / 5 h (SP)4–6 d
Catheter duration (d)3–5 (SP)7–8
Same-day discharge42% overall in a multicenter SP series; 92% of 23 after excluding planned admissions[14][47]Rare
Postoperative hematuriaReduction proposed; no direct comparison[35]No direct comparative estimate
Irritative symptomsReduction proposed, not demonstrated[35]No direct comparative estimate

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​

In an open simple-prostatectomy retrospective before-and-after series (Okorie 2010), clot retention occurred in 11/43 men with standard hemostasis plus CBI and 2/39 with modified bladder-neck repair and no CBI (p = 0.01); two bladder-wall disruptions occurred in the earlier group and none in the later group.[49]

Technical pearls and pitfalls​

  • Barbed suture (2-0 V-Loc or similar) maintains tension without knot-tying 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 apical visualization.
  • Posterior wall first. Some surgeons start at 6 o'clock where the mucosa is thickest and the trigone is a firm 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.

In small non-randomized reports using circumferential reconstruction, postoperative CBI was not routinely used; selected single-port series reported same-day discharge, and one reported median catheter duration of 3 days in its final 19 patients after technique adjustment.[14][34][47]

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 timeLongerSimilarNot reported for HoLEP; ThuLEP shorter
EBLLowerSimilar—
Transfusion rateLower—Higher
LOSShorterShorter with RASP (LSP longer)Longer
Catheter durationShorter—Longer
ComplicationsLowerSimilar—
IPSS / QmaxNo significant difference detectedNo significant difference detectedNo significant difference detected[7]

Pyrgidis 2025 German nationwide inpatient analysis (n = 46,234 without concomitant bladder stones; 96% open, 3% robotic, 1% laparoscopic): compared with transcapsular OSP, in-hospital transfusion was lower with LSP (6.5%) and RASP (7.3%) versus 13%, in-hospital retention was less frequent, and median stay was 4 d (LSP) and 7 d (RASP) versus 9 d (transcapsular OSP).[15]

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

vs HoLEP for prostates > 80 cc​

Both are guideline-recommended for large glands. In a multicenter randomized trial of 110 men with prostate volumes ≥120 mL (36 LSP, 32 RASP, 42 HoLEP), functional outcomes showed no significant between-group difference over mean 26.15-month follow-up; LSP catheterization was longer than in the other groups, and the simple-prostatectomy groups had longer hospitalization than HoLEP.[62]

Lee 2023 retrospective single-center comparison (n = 340: 209 HoLEP, 66 OSP, 65 RSP):[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 and meta-analysis, Grosso 2024 propensity-matched, Palacios 2023 SP-RASP versus HoLEP and Glucksman 2026 single-center MP versus SP versus HoLEP synthesis:[39][40][41][42]

ParameterRASPHoLEPp
OR time~ 50 min longershorter0.001
EBL (mL)200 in Benarroche's RASP-vs-OSP cohort[17]; 326 in Lee's three-arm cohort[18]66 in Lee's HoLEP cohort[18]<0.0001 overall across HoLEP, OSP and RASP in Lee[18]
Transfusion ratehigher75% lower risk with HoLEPsig[39]
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[41]
IPSS / QmaxequivalentequivalentNS
Transient incontinence (SP-RASP vs HoLEP)5% de novo; 8% transient28% de novo; 30% transient< 0.01 (two-group); 0.004 (three-group overall)[41][42]
Antegrade ejaculation (propensity-matched)55%7%0.001[40]
Trifecta (Grosso: no complication by 1 mo, Qmax >15 mL/s at 1 mo, no urinary incontinence at 3 mo)82.6%76.1%NS[40]
Grade 2 complications1.87× higher risk with RASPlowersig
Grade ≥ 3 complications3.41× higher risk with RASPlowersig
Median % adenoma removed (SP-RASP vs HoLEP)57%51%0.10[41]

Summary:

  • Functional outcomes (IPSS, Qmax, PVR) were similar across the cited studies and meta-analyses.[39][43]
  • HoLEP advantages. In the Benzouak meta-analysis HoLEP had about 49 min shorter operative time, 3.8 d shorter catheterization and 1.5 d shorter stay, with a 75% lower transfusion risk. RASP patients had 1.87 times the risk of grade 2 complications and 3.41 times the risk of grade 3 or higher complications.[39]
  • Advantages reported in selected RASP cohorts. A retrospective SP-RASP versus HoLEP comparison reported transient de novo incontinence of 5% versus 28% and same-day discharge of 48% versus 8%; a separate propensity-matched RASP versus HoLEP comparison reported antegrade ejaculation of 55.3% versus 6.8%.[40][41] A 2026 meta-analysis of 13 studies (n = 1,993) found no significant pooled difference in postoperative stress or urge incontinence between HoLEP and RASP.[56]
  • Learning curve. RASP is described as having a shorter learning curve than HoLEP because its steps mirror robotic radical prostatectomy. HoLEP is described as having a steep learning curve (50–100+ cases for proficiency).[7][39]
  • SP-RASP specifically. One series favors it 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 versus 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​

Gangwish 2025 was a single-institution retrospective comparison of 172 men with prostates > 80 mL (111 Aquablation, 61 open or robotic simple prostatectomy), adjusted by inverse probability weighting:[44]

  • Aquablation. Simple prostatectomy had higher transfusion rates (OR 4.22), longer stay (by 1.7 d) and longer operating time (by approximately 119 min).[44]
  • Simple prostatectomy. Better 1-yr IPSS (β = −3.4, p = 0.005), lower retreatment (OR 0.46, p = 0.019) and less postoperative alpha-blocker use (p = 0.001).[44]
  • QoL and adverse-event rates were comparable.

In WATER II (101 men with 80–150 mL prostates), Kaplan–Meier freedom from a secondary BPH procedure at 5 yr was 96.3%; 60/101 completed the 5-yr visit, and among participants with 5-yr measurements mean IPSS fell 15.9 points and mean Qmax rose 9.2 mL/s.[45] WATER II enrolled prostates of 80–150 mL, whereas RASP has no defined upper size limit; a case of 470 g has been reported.[37]

Clinical efficacy​

OutcomeSimple prostatectomy
IPSS improvement−14 to −22 points at 8–40 mo
Qmax improvement (open prostatectomy)+16.5 to +20.2 mL/s; efficacy maintained up to 6 yr[51]
Postop IPSS (RASP)Median 3–5
Postop Qmax (RASP, prostates ≥100 cm³)Mean 18–29.6 mL/s across cohorts[57]
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​

Reoperation after simple prostatectomy is low in observational data.

  • Gilfrich 2021 (German claims, n = 43,041, 5-yr follow-up): open simple prostatectomy carried a lower reintervention hazard than TURP (HR 0.43, 95% CI 0.37–0.50); laser enucleation did not differ significantly (HR 0.84, 95% CI 0.66–1.08).[2]
  • He 2023 systematic review (119 studies overall): pooled reoperation after open prostatectomy was 1.3% at 1 yr (7 studies; 95% CI 0.3–2.8%) and 4.4% at 5 yr (4 studies; 95% CI 1.5–8.7%).[3]
  • Eredics 2018 Austrian nationwide: 8-yr re-TURP rate 4.3% after open prostatectomy versus 8.3% after primary TURP.[20]
  • A 1993 study of 92 patients treated with either transurethral or open prostatectomy reported that 95% of the combined cohort remained nonobstructed and subjectively satisfied at 5 years.[21]

Complications​

Perioperative

  • Blood loss and transfusion. Blood loss remains a perioperative concern, especially with open surgery. Retrospective cohorts reported median RASP versus OSP estimated blood loss of 200 versus 400 mL (47 versus 56 men)[17] and estimated blood loss of 326 versus 795 mL (65 versus 66 men)[18]. The first cohort recorded transfusion in 0/47 versus 6/56 men; German inpatient data recorded 7.3% (98/1,335) after RASP versus 13% (1,472/11,755) after transcapsular OSP.[17][18][15] Earlier selected series reported 0% transfusion in more than 75% of eight RASP case series (109 men total), while one 37-man open series had mean blood loss of 841 mL and transfusion in 6/37 (16%).[22][23]
  • Mortality. < 1%. EAU 2026 cites mortality of 0.2% at 30 days and 0.4% at 90 days in a series of 1,286 men, and a transfusion rate of about 7–14%.[6][20][51]
  • Overall complication rate. 30% with RASP (mostly Clavien I–II); 4.5% Clavien IIIb in one series.[12]
  • Venous thromboembolism. One pulmonary embolism occurred among 37 men in a single-surgeon open series; the cohort is too small to estimate current risk.[23] No recommendation specific to simple prostatectomy exists; as an open or robotic major pelvic operation it is reasonable to apply the general urologic-surgery risk framework on the VTE Prophylaxis page.

Postoperative

  • Bladder neck contracture. None among 150 RASP patients at mean 31.3 months; 5/151 (3.3%) evaluable open transvesical prostatectomy patients at mean 41.8 months.[19][24] One chapter's authors report bladder-neck stenosis as more common in their laparoscopic experience and associate it with a transvesicocapsular incision, recommending a transverse incision at the bladder-neck level instead; this is an unquantified single-center observation.[53]
  • Urethral stricture. 1/151 (0.6%); meatal stenosis occurred in 2/151 (1.3%) evaluable open transvesical prostatectomy patients at mean 41.8 months.[24]
  • Urinary incontinence. A review reports 0–20% at 0–3 months after open or robotic simple prostatectomy; an open series reported stress incontinence in 3/37 (8%) without specifying persistence.[1][23]
  • UTI: variable.
  • Long-term. EAU 2026 cites persistent incontinence, bladder neck contracture and urethral stricture in about 6% combined, and endourologic reintervention of 0.9%, 3.0%, 6.0% and 8.8% at 3 months, 1 year, 5 years and 8 years after open prostatectomy in an Austrian nationwide study of 2,452 men.[51]

Sexual function​

  • Retrograde ejaculation 80–90%. Most common sexual side effect after open or robotic simple prostatectomy; the same review reports 60–75% after TURP.[1]
  • Erectile dysfunction 3–5% after open or robotic simple prostatectomy in a review table.[1]
  • In a retrospective single-center comparison of 45 men, Madigan urethra-sparing RASP (n = 14) was associated with higher self-reported IIEF and MSHQ scores at 1 year than Millin (n = 23) or Freyer (n = 8) (IIEF p = 0.04; MSHQ p = 0.008).[13]
  • Sexual desire and overall satisfaction generally preserved; orgasm and ejaculation commonly affected.[25]

Impact on subsequent radical prostatectomy​

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

  • Higher positive surgical margin rate (OR 1.39)[26]
  • Lower continence at 3 mo and 1 yr (OR 0.48 and 0.44)[26]
  • Lower erectile function recovery at 1 yr (OR 0.60)[26]

Salvage simple prostatectomy after failed prior procedures​

Retrospective series describe RASP after failed transurethral procedures. Pathak 2023 studied 124 men (26 salvage after TURP, TUMT, TUNA, or UroLift); postoperative IPSS was 5.33 after primary and 8.00 after salvage RASP at about 12 months (p = 0.38). Lee 2023 studied 520 men, including 87 (16.7%) with prior TURP, PVP, TUMT, prostatic urethral lift, or Rezūm; measured perioperative and functional outcomes did not differ significantly between groups.[27][28]

Advantages and limitations​

Advantages

  • Low reoperation rates in observational data
  • Large symptom and flow improvements
  • Size-independent, with no upper limit on prostate volume
  • Can address concomitant bladder pathology (stones, diverticula)
  • RASP offers minimally invasive recovery with a learning curve described as shorter than HoLEP
  • Effective as salvage after failed prior procedures

Limitations

  • Requires general / regional anesthesia and hospitalization
  • Higher retrograde ejaculation rate (80–90%)[1]
  • 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​

Videos​

Extraperitoneal Laparoscopic Simple Prostatectomy: Step by Step
AUA University Core Videos (2017)
Robotic-Assisted Suprapubic Simple Prostatectomy: Step by Step
AUA University Core Videos (2017)
Single-Port Robotic Transvesical Simple Prostatectomy (STEP)
Mutahar Ahmed
Extraperitoneal Robotic Simple Prostatectomy (Millin): Step by Step
Santos PB, et al. Urology Video Journal 2026 (CC BY 4.0)
Open source videoRead the article

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