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Influence of anterior fibromuscular stroma on incontinence outcomes in RASP and HoLEP: a critical analysis of Grosso et al.‘s findings

Prostate Cancer and Prostatic Diseases (2024)Cite this article

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I write in response to the intriguing article authored by Andrea-Grosso et al. [1], which explores the comparison between robot-assisted simple prostatectomy (RASP) and Holmium laser enucleation of the prostate (HoLEP). Several review articles have also delved into this topic, primarily focusing on parameters such as surgical time, hospital stay, and catheterization time. In these aspects, RASP often finds itself unable to match the advantages offered by HoLEP. However, when considering postoperative urinary incontinence and urethral stricture, HoLEP appears to fall short, presenting challenges for both surgeons and patients alike. Postoperative urinary incontinence following benign prostatic hyperplasia (BPH) surgery is influenced by a variety of factors. These include non-modifiable factors such as patient age, prostate size, body weight [2], and the stage of BPH progression [3], as well as modifiable factors like the choice of surgical technique, ranging from robotic simple prostatectomy to various transurethral enucleation methods. Among the transurethral techniques, there are several approaches, including anteroposterior [4], top-down, Omega sign, and AFS-preserved [5] enucleation. The relative merits and drawbacks of each technique are currently under active investigation, with ongoing research seeking to determine the most effective approach in mitigating postoperative incontinence.

HoLEP entails retrograde access through the urethra to initiate enucleation within the prostate, passing through the external sphincter (ES) before entering the prostate. Consequently, the current mainstream approach involves early apical release, aimed at safeguarding the ES or the portions of the ES extending into the prostate from potential damage during subsequent traction injury. This protective measure has proven effective in significantly reducing postoperative urinary incontinence [4]. Conversely, RASP proceeds in an antegrade fashion entailing a transverse anterior incision of the prostate capsule to access the transition zone (T zone) of the prostate, with the ES serving as the endpoint. During the inevitable process of dissecting and separating the T zone and peripheral zone, as dictated by surgical principles, forces are applied to the T zone through traction and counter-traction to achieve successful separation. Remarkably, despite the greater force exerted by robotic instruments compared to endoscopy, this process does not result in the urinary incontinence hypothesized in HoLEP.

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References

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Authors and Affiliations

  1. Department of Urology, Chang Gung Memorial Hospital at Linkou, Taoyuan, 333, Taiwan

    Yu-Hsiang Lin & Horng-Heng Juang

  2. School of Medicine, Chang Gung University, Taoyuan, 333, Taiwan

    Yu-Hsiang Lin

  3. Department of Anatomy, School of Medicine, Chang Gung University, Kwei-shan, Taoyuan, 333, Taiwan

    Horng-Heng Juang

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  1. Yu-Hsiang Lin
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Concept and design: [YHL,HHJ], drafting of the manuscript: [YHL]., critical revisions to manuscript: [YHL,HHJ].

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Correspondence to Yu-Hsiang Lin.

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Lin, YH., Juang, HH. Influence of anterior fibromuscular stroma on incontinence outcomes in RASP and HoLEP: a critical analysis of Grosso et al.‘s findings. Prostate Cancer Prostatic Dis (2024). https://doi.org/10.1038/s41391-024-00807-1

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  • DOI: https://doi.org/10.1038/s41391-024-00807-1

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