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.

我写这篇文章是为了回应 Andrea-Grosso 等人撰写的有趣文章。 [1]，探讨了机器人辅助单纯前列腺切除术（RASP）和钬激光前列腺剜除术（HoLEP）之间的比较。几篇评论文章也深入探讨了这个主题，主要关注手术时间、住院时间和导管插入时间等参数。在这些方面，RASP常常发现自己无法与HoLEP提供的优势相匹配。然而，当考虑术后尿失禁和尿道狭窄时，HoLEP 似乎存在不足，这给外科医生和患者都带来了挑战。良性前列腺增生（BPH）手术后尿失禁受到多种因素的影响。其中包括不可改变的因素，如患者年龄、前列腺大小、体重 [2] 和 BPH 进展阶段 [3]，以及可改变的因素，如手术技术的选择，从机器人简单前列腺切除术到各种经尿道手术去核方法。在经尿道技术中，有多种方法，包括前后术[4]、自上而下、Omega 征和保留 AFS [5] 剜除术。目前正在积极研究每种技术的相对优点和缺点，正在进行的研究旨在确定减轻术后失禁的最有效方法。

HoLEP 需要通过尿道逆行进入前列腺内，在进入前列腺之前穿过外括约肌 (ES)。因此，目前的主流方法涉及早期根尖释放，旨在保护 ES 或 ES 延伸到前列腺的部分在随后的牵引损伤期间免受潜在损伤。这种保护措施已被证明可以有效显着减少术后尿失禁[4]。相反，RASP 以顺行方式进行，需要对前列腺囊进行横向前切口，以进入前列腺的过渡区（T 区），以 ES 作为终点。在解剖和分离T区和周边区的不可避免的过程中，根据手术原理，通过牵引和反牵引对T区施加力以实现成功分离。值得注意的是，尽管与内窥镜检查相比，机器人仪器施加的力更大，但这一过程并不会导致 HoLEP 中假设的尿失禁。