[Endoscopic enucleation for prostate volumes ≥ 200 ml: current evidence, technical challenges, and clinical...

Anatomical endoscopic enucleation of the prostate (AEEP) has become an established size-independent standard surgical treatment for benign prostatic hyperplasia. However, evidence regarding treatment of patients with prostate volumes ≥ 200 mL remains limited. This review aims to evaluate the available literature on functional outcomes, complications, technical challenges, and alternative surgical approaches in patients with extremely large prostates.

A systematic literature search was performed in PubMed/MEDLINE, Web of Science, and Scopus. Studies reporting outcomes of endoscopic enucleation in patients with prostate volumes ≥ 200 mL were included. Perioperative outcomes, functional results, complications, and comparisons with alternative surgical techniques were analyzed.

The available evidence consists exclusively of retrospective case series from specialized centers. Functional outcomes, including symptom relief, improvement in urinary flow rate, and reduction of post void residual urine, were comparable to those reported for smaller prostate volumes. However, operative and morcellation times were longer, and complication and transfusion rates were increased. Bleeding-related complications were found to correlate with prostate volume. Technical challenges mainly arise from altered anatomy during enucleation and morcellation. In selected cases, staged morcellation, open cystotomy for adenoma retrieval, or temporary perineal urethrotomy may be required. Compared with open simple prostatectomy, AEEP is associated with lower morbidity. Robot-assisted simple prostatectomy represents a potential alternative in experienced centers but has not demonstrated clear functional advantages to date.

AEEP is an effective and safe treatment option for prostate volumes ≥ 200 mL. Despite greater technical complexity and higher rates of bleeding-related complications, functional outcomes are comparable to those achieved in smaller glands. In experienced hands, AEEP offers the best available evidence while maintaining lower morbidity than alternative surgical approaches. However, current evidence is derived almost exclusively from expert centers, limiting the generalizability of these findings to institutions with less experience.