Laparoscopic versus robotic abdominal and pelvic surgery: a systematic review of randomised controlled trials

BACKGROUND

The current evidence is inconclusive on whether robotic or laparoscopic surgery is the optimal platform for minimally invasive surgery. Existing comparisons techniques focus on short-term outcomes only, while potentially being confounded by a lack of standardisation in robotic procedures. There is a pertinent need for an up-to-date comparison between minimally invasive surgical techniques. We aimed to systematically review randomised controlled trials comparing robotic and laparoscopic techniques in major surgery.

METHODS

Embase, Medline and Cochrane Library were searched from their inception to 13th September 2022. Included studies were randomised controlled trials comparing robotic and laparoscopic techniques in abdominal and pelvic surgery. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Short-term, health-related quality of life, and long-term, outcomes were analysed.

RESULTS

Forty-five studies, across thirteen procedures, involving 7364 patients were included. All of the studies reported non-significant differences in mortality between robotic and laparoscopic surgery. In majority of studies, there was no significant difference in complication rate (n = 31/35, 85.6%), length of postoperative stay (n = 27/32, 84.4%), and conversion rate (n = 15/18, 83.3%). Laparoscopic surgery was associated with shorter operative time (n = 16/31, 51.6%) and lower total cost (n = 11/13, 84.6%). Twenty three studies reported on quality of life outcomes; majority (n = 14/23, 60.9%) found no significant differences.

CONCLUSION

There were no significant differences between robotic surgery and laparoscopic surgery with regards to mortality and morbidity outcomes in the majority of studies. Robotic surgery was frequently associated with longer operative times and higher overall cost. Selected studies found potential benefits in post-operative recovery time, and patient-reported outcomes; however, these were not consistent across procedures and trials, with most studies being underpowered to detect differences in secondary outcomes. Future research should focus on assessing quality of life, and long-term outcomes to further elucidate where the robotic platform could lead to patient benefits, as the technology evolves.

Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes

PURPOSE

To provide a systematic analysis of the comparative outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer based on the best currently available evidence.

METHODS

An independent systematic review of the literature was performed up to February 2021, using MEDLINE^®, EMBASE^®, and Web of Science^® databases. Preferred reporting items for systematic review and meta-analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle-Ottawa scale for non-randomized controlled trials. Demographics and clinical characteristics, surgical, pathological, and functional outcomes were collected.

RESULTS

Twenty-six studies were identified. Only 16 "high-quality" (RCTs and Newcastle-Ottawa scale 8-9) studies were included in the meta-analysis. Among the 13,752 patients included, 6135 (44.6%) and 7617 (55.4%) were RARP and LRP, respectively. There was no difference between groups in terms of demographics and clinical characteristics. Overall and major complication (Clavien-Dindo ≥ III) rates were similar in LRP than RARP group. The biochemical recurrence (BCR) rate at 12months was significantly lower for RARP (OR: 0.52; 95% CI 0.43-0.63; p < 0.00001). RARP reported lower urinary incontinence rate at 12months (OR: 0.38; 95% CI 0.18-0.8; p = 0.01). The erectile function recovery rate at 12months was higher for RARP (OR: 2.16; 95% CI 1.23-3.78; p = 0.007).

CONCLUSION

Current evidence shows that RARP offers favorable outcomes compared with LRP, including higher potency and continence rates, and less likelihood of BCR. An assessment of longer-term outcomes is lacking, and higher cost remains a concern of robotic versus laparoscopic prostate cancer surgery.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.