Surgical Results and Complications for Open, Laparoscopic, and Robot-assisted Radical Prostatectomy: A Reverse Systematic Review

Abstract

Context: The advantages of minimally invasive surgery for radical prostatectomy (RP) have been demonstrated in a number of systematic reviews (SRs). However, the rigorous study selection process for SR means that a lot of information can be excluded, leading to a very specific clinical scenario that is often unrepresentative of real life. Our new reverse SR methodology generates a heterogeneous population database that covers a wide range of clinical scenarios.

Objective: To compare perioperative surgical results and complications for open retropubic RP (RRP), laparoscopic RP (LRP), and robot-assisted RP (RARP) in a reverse SR.

Evidence acquisition: Eight databases were searched for SRs on RRP, LRP, or RARP between 2000 and 2020 (80 SRs). All references used in these SRs were captured for analysis (1724 articles). Perioperative outcomes and complications were compared among the RRP, LRP, and RARP approaches.

Evidence synthesis: We identified 559 (32.4%) reports on RRP, 413 (23.9%) on LRP, and 752 (43.7%) on RARP, involving 1 353 485 patients overall. RARP showed a significantly higher annual volume of surgery per surgeon (AVSS) in comparison to RRP and LRP (mean 64.29, 43.26, and 41.47, respectively), a higher percentage of low-risk patients (prostate-specific antigen <10 ng/ml, Gleason <7, stage <cT2), and a lower rate of lymphadenectomy, culminating in a lower complication rate (12.3% for RARP, 16.3% for LRP, 20.2% for RRP). Among all outcomes, only AVSS was significantly correlated with complication rates. An AVSS of 30, 95 and 95 surgeries/yr was required for RARP, LRP, and RRP, respectively, to obtain a complication rate of 12.3% (average for RARP). RARP showed better performance for all perioperative variables studied except for operative time (operative time: 199.8 vs 214.9 vs 169.5 min; estimated blood loss: 228.2 vs 408.0 vs 852.1 ml; blood transfusion rate: 2.8% vs 6.5% vs 19.8%; length of stay: 2.9 vs 5.7 vs 6.1 d; catheter time: 7.8 vs 8.5 vs 11.0 d for RARP vs LRP vs RRP).

Conclusions: Our reverse SR involved a wide real-life representative sample and reference values established in the literature and revealed that minimally invasive surgery had the best perioperative and complication results, especially RARP, which was associated with less complex cases, higher annual surgeon volume, and greater performance.

Patient summary: We used a wide sample representative of real-life surgical practice and reference values established in the literature for three techniques for removal of the prostate to guide patients and physicians in deciding the best surgical treatment for prostate cancer according to availability.

Keywords: Complications; Laparoscopic surgery; Methodology; Open surgery; Radical prostatectomy; Reverse systematic review; Robot-assisted surgery.

Fig. 1

Study design showing the two phases of the reverse systematic review. The first phase involves the selection of classic systematic reviews from the literature. The second phase involves selection of primary studies used in the reviews selected in the first phase. RRP = open radical prostatectomy; LRP = laparoscopic radical prostatectomy; RARP = robot-assisted radical prostatectomy.

Fig. 2

Comparison of the mean values for perioperative variables among the three techniques. RRP = open radical prostatectomy; LRP = laparoscopic radical prostatectomy; RARP = robot-assisted radical prostatectomy; EBL = estimated blood loss.

Fig. 3

Nonlinear regression models for correlation of complication rates and annual surgery volume per surgeon for each technique. Red lines denote nonlinear regression based on the rational model. RRP = open radical prostatectomy; LRP = laparoscopic radical prostatectomy; RARP = robot-assisted radical prostatectomy.