The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

Abstract

Objective: To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

Background: Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

Methods: PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

Results: Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

Conclusions: Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Keywords: cancer surgery; da Vinci; meta-analysis; oncologic surgery; outcomes; perioperative; robot surgery.

FIGURE 1

Summary PRISMA flowchart. Flowchart showing inclusion and exclusion of each paper for each procedure. *LAR group also includes total mesorectal resection and ISR. For identification, searches in each database were created using a combination of robotic, (eg, robot, robotic, robotically, “da Vinci,” “intuitive surgical”), indication (eg, cancerous, malignancy, etc), anatomic (eg, prostate, renal, and uterine), and procedure (eg, nephrectomy and RC) or specialty (renal, gynecology, and urology) terms. For the screening step, articles including patients with primary, localized cancer who underwent one of the procedures of interest using da Vinci surgery were assessed. At the eligibility step, only studies published within the timeframe reporting primary clinical data (no reviews, comments, etc) and that compared da Vinci surgery to another surgical approach, with at least 20 patients in each arm were considered (no case series or case reports). Only RCTs, prospective studies, and database studies were included. Included in the review: English language studies reporting on an adult population, treated using standard surgical techniques (ie, no transanal or single-port), with the data stratified by procedure, indication, and surgical approach for at least one outcome of interest (OT, blood transfusions, estimated blood loss, conversions to open surgery, length of hospital stay, 30 days: postoperative complications, readmissions, reoperations, and mortality). Papers with redundant patient populations and similar conclusions were excluded. Included in meta-analysis: papers where mean and SD could be extracted or calculated for continuous outcomes and event n and total n could be extracted or calculated for binary data such that data could be pooled were included in the meta-analysis. Adding across columns does not equal a total number of unique papers; Shah 2022 Impact is included in lung lobectomy, PN, LAR, and RC. Detailed flowcharts for each procedure that show exclusion reasons can be found in Supplementary Figs. 1–6. Details on papers that were included in the review in which data could not be pooled are listed in Supplementary Table 12 (Supplemental Digital Content Table 12, http://links.lww.com/SLA/F333). COMPARE indicates comparing perioperative outcomes of oncologic minimally invasive laparoscopic, da vinci robotic, and open procedures: a systematic review and meta-analysis of the evidence; ISR, inter sphincteric resection; LAR, low anterior resection; P&I, procedure and indication; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PSE, Pubmed Scopus Embase; RC, right colectomy; refs, references; TME, total mesorectal excision.

FIGURE 2

Forest plots for (A) conversions for dV-RAS versus lap/VATS, (B) OT for dV-RAS versus lap/VATS, (C) OT for dV-RAS versus open surgery, (D) blood loss for dV-RAS versus lap/VATS, and (E) blood loss for dV-RAS versus open surgery. Black squares visually represent the effect size and the black line represents the 95% CI. The black diamond represents the overall pooled effect size and its horizontal size represents the 95% CI. COMPARE indicates comparing perioperative outcomes of oncologic minimally invasive laparoscopic, da vinci robotic, and open procedures: a systematic review and meta-analysis of the evidence; df, degrees of freedom; ISR, intersphincteric resection; IV, inverse variance; LAR, low anterior resection; TME, total mesorectal excision.

FIGURE 3

Forest plots for blood transfusions for (A) dV-RAS versus lap/VATS and (B) for dV-RAS versus open surgery, hospital stay for (C) dV-RAS versus lap/VATS and (D) dV-RAS versus open surgery, 30-day postoperative complications for (E) dV-RAS versus lap/VATS and (F) dV-RAS versus open surgery. Black squares visually represent the effect size and the black line represents the 95% CI. The black diamond represents the overall pooled effect size and its horizontal size represents the 95% CI. COMPARE indicates comparing perioperative outcomes of oncologic minimally invasive laparoscopic, da vinci robotic, and open procedures: a systematic review and meta-analysis of the evidence; df, degrees of freedom; ISR, intersphincteric resection; IV, inverse variance; LAR, low anterior resection; TME, total mesorectal excision.

FIGURE 4

Forest plots for 30-day readmissions for (A) dV-RAS versus lap/VATS and (B) dV-RAS versus open surgery, 30-day reoperations for (C) dV-RAS versus lap/VATS, (D) dV-RAS versus open surgery, and 30-day mortality for (E) dV-RAS versus lap/VATS, and (F) dV-RAS versus open surgery. Black squares visually represent the effect size and the black line represents the 95% CI. The black diamond represents the overall pooled effect size and its horizontal size represents the 95% CI. df indicates degrees of freedom; ISR, intersphincteric resection; IV, inverse variance; LAR, low anterior resection.