Robotic-assisted versus laparoscopic radical prostatectomy for prostate cancer: the first separate systematic review and meta-analysis of randomised controlled trials and non-randomised studies
Authors: Ma Jianglei , Xu Weidong , Chen Rui , Zhu Yasheng , Wang Ye , Cao Wanli , Ju Guanqun , Ren Jizhong , Ye Xiaofei , He Qian , Chang Yifan , Ren Shancheng 
Published: April 2023

Background:
Due to the lack of sufficient evidence, it is not clear whether robotic-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) is better for prostate cancer. The authors conducted this study by separately pooling and analysing randomised controlled trials (RCTs) and non-randomised studies to compare the perioperative, functional, and oncologic outcomes between RARP and LRP.

Methods:
A systematic literature search was performed in March 2022 using Cochrane Library, Pubmed, Embase, Medline, Web of Science, and China National Knowledge Infrastructure. Two independent reviewers performed literature screening, data extraction and quality assessment according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Subgroup analysis and sensitivity analysis were performed.

Results:
A total of 46 articles were included, including 4 from 3 RCTs and 42 from non-randomised studies. For RCTs, meta-analysis showed that RARP and LRP were similar in blood loss, catheter indwelling time, overall complication rate, overall positive surgical margin and biochemical recurrence rates, but quantitative synthesis of non-randomised studies showed that RARP was associated with less blood loss [weighted mean difference (WMD)=−71.99, 95% CI −99.37 to −44.61, P<0.001], shorter catheterization duration (WMD=−1.03, 95% CI −1.84 to −0.22, P=0.010), shorter hospital stay (WMD=−0.41, 95% CI −0.68 to −0.13, P=0.004), lower transfusion rate (OR=0.44, 95% CI 0.35–0.56, P<0.001), lower overall complication rate (OR=0.72, 95% CI 0.54–0.96, P=0.020), and lower biochemical recurrence rate (OR=0.78, 95% CI 0.66–0.92, P=0.004), compared with LRP. Both meta-analysis of RCTs and quantitative synthesis of non-randomised studies showed that RARP was associated with improved functional outcomes. From the results of the meta-analysis of RCTs, RARP was higher than LRP in terms of overall continence recovery [odds ratio (OR)=1.60, 95% CI 1.16–2.20, P=0.004), overall erectile function recovery (OR=4.07, 95% CI 2.51–6.60, P<0.001), continence recovery at 1 month (OR=2.14, 95% CI 1.25–3.66, P=0.005), 3 (OR=1.51, 95% CI 1.12–2.02, P=0.006), 6 (OR=2.66, 95% CI 1.31–5.40, P=0.007), and 12 months (OR=3.52, 95% CI 1.36–9.13, P=0.010) postoperatively, and potency recovery at 3 (OR=4.25, 95% CI 1.67–10.82, P=0.002), 6 (OR=3.52, 95% CI 1.31–9.44, P=0.010), and 12 months (OR=3.59, 95% CI 1.78–7.27, P<0.001) postoperatively, which were consistent with the quantitative synthesis of non-randomised studies. When sensitivity analysis was performed, the results remained largely unchanged, but the heterogeneity among studies was greatly reduced.

Conclusion:
This study suggests that RARP can improve functional outcomes compared with LRP. Meanwhile, RARP has potential advantages in perioperative and oncologic outcomes.