Table A21:
Summary of Recent Health Technology Assessments and Systematic Reviews on Robot-Assisted Versus Open or Laparoscopic Radical Prostatectomy
| Author, Year | Search Period and Databases | Included Studies | Comparison | Primary Conclusions |
|---|---|---|---|---|
| Duffey et al, 2011145 | Nov 2009—Nov 2010 (Medline) | 21 non-RCTs | Open | Robot-assisted: lower blood loss, transfusion rate, length of stay; no definitive conclusions for functional and oncological outcomes |
| Ferronha et al, 2011146 | 2000—Oct 2009 (PubMed, Medline) | 37 studies | Open, laparoscopic | Robot-assisted and laparoscopic: lower blood loss, transfusion rate Robot-assisted and open: shorter operative time No difference in PSM rate, continence, and potency between 3 groups |
| Health Information and Quality Authority, 2011147 | 1950—Mar 2011 (Medline, Embase, EBSCO, CINAHL, Cochrane, DARE, HTA database, Journal of Robotic Surgery) | 50 studies (1 RCT, 49 non-RCTs) | Open, laparoscopic | Robot-assisted vs. open: decreased PSM rate for pT2 cancer, improved functional outcomes (urinary continence and sexual function), reduced transfusion rate and length of stay; increased operative time Robot-assisted vs. laparoscopic: no significant differences for operative time, transfusion rate, conversion to open, sexual function, oncologic outcomes; marginal improvements in urinary continence, small reductions in length of stay |
| Ho et al, 2011111 | 1950—Oct 2009 (Medline, BIOSIS Previews, Embase, CINAHL, PubMed, CINAHL, Cochrane) | 51 non-RCTs | Open, laparoscopic | Robot-assisted vs. open: longer operative time; shorter length of stay; reduced PSM rate in pT2 (inconclusive for pT3), complication rate, blood loss, and transfusion rate; improved continence at 3 and 12 months, improved sexual function at 12 months Robot-assisted vs. laparoscopic: reduced operative time, length of stay, blood loss, and transfusion rate; inconclusive for PSM rate (for pT2 and pT3), complication rate, and urinary continence (at 3 months and 12 months) |
| Ficarra et al, 2012148 | Jan 2008—Aug 2011 (Medline, Embase, Web of Science) | 31 studies | Open, laparoscopic | 12- and 24-month potency rates in the robot-assisted group ranged from 54% to 90% and from 63% to 94%, respectively Robot-assisted radical prostatectomy vs. open: better potency rates at 12 months (OR 2.84, 95% CI 1.46–5.43, P = .002) Robot-assisted vs. laparoscopic for potency: nonsignificant improvement (OR 1.89, P = .21) Age, baseline potency status, comorbidities index, and extension of the nerve-sparing procedure were the most relevant preoperative and intraoperative predictors of potency recovery after robot-assisted radical prostatectomy Available data seemed to support the use of cautery-free dissection or pinpointed low-energy cauterization for robot-assisted radical prostatectomy |
| Ficarra et al, 2012149 | Jan 2008—Aug 2011 (Medline, Embase, Web of Science) | 51 studies | Open, laparoscopic | Robot-assisted vs. open: better 12-month urinary continence recovery (OR 1.53, P = .03) Robot-assisted vs. laparoscopic: better 12-month urinary continence recovery (OR 2.39, P = .006) 12-month urinary incontinence rates ranged from 4% to 31%, with a mean value of 16% using a no-pad definition; considering a no-pad or safety-pad definition, incidence ranged from 8% to 11%, with a mean value of 9% Age, body mass index, comorbidity index, lower urinary tract symptoms, and prostate volume were the most relevant preoperative predictors of urinary incontinence after robot-assisted radical prostatectomy Posterior musculofascial reconstruction with or without anterior reconstruction was associated with a small advantage in urinary continence recovery 1 month after robot-assisted radical prostatectomy Only complete reconstruction was associated with a significant advantage in urinary continence 3 months after robot-assisted radical prostatectomy (OR 0.76, P = .04) |
| Gleitsmann et al, 2012150 | Jan 2002—Jan 2012 (Medline, Medicaid Evidence-based Decisions Project) | 55 studies | Open, laparoscopic | Robot-assisted vs. open and laparoscopic: moderate evidence for reduced length of hospital stay, blood loss, and transfusion rates; moderate evidence for no difference in complication rates Robot-assisted vs. open: moderate evidence for increased operative time, reduced PSM rate, increased urinary continence and sexual function; low evidence of no difference in biochemical recurrence-free survival Robot-assisted vs. laparoscopic: moderate evidence for reduced operative time; no difference in PSM rate Moderate evidence that surgeons experienced in robot-assisted had improvements in most clinical outcomes (except blood loss) compared with less experienced surgeons |
| Moran et al, 2013151 | Jan 2000—Mar 2011 (Medline, Embase, CINAHL, Cochrane, Journal of Robotic Surgery) | 51 studies (1 RCT, 50 non-RCT) | Open, laparoscopic | Robot-assisted vs. open: reduced PSM rates for pT2 (RR 0.63, 95% CI 0.49–0.81, P < .001), improved sexual function at 12 months (RR 1.60, 95% CI 1.33–1.93, P < .001), improved urinary function at 12 months (RR 1.06, 95% CI 1.02–1.11, P < .01) Robot-assisted vs. laparoscopic: slightly improved urinary function at 12 months (RR 1.09, 95% CI 1.02—1.17, P = .013) |
| Novara et al, 2012152 | Jan 2008—Aug 2011 (Medline, Embase, Web of Science) | 79 studies | Open, laparoscopic | Mean PSM rate was 15% in all cancers and 9% in pathologically localized cancers, with some tumour characteristics being the most relevant predictors of PSMs Robot-assisted vs. open: similar overall PSM rate (OR 1.21, P = .19) and pT2 PSM rate (OR 1.25, P = .31); similar biochemical recurrence-free survival (HR 0.9, P = .53) Robot-assisted vs. laparoscopic: similar overall PSM rate (OR 1.12, P = .47) and pT2 PSM rate (OR 0.99; P = .97); similar biochemical recurrence-free survival (HR 0.5, P = .14) Several surgeon-related characteristics or procedure-related issues may play a major role in PSM rates 7-year biochemical recurrence-free survival estimates of about 80% |
| Novara et al, 2012153 | Jan 2008—Aug 2011 (Medline, Embase, Web of Science) | 72 studies | Open, laparoscopic | Robot-assisted: overall mean operative time 152 minutes; mean blood loss 166 mL; mean transfusion rate 2%; mean catheterization time 6.3 days; mean length of hospital stay 1.9 days; mean complication rate 9%, with most of the complications being of low grade—lymphocele/lymphorrhea (3.1 %), urine leak (1.8%), and reoperation (1.6%) were the most prevalent surgical complications Robot-assisted vs. open: lower blood loss (weighted mean difference 582.77, P < .001) and transfusion rate (OR 7.55, P < .001); no difference in operative time or complication rate Robot-assisted vs. laparoscopic: reduced transfusion rate (OR 2.56, P = .005); no difference in operative time, blood loss, or complication rate |
| Ramsay et al, 2012154 | Jan 1995—Oct 2010 (Medline, Embase, BIOSIS, Science Citation Index, CENTRAL, DARE, CDSR, conference abstracts) | 58 reports of 54 studies (1 RCT, 57 reports of 53 non-RCTs) | Laparoscopic | Robot-assisted vs. laparoscopic: lower complication rates (anastomotic leak and organ injury only), PSM rate (17.0% vs. 23.6%, OR 0.69, 95% credible interval 0.51–0.96), transfusion rate (OR 0.71, 95% credible interval 0.31–1.62), and operative time (−12.4 minutes, 95% credible interval −16.5 to −8.1 minutes); no difference in urinary continence at 12 months (OR 0.55, 95% credible interval 0.09–2.84) or biochemical recurrence rate (OR 0.89, 95% credible interval 0.24–3.34); insufficient data to assess any differences in quality of life, sexual function, length of hospital stay, or catheterization duration; no difference in surgeon learning rates |
| Tewari et al, 2012155 | Jan 2012—Dec 2010 (PubMed, Scopus) | 400 studies (187 robot-assisted, 96 open, 117 laparoscopic) | Open, laparoscopic | Robot-assisted and laparoscopic vs. open: lower blood loss, transfusion rate, and length of stay Robot-assisted vs. open and laparoscopic: lower complication rates After propensity adjustment, PSM rates for laparoscopic were higher than robot-assisted but were similar to open Complication rates low for all groups, but lowest for robot-assisted Rates for the following showed significant differences between groups, generally favouring robot-assisted: readmission; reoperation; nerve, ureteral, or rectal injury; deep vein thrombosis; pneumonia; hematoma; lymphocele; anastomotic leak; fistula; and wound infection |
| Sandoval Salinas et al, 2013156 | 1948—Oct 2012 (Medline, Embase, LILACS, CENTRAL, DARE) | 2 RCTs | Laparoscopic | Robot-assisted vs. laparoscopic: improved sexual function and urinary continence; no differences in perioperative outcomes |
| De Carlo et al, 2014157 | ?—Dec 2013 (PubMed, Embase) | 25 studies | Open, laparoscopic | Robot-assisted and laparoscopic: operative time, blood loss, transfusion rates, catheterization duration, length of hospital stay, complication rate were most optimal in the laparoscopic approaches Data insufficient to prove superiority of any surgical approach for functional and oncological outcomes |
| Agarwal et al, 2015158 | Search period unspecified (PubMed, Cochrane) | 19 non-RCTs | Open | Robot-assisted: not unequivocally shown to be superior to open for functional and oncological outcomes |
| Pan et al, 2015159 | Jan 2009—Oct 2013 (PubMed, Google Scholar, Embase, Web of Science) | 6 studies | Open | Robot-assisted vs. open: longer operative time (weighted mean difference 64.84, 95% CI 44.12—85.55, P < .001); no difference in transfusion rate, PSM rate, or 3-and 12-month urinary continence; improved potency at 3 months (OR 2.80, 95% CI 1.83—4.27, P < . 001) and 12 months (OR 1.70, 95% CI 1.30—2.23, P < .001) |
| Allan et al, 2016160 | 1950—Dec 2014 (Medline, Scopus, CDSR, Central) | 2 RCTs | Laparoscopic | Robot-assisted: significantly higher rate of return to erectile function (RR 1.51, 95% CI 1.19–1.92) and continence (RR 1.14, 95% CI 1.04–1.24); no significant differences in operative time, blood loss, transfusion rate, or biochemical recurrence (RR 1.01, 95% CI 0.91–1.12) |
| Seo et al, 2016131 | Jan 1980—Aug 2013 (Medline, Embase, Cochrane, KoreaMed, KMbase, RISS4U, KISS, KISTI, NDSL) | 61 non-RCTs (38 from previous systematic reviews) | Open | Robot-assisted: improved perioperative and functional outcomes (urinary continence and erectile function), lower complication rate; no difference for positive surgical margin or biochemical recurrence-free survival |
Abbreviations: CDSR, Cochrane Database of Systematic Reviews; CENTRAL, Cochrane Central Register of Controlled Trials; CI, confidence interval; CINAHL, Cumulative Index of Nursing and Allied Health Literature; DARE, Database of Abstracts and Reviews of Effects; HR, hazard ratio; HTA, health technology assessment; KISS, Korean Studies Information Service System; KISTI, Korean Institute of Science and Technology Information; LILACS, Latin American and Caribbean Literature on the Health Sciences; NDSL, National Digital Science Library; OR, odds ratio; PSM, positive surgical margin; RCT, randomized controlled trial; RISS4U, Research Information Service System for You; RR, relative risk.