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  • Review Article
  • Clinical Research
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Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases

Prostate Cancer and Prostatic Diseases volume 26, pages 495–510 (2023)Cite this article

Subjects

Abstract

Background

Current guidelines recommend simple prostatectomy or endoscopic enucleation of the prostate (EEP) as treatment of choice for bladder prostatic obstruction (BPO) caused by large prostate glands. We aimed to provide a wide-ranging analysis of the currently available evidence, comparing safety and effectiveness of robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP), laparoscopic simple prostatectomy (LSP), and laser EEP.

Methods

A systematic search was performed across MEDLINE, EMBASE, and Web of Science databases for retrospective and prospective studies comparing RASP to OSP or LSP or laser EEP (HoLEP/ThuLEP). Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design the search strategies, selection criteria, and evidence report. A meta-analysis evaluated perioperative safety and effectiveness outcomes. The weighted mean difference and risk ratio were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale and the Cochrane Collaboration’s tool for RCT article assessing risk of bias.

Results

15 studies, including 6659 patients, were selected for meta-analysis: 13 observational studies, 1 non-randomized prospective study, and 1 randomized controlled trial. RASP was associated with statistically significant longer operative time (OT) and lower postoperative complication rate, length of stay (LOS), estimated blood loss (EBL), and transfusion rate (TR) compared to OSP. LSP showed longer LOS and lower postoperative SHIM score, with no difference in OT, EBL, and complications. Compared to laser EEP, RASP presented longer LOS and catheterization time and higher TR. ThuLEP presented shorter OT than RASP. No difference were found in functional outcomes between groups both subjectively (IPSS, QoL) and objectively (Qmax, PVR).

Conclusion

RASP has become a size-independent treatment for the management of BPO caused by a large prostate gland. It can duplicate the functional outcomes of OSP while offering a better safety profile. When compared to LSP, the latter still stands as a valid lower-cost option, but it requires solid laparoscopic skill sets and therefore it is unlikely to spread on larger scale. When compared to laser EEP, RASP offers a shorter learning curve, but it still suffers from longer catheterization time and LOS.

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Fig. 1: PRISMA flowchart.
Fig. 2: Forest plots of perioperative outcomes and postoperative complications for robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP).
Fig. 3: Forest plots of urodynamic outcomes for robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP).
Fig. 4: Forest plots of functional outcomes for robot-assisted simple prostatectomy (RASP) versus open simple prostatectomy (OSP).
Fig. 5: Forest plots perioperative outcomes and postoperative complications for robot-assisted simple prostatectomy (RASP) versus laparoscopic simple prostatectomy (LSP).
Fig. 6: Forest plots of urodynamic and sexual outcomes for robot-assisted simple prostatectomy (RASP) versus laparoscopic simple prostatectomy (LSP).
Fig. 7: Forest plots of functional outcomes for robot-assisted simple prostatectomy (RASP) versus laparoscopic simple prostatectomy (LSP).
Fig. 8: Forest plots of perioperative outcomes for robot-assisted simple prostatectomy (RASP) versus endoscopic enucleation of the prostate (EEP).
Fig. 9: Forest plots of postoperative complications for robot-assisted simple prostatectomy (RASP) versus endoscopic enucleation of the prostate (EEP).
Fig. 10: Forest plots of urodynamic and functional outcomes for robot-assisted simple prostatectomy (RASP) versus endoscopic enucleation of the prostate (EEP).

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Authors and Affiliations

  1. Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy

    Savio Domenico Pandolfo, Vincenzo Mirone & Ciro Imbimbo

  2. Department of Maternal-Infant and Urologic Sciences, “Sapienza” University of Rome, Policlinico Umberto I Hospital, Rome, Italy

    Francesco Del Giudice

  3. Department of Urology, Stanford Medical Center, Stanford, CA, USA

    Francesco Del Giudice & Benjamin I. Chung

  4. Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy

    Celeste Manfredi & Marco De Sio

  5. Urology Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy

    Rocco Damiano & Fabio Crocerossa

  6. Department of Urology, Rush University Medical Center, Chicago, IL, USA

    Edward E. Cherullo & Riccardo Autorino

  7. Urology Unit, Ospedale Sant’Andrea, La Sapienza University of Rome, Rome, Italy

    Cosimo De Nunzio

  8. USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Giovanni E. Cacciamani

  9. Department of Urology, Villa Stuart, Private Hospital, Rome, Italy

    Luca Cindolo

  10. Division of Urology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy

    Francesco Porpiglia

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Contributions

Conceptualization: SDP, FC, RA; Methodology: SDP, FC, RA; Data acquisition: SDP; Analysis: SDP, FC; Writing—original draft preparation: SDP, FC, RA; Writing—review and editing: SDP, FC, RC; Supervision: FDG, BIC, CM, MDS, RD, EEC, CDN, GEC, LC, FP, VM, CI; Project administration: SDP, FC, RA. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Riccardo Autorino.

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Pandolfo, S.D., Del Giudice, F., Chung, B.I. et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis 26, 495–510 (2023). https://doi.org/10.1038/s41391-022-00616-4

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