Literature Review and Discussion
Robotics-assisted surgery has spread rapidly as a technique to develop
laparoscopic surgery through innovative technological improvements, such
as 3D imaging with a high magnifying lens and freedom of clamps in
varying degrees, leading to improved safety and better functional
recovery. In the urological field, it enabled a highly fine operation in
a narrow field, such as the pelvic cavity or retroperitoneal space.
Better results were recognized especially in perioperative complications
and recovery of postoperative QOL than other procedures such as open or
laparoscopic. Robotic assistance definitely brought a paradigm shift in
urological surgery [6].
In this sense, a study presented simple transvesical prostatectomy via
percutaneous single door using the new robotic surgical system SP ®. Ten
patients underwent simple single-door transvesical prostatectomy between
February and November 2019. Percutaneous access to the bladder dome was
performed and all SP ® instruments were inserted through the SP ®
multichannel cannula directly into the bladder. Enucleation of the
prostate adenoma, hemostasis and trigonization were performed according
to the principles of the simple open prostatectomy technique. All
procedures were performed successfully, without the need for conversion
to open surgery. The estimated average size of the prostate in the
preoperative period was 159 (IQR 108-223) grams. There were no
intraoperative complications. The mean operative time and estimated
blood loss were 190 (IQR 146-203) minutes and 100 (IQR 68-175) ml,
respectively. The average weight of the sample in the postoperative
period was 84.3 ± 34 grams. The average hospital stay was 19 (IQR 17 -
28) hours. All patients were satisfied with the urine flow after removal
of the catheter without any episode of acute urinary retention from 1 to
6 months postoperatively. Therefore, simple single-port transvesical
prostatectomy can be offered as an alternative treatment option for the
surgical treatment of lower urinary tract symptoms associated with large
prostate adenoma. Saving the peritoneal cavity, minimal bladder
dissection, excellent visualization of the prostate fossa can be some of
the potential advantages of this minimally invasive approach.
Comparative studies with standard techniques are recommended to assess
the surgical outcome and postoperative morbidity of each treatment
modality [7].
Still, most of the evidence found in the present study was observational
studies related to case series or case reports of several services that
used the technology. Some of these studies explored only variations of
the consolidated surgical techniques. The most robust studies found were
3 systematic reviews included.
The Cochrane review was designed with the aim of comparing radical
prostatectomy by laparoscopy or robot-assisted radical prostatectomy
with open radical prostatectomy, in men with localized prostate cancer.
Searches were carried out in multiple databases for randomized clinical
trials (RCTs), or quasi-randomized, published until June 2017, for
direct comparison between technologies. Study selection, data
extraction, and quality assessment were performed by 2 independent
researchers. Only 2 RCTs were included, one comparing laparoscopic
prostatectomy with open surgery [18] and the other comparing
robot-assisted prostatectomy with open surgery [19] in participants
with localized prostate cancer. In this report, only the results of the
study that evaluated robot-assisted prostatectomy will be considered
[19]. The outcomes of overall survival and prostate cancer-related
survival have not been evaluated.
In addition, another study showed that there were no differences between
robot-assisted prostatectomy and open prostatectomy for quality of life,
urinary and sexual outcomes, surgery-related complications, severe
complications and pain after 12 weeks of surgery. Robot surgery has
reduced hospital stay compared to open surgery [17].
The duration of surgery (mean of 202.03 minutes (standard deviation SD =
51.36) versus 234.34 minutes (SD = 37.07); p <0.001 and time
in the operating room (mean of 246, 08 minutes (SD = 55.12) versus
280.37 minutes (SD = 36.36); p <0.0001 were lower for
robot-assisted prostatectomy than for open prostatectomy, respectively,
however, there was no difference between the groups in time spent on
recovery. [19] The estimate of total blood loss was lower for
robot-assisted prostatectomy than for open prostatectomy (443.74 mL (SD
= 294.29) versus 1,338.14 mL ( SD = 591.47); p <0.0001
[19].
In addition, the systematic review with meta-analysis prepared by the
Austrian institute Ludwig Boltzmann Institut für Health Technology
Assessment (LBI-HTA) 9 in 2015 assessed the effectiveness, safety, and
costs associated with the use of RS in some selected indications. For
the radical prostatectomy procedure, the comparators selected were open
surgery and laparoscopic surgery. None of the studies identified showed
an explicit benefit of RS for patients, including nephrectomy,
adrenalectomy, prostatectomy, cystectomy or hysterectomy procedures.
Specifically for the outcomes related to the prostatectomy procedure, 1
randomized clinical study and 8 prospective cohort studies were
included. The main results of meta-analysis on robotically assisted
radical prostatectomy included in the systematic review for outcomes:
urinary continence 6 and 12 months after surgery, sexual dysfunction,
duration of the surgical procedure and general complications [20].
The meta-analysis showed no statistically significant difference between
robot-assisted surgery and open surgery in the patient’s likelihood of
continence 6 or 12 months after surgery. In addition, there was a
relatively high heterogeneity (I² = 66 and 72%, respectively) between
studies [20].
The meta-analysis showed that robot-assisted surgery was more likely to
maintain sexual function preserved 12 months after surgery than with
open surgery (relative risk 1.59; 95% CI 1.28 to 1.99). Although with
relatively high heterogeneity (I² = 73%), all studies showed an effect
in favor of RS. The meta-analysis showed a shorter stay of 1.5 days in a
robot-assisted prostatectomy compared to open surgery (p
<0.0001). The studies, however, showed a very high
heterogeneity (I² = 99%) [20].
The meta-analysis showed a difference in the occurrence of general
complications between a robot-assisted prostatectomy and an open
surgical prostatectomy, statistically significant (p = 0.05) in favor of
robot-assisted prostatectomy (relative risk 0.72). However, individual
studies showed a high heterogeneity (I² = 72%), with favorable effects
on both sides, both in favor of the intervention and for the comparator
[20].
Assessment of the quality of evidence and risk of bias Regarding the
comparison of robotically assisted surgery with open surgery or surgery
via laparoscopy, the systematic review, in general, showed a low risk of
bias, having clearly defined the structured question, the literature
search, independent evaluations, heterogeneity analysis, and statistical
analysis. The identified cohort studies, both in comparison with open
surgery and laparoscopic surgery, demonstrated a high risk of selection
bias and the description of a similar prognosis was not described in
detail. In addition, the high heterogeneity, the low number of patients,
the lack of blinding and the lack of a report on the loss of patients
who are no longer part of the studies also contributed to the quality of
the evidence being lowered. The quality of these studies and the
strength of the evidence were considered low. Specifically, in
comparison with laparoscopic surgery, the risk of bias from the included
RCT was considered low, with only a high risk detected for a performance
bias caused by the absence of blinding. Only in outcomes where the RCT
can be taken into account, the level of evidence can be considered
moderate. The risk of bias present in the studies is represented in
figures 17 to 20 and the level of quality of the evidence demonstrated
in tables 3 and 4 using the GRADE tool (Grading of Recommendations
Assessment, Development, and Evaluation) [20].