Platinum Priority – Review – Prostate CancerEditorial by Peter C. Albertsen on pp. 365–367 of this issueSystematic Review and Meta-analysis of Perioperative Outcomes and Complications After Robot-assisted Radical Prostatectomy
Introduction
Radical prostatectomy (RP) is a standard surgical treatment for clinically localized prostate cancer [1]. Robot-assisted RP (RARP) has become a very popular procedure in both the United States and Europe, and it has been estimated that >75% of RPs are performed using the da Vinci platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) [2], [3]. As for every surgical procedure, perioperative complications are a major surgical outcome for RP. Some recent population-based studies evaluated prevalence of complications in large cohort of patients who received retropubic RP (RRP) or minimally invasive RP (MIRP; mainly RARP in the United States) and demonstrated lower risk of complications in patients having robotic surgery [4], [5]. However, data from population-based studies might be limited by inaccuracies in data collection that may lead to underreporting of complications and heterogeneity in surgical techniques. We previously reported a systematic review of the literature on RARP demonstrating complication rates ranging from 1.5% to 20% in surgical series published up to 2007 and including the very first cases performed with the da Vinci platform [6]. Moreover, in another systematic review of the literature limited to papers published up to 2008, we demonstrated that prevalence of perioperative complications following RRP, laparoscopic RP (LRP), and RARP was similar [7].
In 2002, Martin et al. proposed a standardized method for reporting complications from surgical procedures. The method was based on 10 criteria, including methods of data accrual, duration of follow-up, presence of outpatient information, definitions of complications, mortality and morbidity rates, procedure-specific complications, severity grading, length of in-hospital stay, and analysis of risk factors [8]. Although such criteria are not routinely applied, some studies evaluated complications following RRP [9], LRP [10], or RARP [11], [12], [13], [14] using such standardized criteria.
Because of the increasing use of RARP as well as the mounting literature in the field on perioperative complications of RARP, we elected to update our previous systematic reviews. Specifically, we aimed to evaluate complication rates following RARP, risk factors for complications after RARP, and surgical techniques to improve complication rates after RARP. We also performed a cumulative analysis of all studies comparing RARP with RRP or LRP in terms of perioperative complications.
Section snippets
Evidence acquisition
To update our previous systematic review [6], [7], we performed a literature search in August 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the term radical prostatectomy in the title and the abstract fields of the records. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. The searches of the Embase and Web of Science databases used the same free-text protocol, keyword,
Quality of the studies and level of evidence
Figure 1 shows the flowchart of this systematic review of the literature. We selected 110 records reporting oncologic outcomes after RARP. One further study (level 2) published during the realization of the systematic review was also added [16].
Thirty-six abstracts or meeting reports and three duplicate publications were excluded. The remaining studies were 21 case series (level 4), 32 studies comparing different techniques in the context of RARP (5 studies, level 2; 18 studies, level 3; 9
Discussion
The data of the present systematic review suggest that RARP can be performed routinely in a reasonably short operative time, with low risk of blood loss and low transfusion rates. Some patient characteristics such as high BMI, large prostate volume, prior abdominal surgery, prior BPH surgery, or presence of median lobe may make the surgical procedure more difficult, possibly increasing operative time, blood loss, or catheterization time. Currently, postoperative complications are relatively
Conclusions
The data of the present systematic review suggest that RARP can be performed routinely with a reasonably limited risk of complications, although some patients with unfavorable clinical or cancer characteristics might be at higher risk. Surgical experience may play a role in improving perioperative outcomes and complications, but its impact has not been sufficiently studied. Finally, cumulative analyses demonstrated that blood loss and transfusion rates were significantly lower with RARP than
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