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].