Surgical and functional outcomes of Retzius‐sparing robotic‐assisted radical prostatectomy versus conventional robotic‐assisted radical prostatectomy in patients with biopsy‐confirmed prostate cancer. Are outcomes worth it? Systematic review and meta‐analysis

Abstract Background Radical prostatectomy is the standard of care for prostate cancer. Retzius‐sparing robotic‐assisted radical prostatectomy (RS‐RARP) is being widely adopted due to positive functional outcomes compared to conventional robotic‐assisted radical prostatectomy (c‐RARP). Concerns regarding potency, oncological outcomes, and learning curve are still a matter of debate. Methods Following Preferred Instrument for Systematic Reviews and Meta‐Analysis guidelines and PROSPERO registration CRD42023398724, a systematic review was performed in February 2023 on RS‐RARP compared to conventional c‐RARP. Outcomes of interest were continence recovery, potency, positive surgical margins (PSM), biochemical recurrence (BCR), estimated blood loss (EBL), length of stay (LOS), operation time and complications. Data were analyzed using R version 4.2.2. Results A total of 17 studies were included, totaling 2751 patients, out of which 1221 underwent RS‐RARP and 1530 underwent c‐RARP. Continence was analyzed using two definitions: zero pad and one safety pad. Cumulative analysis showed with both definitions statistical difference in terms of continence recovery at 1 month (0 pad odds ratio [OR] = 4.57; 95% confidence interval [CI] = [1.32–15.77]; Safety pad OR = 13.19; 95% CI = [8.92–19.49]), as well as at 3 months (0 pad OR, 2.93; 95% CI = [1.57–5.46]; Safety pad OR = 5.31; 95% CI = [1.33–21.13]). Continence recovery at 12 months was higher in the one safety pad group after RS‐RARP (OR = 4.37; 95% CI = [1.97–9.73]). The meta‐analysis revealed that overall PSM rates without pathologic stage classification were not different following RS‐RARP (OR = 1.13; 95% CI = [0.96–1.33]. Analysis according to the tumor stage revealed PSM rates in pT2 and pT3 tumors are not different following RS‐RARP compared to c‐RARP (OR = 1.46; 95% CI = [0.84–2.55]) and (OR = 1.41; 95% CI = [0.93–2.13]), respectively. No difference in potency at 12 months (OR = 0.98; 95% CI = [0.69–1.41], BCR at 12 months (OR = 0.99; 95% CI = [0.46–2.16]), EBL (standardized mean difference [SMD] = −0.01; 95% CI = [−0.31 to 0.29]), LOS (SMD = −0.01; 95% CI = [−0.48 to 0.45]), operation time (SMD = ‐0.14; 95% CI = [−0.41 to 0.12]) or complications (OR = 0.9; 95% CI = [0.62–1.29]) were observed. Conclusions Our analysis suggests that RS‐RARP is safe and feasible. Faster continence recovery rate is seen after RS‐RARP. Potency outcomes appear to be similar. PSM rates are not different following RS‐RARP regardless of pathologic stage. Further quality studies are needed to confirm these findings.