Clinical Outcomes of Robotic Surgery Compared to Conventional Surgical Approaches (Laparoscopic or Open)

A Systematic Overview of Reviews

Hala Muaddi, MD, MSc; Melanie El Hafid; Woo Jin Choi, MD; Erin Lillie, MSc; Charles de Mestral, MD, PhD; Avery Nathens, MD, PhD; Therese A. Stukel, PhD; Paul J. Karanicolas, MD, PhD

Disclosures

Annals of Surgery. 2021;273(3):467-473. 

In This Article

Abstract and Introduction

Abstract

Objective: Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery.

Background: Robotic surgery utilization has increased over the years across a wide range of surgical procedures. However, evidence supporting improved clinical outcomes after robotic surgery is limited.

Methods: We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of systematic reviews from inception to January 2019 for systematic reviews describing postoperative outcomes after robotic surgery. We qualitatively described patient outcomes of commonly performed robotic procedures: radical prostatectomy, hysterectomy, lobectomy, thymectomy, rectal resection, partial nephrectomy, distal gastrectomy, Roux-en-Y gastric bypass, hepatectomy, distal pancreatectomy, and cholecystectomy.

Results: One hundred fifty-four systematic reviews included 336 studies and 18 randomized controlled trials reporting on patient outcomes after robotic compared to laparoscopic or open procedures. Data from the randomized controlled trials demonstrate that robotic-assisted radical prostatectomy offered fewer biochemical recurrence and improvement in quality of recovery and pain scores only up to 6 weeks postoperatively compared to open radical prostatectomy. When compared to laparoscopic prostatectomy, robotic surgery offered improved urinary and sexual functions. Robotic surgery for endometrial cancer had fewer conversion to open compared to laparoscopic. Otherwise, robotic surgery outcomes were similar to conventional surgical approaches for other procedures except for radical hysterectomy where minimally invasive approaches may result in patient harm compared to open approach.

Conclusion: Robotic surgery has been widely incorporated into practise despite limited supporting evidence. More rigorous research focused on patient-important benefits is needed before further expansion of robotic surgery.

Introduction

Laparoscopic surgery revolutionized the field of surgery and is now considered to be the gold standard for many thoracoabdominal procedures. The adoption of laparoscopy has been slow, dating back to 1933 when the first laparoscopic lysis of adhesion was performed.[1] The slow progress and uptake is related to the technological limitations at that time, and to the requirement of clinical evidence to demonstrate clinical safety and patient benefit.[1] To date, there are a large number of randomized controlled trials (RCTs) dedicated to examining patient outcomes after laparoscopic surgery compared to open surgery.[2,3] These trials focus on short- and long-term clinically relevant patient-important outcomes (eg, postoperative morbidity and mortality) and they demonstrate an overall benefit of laparoscopic surgery.[2–4]

Robotic surgery is an extension of laparoscopic surgery. Its advocates report improved dexterity, better ergonomics, enhanced visualization, decreased fatigue, and less surgeon physiological tremor compared to laparoscopic and open surgery.[5] The regulatory approval process for new devices differs from the process of pharmaceutical products.[6,7] Due to these regulatory standards robotic surgery was approved for a broad range of procedures including thoracic, gynecology, urology, and general surgery without the requirement of prospective studies or RCTs demonstrating benefit to patients.[6,7] Nevertheless, robotic surgery has become a symbol of providing advanced care. Competition among hospitals and specialists coupled with their innate curiosity to learn about new tools facilitated the persuasive marketing of robotic surgery.[7] The number of procedures performed robotically is expected to continue to rise as more hospitals invest in this technology. By the end of 2017, there were 4666 robotic consoles installed worldwide; 3000 of those were in the United Stated.

Subsequent to its implementation, numerous observational studies and a few RCTs were published describing the outcomes of robotic surgery. Herein, we perform an overview of systematic reviews to describe and synthesize the current state of evidence for robotic surgical procedures.

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