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

Results

Study Selection

Through the systematic search, 3233 articles were identified (Figure 1). After removal of duplicate studies (n = 795), there were 2438 articles for evaluation. 1816 articles were excluded after title and abstract screening, leaving 622 articles. Of these, 378 were removed because they were published before January 2017 leaving 244 articles for full text review. Of those, 153 systematic reviews met inclusion criteria. The articles included in this overview are described in more details below and summarized in Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140.

Figure 1.

PRISMA flow diagram.

Radical Prostatectomy

Open Radical Prostatectomy Compared to Robotic Assisted Radical Prostatectomy. There was 1 RCT, 14 prospective studies and several retrospective studies comparing robotic-assisted radical prostatectomy to open radical prostatectomy.[11] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarize characteristics of primary studies included in the systematic reviews and data from the RCT.

The RCT enrolled 163 men to the robotic arm and 163 to the open arm. There were no differences in urinary function or erectile dysfunction at 6 weeks, 12 weeks, and 24 months postoperative.[12,13] They also determined no difference in postoperative pain at rest after 24 hours, 1 week, 6 weeks, and 12 weeks.[12,13] However, patients did report less pain (assessed with the surgical pain scale) after robotic surgery at 24 hours and 1 week while performing regular activities when compared to open surgery [4.6 (95% confidence interval (CI) 4.25, 4.95) vs 5.83 (95% CI 5.44, 6.23) P < 0.0001] and [2.51 (95% CI 2.19, 2.82) vs 3.19 (95% CI 2.91, 3.48) P = 0.002] respectively.[13] Furthermore, patients reported higher physical quality of life (measured by the SF-36) after robotic surgery compared to open surgery at 6 weeks postoperative but not at later follow up intervals [53.7 (95% CI 52.7, 54.7) vs 51.96 (95% CI 50.71, 53.3) P = 0.03].[13] There were no statistically significant differences in return to work, or length of time away from work.[13] Furthermore, patients with open surgery had a longer operative time, length of stay (LOS) in hospital, and more estimated blood loss (EBL).[13] There were no differences in the proportion of intraoperative complications, number of units transfused, readmissions to hospital, and insertion of indwelling catheter.[13] Lastly, at 24 months robotic surgery had fewer patients with biochemical Prostate Specific Antigen recurrence than open surgery; however, there were no differences in disease recurrence on imaging.[12]

Laparoscopic Radical Prostatectomy Compared to Robotic Assisted Radical Prostatectomy. There were 2 randomized controlled trails, 10 prospective studies, and 16 retrospective studies comparing robotic-assisted radical prostatectomy to laparoscopic radical prostatectomy.[14] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarize characteristics of primary studies included in the systematic reviews and data from the RCT.

One RCT included 128 patients randomized to robotic-assisted or laparoscopic radical prostatectomy. There were no differences in conversion to open, blood transfusion, duration of catheter insertion, postoperative complications, positive surgical margin, urinary continence or time to urinary continence between the 2 procedures.[15] However, patients after robotic surgery experienced less frequency of erectile dysfunction than laparoscopic surgery (32% vs 77%, P < 0.0001).[15] Another RCT recruited 60 patients to each arm similarly demonstrated no differences in blood loss, operative time, nerve sparing procedure, LOS in hospital, postoperative catherization, biochemical recurrence, and positive surgical margin.[16] More patients in the robotic arm had erectile dysfunction recovery and urinary continence compared to the laparoscopic arm (80% vs 54.2%, P = 0.02) and (80% vs 61.6%, P = 0.04), respectively after 1 year postoperative.[16]

Partial Nephrectomy

Partial Nephrectomy Compared to Robotic Partial Nephrectomy. There were 2 prospective studies, 32 retrospective studies, and no RCTs comparing robotic partial nephrectomy to open partial nephrectomy[17] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes characteristic of the primary studies included in the systematic review.

Laparoscopic Partial Nephrectomy Compared to Robotic Partial Nephrectomy. There was 1 prospective study, 40 retrospective studies, and no RCTs comparing robotic partial nephrectomy to laparoscopic partial nephrectomy.[17] Supplemental Digital Content Table 1 summarizes characteristic of the primary studies included in the systematic review.

Rectal Resection

Robotic Rectal Surgery Compared to Laparoscopic Rectal Surgery. There were 5 RCTs, and several retrospective studies comparing robotic rectal surgery to laparoscopic rectal surgery.[18–22] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarize characteristics of primary studies included in the systematic reviews and data from the RCT.[23]

The systematic review demonstrated no differences in the rate of incomplete total mesorectal excision [2 trials, relative risk (RR) 0.92; 95% CI 0.68, 1.25],[18,21,23] risk of circumferential margin involvement (2 trials, RR 0.82; 95% CI 0.39, 1.73),[20,21,23] mean number of lymph nodes harvested (5 trials, MD −0.35; 95% CI −1.83, 1.12),[18–23] risk of anastomotic leaks (3 trials, RR 1.26; 95% CI 0.39, 4.10),[19,20,22] 30-day mortality (5 trials, RR 0.97; 95% CI 0.14, 6.86),[18–22] 30-day postoperative complications (5 trials, RR 1.02; 95% CI 0.80, 1.31),[18–22] EBL (4 trials, heterogeneity in reporting precluded meta-analysis),[18–20,22] and LOS in hospital (4 trials, MD −0.61; 95% CI −2.23, 1.02) for robotic compared to laparoscopic rectal surgery.[19–21]

However, there was a significant difference in the rate of conversion to open surgery (4 trials, RR 0.58; 95% CI 0.35, 0.97) with the risk of conversion being lower in robotic rectal surgery than laparoscopic rectal surgery.[18–21] the duration of surgery was significantly longer (5 trials, MD 38.43; 95% CI 31.84, 45.01),[18–22] and patients had an earlier return of bowel function (2 trials, MD −0.59; 95% CI −0.95, −0.23) after robotic surgery compared to laparoscopic surgery.[18,22]

Lobectomy

Robotic Assisted Thoracoscopic Surgery Compared to Video Assisted Thoracoscopic Surgery. There were 1 prospective study, 14 retrospective studies, and no RCTs comparing robotic-assisted thoracoscopic surgery to video-assisted thoracoscopic surgery.[24] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes characteristic of the primary studies included in the systematic review.

Thymectomy

There are 7 retrospective and no prospective studies or RCTs investigating the role of robotic thymectomy as an alternative to open thymectomy.[25] An alternative minimally invasive approach include thoracoscopic thymectomy. There are 5 retrospective studies and no prospective or RCTs comparing clinical outcomes after robotic to thoracoscopic thymectomy.[26] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes characteristic of the primary studies included in the systematic review.

Radical Hysterectomy for Cervical cancer

Open Radical Hysterectomy Compared to Robotic Radical Hysterectomy. There were 2 prospective studies, 13 retrospective studies and no RCTs comparing open radical hysterectomy to robotic radical hysterectomy for cervical cancer.[27] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Laparoscopic Radical Hysterectomy Compared to Robotic Radical Hysterectomy There were 11 retrospective studies comparing robotic radical hysterectomy to laparoscopic radical hysterectomy for cervical cancer. No RCTs or prospective studies were identified.[27] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Minimally Invasive Radical Hysterectomy to Open Radical Hysterectomy Most recently, the role minimally invasive radical hysterectomy for management of cervical cancer has been questioned after the Laparoscopic Approach to Cervical Cancer (LACC) trial. this multicenter RCT combined with a large multicenter retrospective analysis demonstrated that minimally invasive approaches are associated with 4-fold higher rate of recurrence and 6-fold higher rate of all-cause death when compared to an open approach.[28,29]

Total Hysterectomy for Endometrial Cancer

Laparoscopic Hysterectomy Compared to Robotic Hysterectomy. There were 1 RCT and several retrospective studies comparing robotic hysterectomy to laparoscopic hysterectomy for endometrial cancer.[30] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarize characteristics of primary studies included in the systematic reviews and data from the RCT.

The RCT randomized 51 patients to laparoscopic hysterectomy and 50 patients to robotic hysterectomy for management of endometrial cancer.[31] They demonstrate shorter operative time [(139 minutes (range 86–197) vs 170 minutes (range 126–259), P < 0.001) and fewer conversions to open surgery (0 vs 5, P = 0.027) with robotic hysterectomy compared to laparoscopic hysterectomy.[31] There were no differences in EBL, postoperative hemoglobin levels, transfusion rates, postoperative pain, or hospital LOS.[31]

Total Hysterectomy for Benign Disease

Laparoscopic Hysterectomy Compared to Robotic Hysterectomy. There were 3 RCTs comparing robotic hysterectomy to laparoscopic hysterectomy for benign uterine disease.[32] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarize characteristics of primary studies included in the systematic reviews and data from the RCT.

The systematic review of the RCTs demonstrated no differences in the rate perioperative complications, LOS in hospital [weighted mean differences (WMD) 0.17 days; 95% CI 0.36, 0.02], operative time (WMD 23.13 minutes; 95% CI −21.25, 67.52), EBL (WMD −17.99; 95% CI −71.29, 35.3), postoperative pain and quality of life of robotic compared to laparoscopic hysterectomy.[32]

Myomectomy for Benign Disease

Abdominal Myomectomy Compared to Robotic Myomectomy. There were 1 prospective study, 11 retrospective studies and no RCTs comparing robotic myomectomy to abdominal myomectomy for uterine fibroids.[33] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Laparoscopic Myomectomy Compared to Robotic Myomectomy. There were 1 prospective study, 9 retrospective studies and no RCTs comparing robotic myomectomy to laparoscopic myomectomy for uterine fibroids.[33] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Hepatectomy

Robotic Liver Resection Compared to Laparoscopic Liver Resection. There were 13 retrospective studies, no prospective studies or RCTs comparing robotic liver resection to laparoscopic liver resection.[34] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Distal Pancreatectomy

Robotic Distal Pancreatectomy Compared to Open Distal Pancreatectomy. There were 6 retrospective studies, no prospective studies or RCTs comparing robotic distal pancreatectomy to open distal pancreatectomy.[35] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Robotic Distal Pancreatectomy Compared to Laparoscopic Distal Pancreatectomy. There were 15 retrospective studies, no prospective studies or RCTs comparing robotic distal pancreatectomy to laparoscopic distal pancreatectomy.[35] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.

Cholecystectomy

Robotic Assisted Cholecystectomy Compared to Laparoscopic Cholecystectomy. There were 5 RCTs, 3 prospective studies, and 18 retrospective studies comparing robotic assisted cholecystectomy to laparoscopic cholecystectomy.[36] Supplemental Digital Content Tables 1 and 2, http://links.lww.com/SLA/C139, http://links.lww.com/SLA/C140 summarizes the outcomes of the RCT and primary study characteristics report by the systematic review.

Systematic review and meta-analysis of the RCTs demonstrated no differences in intraoperative complications, EBL, conversion to open surgery, postoperative complications, LOS in hospital, incisional hernia, and readmission rate to hospital between robotic-assisted and laparoscopic cholecystectomy.[36] However, robotic surgery was associated with longer operative time than laparoscopic surgery [Mean differences (MD) 12.04 minutes; 95% CI 7.26, 16.82].[35]

Subgroup analysis of single incision robotic-assisted cholecystectomy compared to multiple incision laparoscopic cholecystectomy of RCTs showed longer operative time (MD 15.26 minutes; 95% CI −8.82, 21.7). There were no differences in EBL, hospital LOS intraoperative complications, and postoperative complications. Meta-analysis of RCTs comparing multiple incision robotic-assisted cholecystectomy to multiple incision laparoscopic cholecystectomy has longer operative time; however, there were no differences in EBL, conversion rate, intraoperative and postoperative complications, hospital LOS or rate of incisional hernia.[36]

Gastrectomy

Robotic Gastrectomy Compared to Laparoscopic Gastrectomy. There were 19 retrospective studies, no prospective studies or RCTs comparing robotic gastrectomy to laparoscopic gastrectomy.[38] Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic review.[37]

Roux-en-Y Gastric Bypass

Robotic Roux-en-Y Gastric Bypass Compared to Laparoscopic Roux-en-Y Gastric Bypass. There was 1 RCT, 4 prospective studies, and 14 retrospective studies comparing robotic to laparoscopic Roux-en-Y gastric bypass. Supplemental Digital Content Table 1, http://links.lww.com/SLA/C139 summarizes the characteristic of the primary studies reported by the systematic reviews.[38]

The RCT included 15 patients that received robotic and 25 patients that received laparoscopic Roux-en-Y gastric bypass. There were no differences in intraoperative complications, LOS in hospital, or postoperative complications between the 2 groups. Patients in the robotic arm had a shorter operative time compared to laparoscopic arm (153.2 minutes vs 123.5 minutes, P = 0.009) and this difference was more pronounced in patients with elevated BMI.[39]

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