To investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer

To investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article To investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer Jack McDermott, Gavin Calpin, Ashwini Tittawella, Derek Hennessey, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6280174/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Nov, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Objective: To investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer. Methods: A systematic review was performed according to PRISMA/MOOSE guidelines. Dichotomous variables were pooled as odds ratios (OR). Continuous variables were pooled as weighted mean differences (WMD). Quality assessment was performed using the Newcastle-Ottawa score (NOS). Results: Four suitable randomised controlled studies were identified from the literature. 1026 male patients with prostate cancer (LRP n=342, 33.33%; RALP n= 684, 66.67%) were identified as eligible for inclusion. These patients were randomised for definitive operative management to RALP or LRP. There was no statistically significant difference identified in operative time (MD -2.81, 95% CI -12.92 – 7.31, I 2 = 77%, P = 0.59). There was no statistically significant difference identified in operative blood-loss (MD -9.34, 95% CI -55.81 +37.12, I 2 = 77%, P = 0.69). There was no statistically significant difference identified in biochemical recurrence free rates at 12 months. Statistically significant differences were identified in meta-analysis of post-operative urinary continence, and post-operative potency. These favoured RALP over LRP. No statistically significant difference was identified in operative time, operative blood-loss, or biochemical recurrence free rates at 12 months. Conclusion: There is an statistically significant improved post-operative profile of patients having undergone RALP v LRP, in particular with respect to return of sexual function and urinary continence. There was no statistical difference identified in intra-operative blood-loss, perioperative complications, or operative time. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 1. Introduction Prostate cancer is a leading cause of cancer-related morbidity and mortality among men worldwide. Surgical intervention remains a cornerstone of treatment for localised prostate cancer. There are several techniques available, each having distinct advantages and limitations. This literature review critically examines and analyses two primary surgical approaches: laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic (radical) prostatectomy (RALP). Open radical prostatectomy (ORP) is one of the earliest and most traditional methods employed in the surgical treatment of prostate cancer. This approach involves making a lower-midline abdominal incision to access the prostate directly. ORP has been demonstrated to be particularly effective for patients with advanced or aggressive prostate cancer that necessitates extensive lymphadenectomy (1) . However, ORP is associated with considerable morbidity. Studies have shown that patients undergoing ORP experience higher intraoperative blood loss and longer recovery times compared to those undergoing minimally invasive procedures (2) . Common complications following ORP include urinary incontinence and erectile dysfunction, both of which are a significant concern for patients (3) . LRP presents a minimally invasive alternative to ORP. This offers benefits such as reduced postoperative pain, shorter hospital stays, and quicker recovery times (4) . The technique involves multiple small incisions rather than a single large one, which contributes to decreased postoperative pain. However, LRP is technically demanding and characterised by a steep learning curve, which can impact surgical outcomes (5) . This can particularly be the case early on the learning curve. Surgeons must develop advanced laparoscopic skills to achieve outcomes comparable to those of ORP. For experienced surgeons, LRP offers equivalent oncological resection efficacy, while reducing morbidity (5) . Nonetheless, LRP is limited by two-dimensional visualisation and restricted instrument dexterity, making nerve-sparing procedures challenging (6) . RALP, most commonly performed using the daVinci Surgical System, has gained popularity for its enhanced precision, dexterity, and three-dimensional visualisation (6) . The robotic system's articulated instruments and high-definition camera improve ergonomics and visualisation, facilitating nerve-sparing techniques. Comparative studies have indicated that RALP results in reduced blood loss, and shorter hospital stays than both ORP and LRP. RALP has been associated with quicker recovery of urinary continence and sexual function compared to ORP and LRP (7,8) . The technical advantages of RALP contribute to lower positive surgical margin rates and improved functional outcomes, as well as a decreased side-effect profile (9) . Despite its benefits RALP incurs significant financial costs due to the expense of purchasing the robotic system, along with its maintenance. This potentially limits its accessibility in certain healthcare settings (10) . Additionally, the need for considerable specialised training may hinder the feasibility of widespread adoption of RALP (4) . The choice of prostatectomy technique should be tailored appropriately to individual patient factors, surgeon expertise factors, and available institutional resources factors. ORP remains a definite consideration as a surgical choice for complex or advanced cases, while LRP offers minimally invasive benefits but requires substantial surgical expertise. At present in the literature, RALP stands out for its superior functional outcomes and precision but is limited by cost and access. Future research should focus on refining surgical techniques and evaluating long-term outcomes to optimise prostate cancer management. 2. Methods This systematic review and meta-analysis was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 21 ) and MOOSE 22 guidelines. Each author contributed to formulating the study protocol. Local institutional ethical review and approval was not required. Patient, Intervention, Comparison, Outcome Using the PICO framework, the aspects the authors wished to address were: Population – Male patients with organ-confined prostate cancer. Intervention – Definitive operative management. Comparison – Robot-assisted laparoscopic (radical) prostatectomy (RALP) versus laparoscopic radical prostatectomy (LRP). Outcomes – Operative time, operative blood-loss, post-operative urinary continence, post-operative potency, and twelve month biochemical recurrence free rates. 2.1. Search strategy A search was undertaken by the primary author of databases Embase, Pubmed and Scopus using the key search terms “prostate cancer’, “robotic/robot-assisted radical prostatectomy” and “laparoscopic/laparoscopic-assisted prostatectomy”. This was completed in accordance with the Preferred Reporting System for Systematic Reviews and Meta Analyses (PRISMA) guidelines. (10) All English-language clinical studies published between 1st January 2000–31st August 2024 were considered for inclusion in the final meta-analysis. 4793 initial results were discovered. Duplication studies were removed. Once completed, individual abstracts were screened by the author for suitability. Twenty full online manuscripts were then selected for analysis. Four of these were suitable to be included in the final systematic review. This is represented in Fig. 1 . 2.2 Selection Criteria The study included prospective randomised controlled trials (RCTs) only. Cohort studies, journal articles, non-randomized trials, reviews, presentations and book chapters were excluded from the study. Non-English language studies were also excluded from the study. Within suitable studies only data relating to organ-confined prostate cancer, suitable for definitive operative management was considered for this study design. 2.3 Data Extraction and Quality Assessment The following data was extracted and collated from retrieved studies meeting inclusion criteria: (1) First author name, (2) year of publication, (3) RCT, (4) country of origin, (5) number of patients who underwent RALP and LRP, (6) mean age, (7) outcomes of interest. Risk of bias and methodology quality assessment was performed in accordance to the Newcastle-Ottawa Scale 23 . 2.4 Statistical Analysis Operative time and estimated blood loss were expressed as continuous outcomes, reported as mean differences (MDs) and continence, potency and biochemical recurrence rates were expressed as binary outcomes, reported as odds ratios (ORs), expressed with 95% confidence intervals (CIs) following estimation using the Mantel-Haenszel method. Statistical heterogeneity was determined using I 2 statistics. Either fixed or random effects models were applied on the basis of whether significant heterogeneity (I 2 > 50%) existed between studies included in the analysis. All tests of significance were two-tailed with P < 0.050 indicating statistical significance. Meta-analysis was performed using Review Manager, Version 5.4 (Nordic Cochrane Centre, Copenhagen, Denmark). 2.5 Quality Assessment Cochranes risk of bias tool (RoB 2) (24) was used to assess individual study bias. Five items were used to assess for random sequence generation, selection bias, attrition bias, reporting bias and outcome bias. Funnel plots were used to assess each individual outcome for publication bias. 3. Results 3.1 Description of eligible studies The literature search revealed four RCT’s that were included in the final analysis. Bibliographies of the included studies were thoroughly assessed, no additional studies were identified that fit the search criteria. Analysed outcomes were restricted to adult prostate cancer, believed to be organ-confined. Baseline characteristics within the study cohorts were not statistically significantly different between treatment groups. The literature search is outlined in Fig. 1 , as per PRISMA protocol. 3.2 Methodological assessment of studies The RoB2 assessment tool was used to assess for sources of potential bias in each of the four RCTs included in the analysis. Each of the RCTs were deemed to demonstrate a low risk of bias in the domains of randomization, selection of reported results, deviations from selected interventions and missing data. There was patient blinding of operative management techniques performed across all RCTs at time of initial consult and surgical consent. This blinding was at least until after surgery occurred, although it is unclear at which timepoint in the post-operative period patients were made aware of the study arm they were placed into. However, this was not deemed to alter the low risk of overall bias across the study. This is represented in Supplementary Figs. 1.1 and 1.2, which were created with the aid of the Cochrane RoB2 tool. (24) Funnel plots were generated to assess for potential publication bias however there was likely insufficient number of studies included to confidently determine a result. 3.3 Patient characteristics The total number of patients randomised to either RALP or LRP was 1026 across the four studies. A total of 684 patients were randomised to undergo RALP, while 342 patients were randomised to undergo LRP. Characteristics of age, gender, BMI, ASA grade, and previous abdominal surgery did not vary greatly between either group in any of the included studies. 3.4 Outcomes Literature Search A systematic review was undertaken. The primary author searched the databases Pubmed, Scopus and Embase using the key search terms “prostate cancer’, “robotic/robot-assisted radical prostatectomy” and “laparoscopic/laparoscopic-assisted prostatectomy” for articles published between 1st January 2008–31st August 2024. Articles were selected according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA). Meta-analysis was undertaken using Review Manager, Version 5.4 looking specifically at interval data with respect to total operative time, intra-operative blood loss, post-operative urinary continence, post-operative potency, and biochemical recurrence (BCR). Study bias was assessed using Cochrane risk of bias tool along with regression test analysis and funnel plots for publication bias. Operative time There were three studies with a combined 898 patients which compared operative time in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis (MD -2.81, 95% CI -12.92–7.31, I 2 = 77%, P = 0.59) (Fig. 2 ). Operative blood-loss There were three studies with a combined 898 patients which compared operative blood-loss in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis, (MD -9.34, 95% CI -55.81 + 37.12, I 2 = 77%, P = 0.69) (Fig. 3 ). Post-operative urinary continence Post-operative urinary continence rates were analysed at 4 distinct timepoints: 1 month, 3 months, 6 months, and 12 months post-operatively. Stolzenburg et al. did not have data available for 1mth time-point, while Kumar et al. did not have data available for the 12mth time-point. Three studies including 308 patients reported on urinary continence rates 1 month post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (34.4% (53/154)) compared to RALP (53.9% (83/154)) (OR 0.44, 95% CI 0.27 to 0.70 p-value 0.0005) (Fig. 4 ). Four studies including 1026 patients reported on urinary continence rates 3 months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (38.6% (132/342)) compared to RALP (36.1% (247/684)) (OR 0.58, 95% CI 0.41 to 0.81, p-value 0.001) (Fig. 5 ). Four studies including 1026 patients reported on urinary continence rates 6 months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (48.2% (165/342)) compared to RALP (46.7% (320/684)) (OR 0.55, 95% CI 0.39 to 0.76, p-value 0.003) (Fig. 6 ). Three studies including 966 patients reported on continence rates 12-months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (52.9% (165/312)) compared to RALP (53.1% (347/654)) (OR: 0.57, CI 0.41 to 0.79, p-value 0.007) (Fig. 7 ). Post-operative potency Post-operative potency rates were analysed at four distinct timepoints: one month, three months, six months, and twelve months post-operatively. Stolzenburg et al. did not provide data for one month time-point, while Kumar et al. did not have data available for the 12 month time-point. Three studies (308 patients), reported on potency rate one month post-operatively. There was no statistically significant difference between LRP and RALP for incidence of post-operative potency at one month (LRP 14.9% (23/154)) compared to RALP (32.5% (50/154))(OR 0.33, CI 0.07 to 1.55, p-value 0.16) (Fig. 8 ). Four studies (1026 patients), reported on potency rates three months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (12.9% (44/342)) compared to RALP (19.0% (130/684)) (OR 0.32, 95% CI 0.14 to 0.75, p-value 0.008) (Fig. 9 ). Four studies (1026 patients), reported on potency rates six months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (19.3% (66/342)) compared to RALP (23.5% (161/684)) (OR 0.36, 95% CI 0.16 to 0.81, p-value 0.01) (Fig. 10 ). Three studies (966 patients), reported on potency rates twelve months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (17.6% (55/312)) compared to RALP (24.9% (163/654)) (OR: 0.36, 95% CI 0.17 to 0.72, p-value 0.004) (Fig. 11 ). Biochemical recurrence free (BCR-free) Two studies (778 patients), compared BCR-free rates at 12 months post-operatively in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis (OR: 1.15, 95% CI 0.74 to 1.78, p-value 0.54) (Fig. 12 ). The other two included studies (Anastasios et al., Porpiglia et al.,) did not include their figures for BCR-free rates, while they did state there was no statistically significant difference identified in their data set. 4. Discussion This meta-analysis of four RCT’s is comprised of well-matched patient cohorts, randomised either to RALP or LRP for primary operative management of organ-confined prostate cancer. In the statistical analysis performed, operative time and operative blood-loss were included in three of the four studies, with no statistically significant difference appreciated. This would appear to be at odds with the analysis performed by Trinh et al 18 , who found that those undergoing RALP were less likely to receive a blood transfusion, and to experience a perioperative or postoperative complication, as compared with LRP. Hakimi et al 20 , also found in the early results of their small case series lower levels of intra-operative blood loss, shorter operative time and shorter post-operative length of stay. Their experience was of potency and continence rates were comparable. However, they did comment upon a trend toward faster return of functional outcomes in their RALP cohort. Carbonara et al 14 demonstrated RALP having favourable outcomes compared with LRP, namely in increased post-operative potency and continence rates, and a lesser rate of BCR. Our included studies also collected patient demographic data, as well as some markers of biochemical recurrence, namely prostate specific antigen (PSA). They did not show any statistically significant difference in these criteria. The included studies were predominantly tailored toward describing post-operative quality of life markers. Namely, they have provided detailed data on post-operative urinary continence and potency rates. These clinical functional markers were both found to be improved in RALP, when compared to LRP by Trabulsi et al 12 . The meta-analysis performed by Tal et al. 13 reported an improvement in post-operative potency rates, when RALP was compared to LRP. They also reported a trend for improved post-operative potency rate in the younger patients of their cohort, < 60 years old. There is not wholesale conformity within the literature in relation to improvement in sexual functions post-operatively with a robotic approach to prostatectomy. This is borne out in the large RCT performed by Coughlin et al 19 , which compared RALP with open retropubic prostatectomy. They found that any benefits of a robotic approach are related to its minimally invasive nature, and not in fact superiority of the surgical technique. This finding is also echoed by Ilic et al 17 in their review of the literature, which did not find any statistically significant benefit with respect to post-operative urinary continence, sexual function or oncological outcomes in their comparison of RALP against LRP, or indeed ORP. There was a statistically significant difference in post-operative urinary continence rates which extended from one month post-operatively, to twelve months post-operatively. This included all of the check-points used by these RCT’s. Stolzenburg et al 11 , with the inclusion of the LAP-01 trial, provides over half of the patient cohort after their first data point, which was at three months post-operatively. Its results strongly favour RALP over LRP when comparing for post-operative urinary continence. This effect is most noticeable at the 3 month time-point whereby there is a strongly statistical difference. However, the overall rates of return to continence are lower in this study than the other included studies. Holze 15 , a contributor in the LAP-01 trial, further analysed this discrepancy, posseting that this may be related to different definitions of urinary continence. Lee et al 16 , agreed in their review that there appears to be a discrepancy in consistency of definitions of urinary continence, between trials and also between patient and caregiver. 4.1 Strengths & limitations This analysis has strength in the inclusion of only prospective randomised controlled trials. This should confer good quality of data analysed. While this is the case, there were only four such studies identified within the literature. This could be perceived as a limitation as the overall number of study subjects is small. Apart from the LAP-01 trial the raw numbers of study participants are also small, diluting the strength of the analysis. There may also be a lack of homogeneity within reporting standards within the studies. The relatively short timeframe of outcome reporting is also a limitation, although some of these studies have provided later updates with further outcome data. As previously mentioned inconsistencies of outcome definitions between the studies may also colour the results slightly. While this is the case, the comparison within the studies is equal so the statistical analysis should still hold strength. A greater number of dedicated RCTs in this space, with larger numbers of included study subjects would contribute to further strength of any future analyses. 5. Conclusion Robot-assisted surgery is a growing field, in the surgical specialty of urology in particular. Robot-assisted laparoscopic radical prostatectomy is a procedure which, when compared to laparoscopic radical prostatectomy in this analysis of well-matched RCTs, appears to be at least equivocal in terms of oncological and operative outcomes. In addition to this, our analysis demonstrates a statistically significant difference in favour of RALP with respect to post-operative outcome profile when measuring urinary continence rates and sexual function at three months, six months, and twelve months post-operatively. Abbreviations RALP Robotic-Assisted Laparoscopic (radical) Prostatectomy LRP Laparoscopic Radical Prostatectomy ORP Open Radical Prostatectomy PRISMA Preferred reporting items for systematic review and Meta-analysis MOOSE Reporting Guidelines for Meta-analyses of Observational Studies BCR Biochemical Recurrence RCT Randomised Controlled Trial OR Odds Ratio WMD Weighted Mean Differences NOS Newcastle-Ottawa Score Declarations Author Contribution J.McD., D.H., F.O'K. synthesised the idea, wrote the main manuscript textG.C. prepared figuresAll authors reviewed the manuscript prior to submission References Mottet N, Cornford P, van den Bergh RCN, et al. EAU–EANM–ESTRO–ESUR–SIOG guidelines on prostate cancer. Edn. presented at the EAU Annual Congress Amsterdam 2021. ISBN 978-94-92671-13-4. Novara G, Ficarra V, Rosen RC, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431-452. Briganti A, Larcher A, Abdollah F, et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: The essential importance of the percentage of positive cores. Eur Urol. 2012;61(3):480-487. Aly M, Dagenais J, Ramsay C, et al. Comparing clinical and cost outcomes of robotic, laparoscopic, and open radical prostatectomy: Methodology of a Canadian prospective cohort study. BMC Urol. 2020;20(1):58. Steinberg PL, Merglen A, Mir MC, et al. Laparoscopic radical prostatectomy: Perioperative and long-term outcomes in North America. J Endourol. 2012;26(5):546-550. Satkunasivam R, Vilaseca A, Acosta M, et al. Robotic-assisted laparoscopic radical prostatectomy: State of the art in 2013. J Clin Oncol. 2013;31(20):2677-2681. Porpiglia F, Checcucci E, De Cillis S, et al. Retzius-sparing robot-assisted radical prostatectomy: A systematic review. Int J Urol. 2016;23(6):465-473. Montorsi F, Wilson TG, Rosen RC, et al. Best practices in robot-assisted radical prostatectomy: Recommendations of the Pasadena Consensus Panel. Eur Urol. 2015;68(4):521-529. Ficarra V, Novara G, Buffi NM, et al. The "retzius-sparing" technique in robotic-assisted laparoscopic prostatectomy: A review of the literature. Asian J Androl. 2017;18(5):710-716. Cerantola Y, Jeldres C, Tanguay S, et al. Cost-effectiveness and budget impact analyses of the introduction of robot-assisted laparoscopic prostatectomy in the Canadian public healthcare system: A health economic model. BMC Health Serv Res. 2016;16(1):353. Jens-Uwe Stolzenburg, Sigrun Holze, Petra Neuhaus, et al. Robotic-assisted Versus Laparoscopic Surgery: Outcomes from the First Multicentre, Randomised, Patient-blinded Controlled Trial in Radical Prostatectomy (LAP-01). https://doi.org/10.1016/j.eururo.2021.01.030 Trabulsi EJ, Zola JC , Colon-Herdman A, et al. Minimally invasive radical prostatectomy: transition from pure laparoscopic to robotic-assisted radical prostatectomy. Archivos Espanoles de Urologia, 2011, 64(8):823-829. Tal R, Hannah H. Alphs, Paul Krebs, et al. Erectile Function Recovery Rate after Radical Prostatectomy: A Meta-Analysis. https://doi.org/10.1111/j.1743-6109.2009.01351.x Carbonara U., Maya Srinath Fabio Crocerossa, et al. Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes. https://doi.org/10.1007/s00345-021-03687-5 Holze S., Meinhard Mende, Karl V. Healy, et al. Comparison of various continence definitions in a large group of patients undergoing radical prostatectomy: a multicentre, prospective study. https://doi.org/10.1186/s12894-019-0500-6 Lee S.R.,Hong Wook Kim,Jae Won Lee, et al. Discrepancies in Perception of Urinary Incontinence between Patient and Physician after Robotic Radical Prostatectomy.https://doi.org/10.3349/ymj.2010.51.6.883 Ilic D, Sue M Evans, Christie Ann Allan, et al. Laparoscopic and robotic‐assisted versus open radical prostatectomy for the treatment of localised prostate cancer. https://doi.org/10.1002/14651858.CD009625.pub2 Trinh Q-D., Jesse Sammon, Maxine Sun, et al. Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample. doi:10.1016/j.eururo.2011.12.027 Coughlin G. D., John W Yaxley, Prof Suzanne K Chambers, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. https://doi.org/10.1016/S1470-2045(18)30357-7 Hakimi A. A., Jeffrey Blitstein, Marc Feder, et al. Direct Comparison of Surgical and Functional Outcomes of Robotic-Assisted Versus Pure Laparoscopic Radical Prostatectomy: Single-Surgeon Experience. doi:10.1016/j.urology.2008.08.491 Page M., McKenzie J., Bossuyt P. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. https://doi.org/10.1136/bmj.n71 Brooke BS, Schwartz TA, Pawlik TM. MOOSE Reporting Guidelines for Meta-analyses of Observational Studies. JAMA Surg. 2021 Aug 1;156(8):787-788. doi: 10.1001/jamasurg.2021.0522. PMID: 33825847. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010 Sep;25(9):603-5. doi: 10.1007/s10654-010-9491-z. Epub 2010 Jul 22. PMID: 20652370. Sterne JAC, Savović J, Page MJ. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898. Additional Declarations No competing interests reported. Supplementary Files Supplementary.docx Cite Share Download PDF Status: Published Journal Publication published 22 Nov, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 15 May, 2025 Reviews received at journal 14 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviews received at journal 11 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers invited by journal 28 Apr, 2025 Editor assigned by journal 03 Apr, 2025 Submission checks completed at journal 03 Apr, 2025 First submitted to journal 21 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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20:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6280174/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6280174/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-025-02938-6","type":"published","date":"2025-11-22T15:58:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82140059,"identity":"bac97b1f-f7de-4d37-8c6b-7aa0cf971fae","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52684,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of search strategy\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/00157c9bb91d532aeee41fa2.jpg"},{"id":82140063,"identity":"97065eca-ca87-4225-8e99-24b776f1b14f","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56534,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing operative time in LRP and RALP\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/a81b24eb5e919b9995687d94.jpg"},{"id":82142169,"identity":"b3c9bc42-119b-44a5-b7dd-ab199052cf72","added_by":"auto","created_at":"2025-05-07 06:37:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":56026,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing operative blood loss in LRP and RALP\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/5f85ec7d0032a7cd9e653cf3.jpg"},{"id":82140062,"identity":"9b36a000-df05-4721-9d25-e0e6b9af46b9","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":51228,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative urinary continence 1 month post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/5a136de2022fcd791415a7ab.jpg"},{"id":82140064,"identity":"ef0e66d3-6b19-491a-9808-e55cae69f161","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":57843,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative urinary continence 3 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/c5d3a890bfc1178774ebe787.jpg"},{"id":82140065,"identity":"18bd103d-1707-4426-8ca6-f46070424038","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":58885,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative urinary continence 6 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/b13a210c3758ba7dce6fa79b.jpg"},{"id":82142172,"identity":"05460869-2479-4eec-97ba-f087cec9129d","added_by":"auto","created_at":"2025-05-07 06:37:18","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":49708,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative urinary continence 12 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/8c4fbba5be6fff6bf22888c5.jpg"},{"id":82140069,"identity":"9fce8cfe-effc-46d2-80c3-dafccc2eb452","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":51132,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative potency 1 month post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/63cba0d88d159c394498bf95.jpg"},{"id":82140067,"identity":"931e911b-8e33-4788-a0a1-546458e9d431","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":56811,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative potency 3 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/165299db16320a56475a4fc3.jpg"},{"id":82140075,"identity":"bd86bde0-d0fe-4cea-ae06-296217c85f0e","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":58118,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative potency 6 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/64a3db7c1fe7da8183c15b8f.jpg"},{"id":82142170,"identity":"bbabbdb8-9f2c-4bc6-ab0f-7a527b4fead1","added_by":"auto","created_at":"2025-05-07 06:37:18","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":51411,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing post-operative potency 12 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/64c3bd02de7f606877b60a99.jpg"},{"id":82144388,"identity":"abed5ea0-bef9-4dee-8e7e-22b4f18a0ffe","added_by":"auto","created_at":"2025-05-07 06:45:18","extension":"jpg","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":44298,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot comparing BCR-free rates at 12 months post-op in LRP and RALP\u003c/p\u003e","description":"","filename":"12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/683cbf7d4b8cd97418342a94.jpg"},{"id":96650190,"identity":"02de746e-15fc-4589-98a0-437e5abf8c97","added_by":"auto","created_at":"2025-11-24 16:09:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1243459,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/ca1a7a89-ac73-4483-be00-deb9186ef37d.pdf"},{"id":82140061,"identity":"8c23b3dc-a484-449a-8863-9634899b39b7","added_by":"auto","created_at":"2025-05-07 06:29:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":82675,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-6280174/v1/df3c94c3cc8a3e5d796c14ec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTo investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eProstate cancer is a leading cause of cancer-related morbidity and mortality among men worldwide. Surgical intervention remains a cornerstone of treatment for localised prostate cancer. There are several techniques available, each having distinct advantages and limitations. This literature review critically examines and analyses two primary surgical approaches: laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic (radical) prostatectomy (RALP). Open radical prostatectomy (ORP) is one of the earliest and most traditional methods employed in the surgical treatment of prostate cancer. This approach involves making a lower-midline abdominal incision to access the prostate directly. ORP has been demonstrated to be particularly effective for patients with advanced or aggressive prostate cancer that necessitates extensive lymphadenectomy\u003csup\u003e(1)\u003c/sup\u003e. However, ORP is associated with considerable morbidity. Studies have shown that patients undergoing ORP experience higher intraoperative blood loss and longer recovery times compared to those undergoing minimally invasive procedures\u003csup\u003e(2)\u003c/sup\u003e. Common complications following ORP include urinary incontinence and erectile dysfunction, both of which are a significant concern for patients\u003csup\u003e(3)\u003c/sup\u003e. LRP presents a minimally invasive alternative to ORP. This offers benefits such as reduced postoperative pain, shorter hospital stays, and quicker recovery times\u003csup\u003e(4)\u003c/sup\u003e. The technique involves multiple small incisions rather than a single large one, which contributes to decreased postoperative pain. However, LRP is technically demanding and characterised by a steep learning curve, which can impact surgical outcomes\u003csup\u003e(5)\u003c/sup\u003e. This can particularly be the case early on the learning curve. Surgeons must develop advanced laparoscopic skills to achieve outcomes comparable to those of ORP. For experienced surgeons, LRP offers equivalent oncological resection efficacy, while reducing morbidity\u003csup\u003e(5)\u003c/sup\u003e. Nonetheless, LRP is limited by two-dimensional visualisation and restricted instrument dexterity, making nerve-sparing procedures challenging\u003csup\u003e(6)\u003c/sup\u003e. RALP, most commonly performed using the daVinci Surgical System, has gained popularity for its enhanced precision, dexterity, and three-dimensional visualisation\u003csup\u003e(6)\u003c/sup\u003e. The robotic system's articulated instruments and high-definition camera improve ergonomics and visualisation, facilitating nerve-sparing techniques. Comparative studies have indicated that RALP results in reduced blood loss, and shorter hospital stays than both ORP and LRP. RALP has been associated with quicker recovery of urinary continence and sexual function compared to ORP and LRP\u003csup\u003e(7,8)\u003c/sup\u003e. The technical advantages of RALP contribute to lower positive surgical margin rates and improved functional outcomes, as well as a decreased side-effect profile\u003csup\u003e(9)\u003c/sup\u003e. Despite its benefits RALP incurs significant financial costs due to the expense of purchasing the robotic system, along with its maintenance. This potentially limits its accessibility in certain healthcare settings\u003csup\u003e(10)\u003c/sup\u003e. Additionally, the need for considerable specialised training may hinder the feasibility of widespread adoption of RALP\u003csup\u003e(4)\u003c/sup\u003e. The choice of prostatectomy technique should be tailored appropriately to individual patient factors, surgeon expertise factors, and available institutional resources factors. ORP remains a definite consideration as a surgical choice for complex or advanced cases, while LRP offers minimally invasive benefits but requires substantial surgical expertise. At present in the literature, RALP stands out for its superior functional outcomes and precision but is limited by cost and access. Future research should focus on refining surgical techniques and evaluating long-term outcomes to optimise prostate cancer management.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis systematic review and meta-analysis was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e) and MOOSE\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e guidelines. Each author contributed to formulating the study protocol. Local institutional ethical review and approval was not required.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePatient, Intervention, Comparison, Outcome\u003c/em\u003e \u003c/p\u003e \u003cp\u003eUsing the PICO framework, the aspects the authors wished to address were:\u003c/p\u003e \u003cp\u003ePopulation \u0026ndash; Male patients with organ-confined prostate cancer.\u003c/p\u003e \u003cp\u003eIntervention \u0026ndash; Definitive operative management.\u003c/p\u003e \u003cp\u003eComparison \u0026ndash; Robot-assisted laparoscopic (radical) prostatectomy (RALP) versus laparoscopic radical prostatectomy (LRP).\u003c/p\u003e \u003cp\u003eOutcomes \u0026ndash; Operative time, operative blood-loss, post-operative urinary continence, post-operative potency, and twelve month biochemical recurrence free rates.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Search strategy\u003c/h2\u003e \u003cp\u003eA search was undertaken by the primary author of databases Embase, Pubmed and Scopus using the key search terms \u0026ldquo;prostate cancer\u0026rsquo;, \u0026ldquo;robotic/robot-assisted radical prostatectomy\u0026rdquo; and \u0026ldquo;laparoscopic/laparoscopic-assisted prostatectomy\u0026rdquo;. This was completed in accordance with the Preferred Reporting System for Systematic Reviews and Meta Analyses (PRISMA) guidelines. \u003csup\u003e(10)\u003c/sup\u003e All English-language clinical studies published between 1st January 2000\u0026ndash;31st August 2024 were considered for inclusion in the final meta-analysis. 4793 initial results were discovered. Duplication studies were removed. Once completed, individual abstracts were screened by the author for suitability. Twenty full online manuscripts were then selected for analysis. Four of these were suitable to be included in the final systematic review. This is represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Selection Criteria\u003c/h2\u003e \u003cp\u003eThe study included prospective randomised controlled trials (RCTs) only. Cohort studies, journal articles, non-randomized trials, reviews, presentations and book chapters were excluded from the study. Non-English language studies were also excluded from the study. Within suitable studies only data relating to organ-confined prostate cancer, suitable for definitive operative management was considered for this study design.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Extraction and Quality Assessment\u003c/h2\u003e \u003cp\u003e The following data was extracted and collated from retrieved studies meeting inclusion criteria: (1) First author name, (2) year of publication, (3) RCT, (4) country of origin, (5) number of patients who underwent RALP and LRP, (6) mean age, (7) outcomes of interest. Risk of bias and methodology quality assessment was performed in accordance to the Newcastle-Ottawa Scale\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e \u003cp\u003eOperative time and estimated blood loss were expressed as continuous outcomes, reported as mean differences (MDs) and continence, potency and biochemical recurrence rates were expressed as binary outcomes, reported as odds ratios (ORs), expressed with 95% confidence intervals (CIs) following estimation using the Mantel-Haenszel method. Statistical heterogeneity was determined using I\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e statistics. Either fixed or random effects models were applied on the basis of whether significant heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026gt;\u0026thinsp;50%) existed between studies included in the analysis. All tests of significance were two-tailed with P\u0026thinsp;\u0026lt;\u0026thinsp;0.050 indicating statistical significance. Meta-analysis was performed using Review Manager, Version 5.4 (Nordic Cochrane Centre, Copenhagen, Denmark).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Quality Assessment\u003c/h2\u003e \u003cp\u003eCochranes risk of bias tool (RoB 2) \u003csup\u003e(24)\u003c/sup\u003e was used to assess individual study bias. Five items were used to assess for random sequence generation, selection bias, attrition bias, reporting bias and outcome bias. Funnel plots were used to assess each individual outcome for publication bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Description of eligible studies\u003c/h2\u003e \u003cp\u003eThe literature search revealed four RCT\u0026rsquo;s that were included in the final analysis. Bibliographies of the included studies were thoroughly assessed, no additional studies were identified that fit the search criteria. Analysed outcomes were restricted to adult prostate cancer, believed to be organ-confined. Baseline characteristics within the study cohorts were not statistically significantly different between treatment groups. The literature search is outlined in Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e1\u003c/span\u003e, as per PRISMA protocol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Methodological assessment of studies\u003c/h2\u003e \u003cp\u003eThe RoB2 assessment tool was used to assess for sources of potential bias in each of the four RCTs included in the analysis. Each of the RCTs were deemed to demonstrate a low risk of bias in the domains of randomization, selection of reported results, deviations from selected interventions and missing data. There was patient blinding of operative management techniques performed across all RCTs at time of initial consult and surgical consent. This blinding was at least until after surgery occurred, although it is unclear at which timepoint in the post-operative period patients were made aware of the study arm they were placed into. However, this was not deemed to alter the low risk of overall bias across the study. This is represented in Supplementary Figs.\u0026nbsp;1.1 and 1.2, which were created with the aid of the Cochrane RoB2 tool. \u003csup\u003e(24)\u003c/sup\u003e Funnel plots were generated to assess for potential publication bias however there was likely insufficient number of studies included to confidently determine a result.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Patient characteristics\u003c/h2\u003e \u003cp\u003eThe total number of patients randomised to either RALP or LRP was 1026 across the four studies. A total of 684 patients were randomised to undergo RALP, while 342 patients were randomised to undergo LRP.\u003c/p\u003e \u003cp\u003eCharacteristics of age, gender, BMI, ASA grade, and previous abdominal surgery did not vary greatly between either group in any of the included studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Outcomes\u003c/h2\u003e \u003cp\u003eLiterature Search\u003c/p\u003e \u003cp\u003e A systematic review was undertaken. The primary author searched the databases Pubmed, Scopus and Embase using the key search terms \u0026ldquo;prostate cancer\u0026rsquo;, \u0026ldquo;robotic/robot-assisted radical prostatectomy\u0026rdquo; and \u0026ldquo;laparoscopic/laparoscopic-assisted prostatectomy\u0026rdquo; for articles published between 1st January 2008\u0026ndash;31st August 2024. Articles were selected according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA). Meta-analysis was undertaken using Review Manager, Version 5.4 looking specifically at interval data with respect to total operative time, intra-operative blood loss, post-operative urinary continence, post-operative potency, and biochemical recurrence (BCR). Study bias was assessed using Cochrane risk of bias tool along with regression test analysis and funnel plots for publication bias.\u003c/p\u003e \u003cp\u003e \u003cem\u003eOperative time\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere were three studies with a combined 898 patients which compared operative time in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis (MD -2.81, 95% CI -12.92\u0026ndash;7.31, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;77%, P\u0026thinsp;=\u0026thinsp;0.59) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eOperative blood-loss\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThere were three studies with a combined 898 patients which compared operative blood-loss in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis, (MD -9.34, 95% CI -55.81\u0026thinsp;+\u0026thinsp;37.12, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;77%, P\u0026thinsp;=\u0026thinsp;0.69) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003ePost-operative urinary continence\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePost-operative urinary continence rates were analysed at 4 distinct timepoints: 1 month, 3 months, 6 months, and 12 months post-operatively. Stolzenburg et al. did not have data available for 1mth time-point, while Kumar et al. did not have data available for the 12mth time-point.\u003c/p\u003e \u003cp\u003eThree studies including 308 patients reported on urinary continence rates 1 month post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (34.4% (53/154)) compared to RALP (53.9% (83/154)) (OR 0.44, 95% CI 0.27 to 0.70 p-value 0.0005) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFour studies including 1026 patients reported on urinary continence rates 3 months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (38.6% (132/342)) compared to RALP (36.1% (247/684)) (OR 0.58, 95% CI 0.41 to 0.81, p-value 0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFour studies including 1026 patients reported on urinary continence rates 6 months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (48.2% (165/342)) compared to RALP (46.7% (320/684)) (OR 0.55, 95% CI 0.39 to 0.76, p-value 0.003) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThree studies including 966 patients reported on continence rates 12-months post-operatively. LRP was associated with a significantly reduced incidence of urinary continence (52.9% (165/312)) compared to RALP (53.1% (347/654)) (OR: 0.57, CI 0.41 to 0.79, p-value 0.007) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003ePost-operative potency\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePost-operative potency rates were analysed at four distinct timepoints: one month, three months, six months, and twelve months post-operatively. Stolzenburg et al. did not provide data for one month time-point, while Kumar et al. did not have data available for the 12 month time-point.\u003c/p\u003e \u003cp\u003eThree studies (308 patients), reported on potency rate one month post-operatively. There was no statistically significant difference between LRP and RALP for incidence of post-operative potency at one month (LRP 14.9% (23/154)) compared to RALP (32.5% (50/154))(OR 0.33, CI 0.07 to 1.55, p-value 0.16) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFour studies (1026 patients), reported on potency rates three months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (12.9% (44/342)) compared to RALP (19.0% (130/684)) (OR 0.32, 95% CI 0.14 to 0.75, p-value 0.008) (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFour studies (1026 patients), reported on potency rates six months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (19.3% (66/342)) compared to RALP (23.5% (161/684)) (OR 0.36, 95% CI 0.16 to 0.81, p-value 0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThree studies (966 patients), reported on potency rates twelve months post-operatively. LRP was associated with a significantly reduced incidence of potency at this time-point (17.6% (55/312)) compared to RALP (24.9% (163/654)) (OR: 0.36, 95% CI 0.17 to 0.72, p-value 0.004) (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003cem\u003eBiochemical recurrence free (BCR-free)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTwo studies (778 patients), compared BCR-free rates at 12 months post-operatively in LRP and RALP. No statistically significant difference was demonstrated between the groups at meta-analysis (OR: 1.15, 95% CI 0.74 to 1.78, p-value 0.54) (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe other two included studies (Anastasios et al., Porpiglia et al.,) did not include their figures for BCR-free rates, while they did state there was no statistically significant difference identified in their data set.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis meta-analysis of four RCT\u0026rsquo;s is comprised of well-matched patient cohorts, randomised either to RALP or LRP for primary operative management of organ-confined prostate cancer. In the statistical analysis performed, operative time and operative blood-loss were included in three of the four studies, with no statistically significant difference appreciated. This would appear to be at odds with the analysis performed by Trinh et al\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, who found that those undergoing RALP were less likely to receive a blood transfusion, and to experience a perioperative or postoperative complication, as compared with LRP. Hakimi et al\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, also found in the early results of their small case series lower levels of intra-operative blood loss, shorter operative time and shorter post-operative length of stay. Their experience was of potency and continence rates were comparable. However, they did comment upon a trend toward faster return of functional outcomes in their RALP cohort. Carbonara et al\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e demonstrated RALP having favourable outcomes compared with LRP, namely in increased post-operative potency and continence rates, and a lesser rate of BCR. Our included studies also collected patient demographic data, as well as some markers of biochemical recurrence, namely prostate specific antigen (PSA). They did not show any statistically significant difference in these criteria. The included studies were predominantly tailored toward describing post-operative quality of life markers. Namely, they have provided detailed data on post-operative urinary continence and potency rates. These clinical functional markers were both found to be improved in RALP, when compared to LRP by Trabulsi et al \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe meta-analysis performed by Tal et al.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e reported an improvement in post-operative potency rates, when RALP was compared to LRP. They also reported a trend for improved post-operative potency rate in the younger patients of their cohort, \u0026lt;\u0026thinsp;60 years old. There is not wholesale conformity within the literature in relation to improvement in sexual functions post-operatively with a robotic approach to prostatectomy. This is borne out in the large RCT performed by Coughlin et al\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, which compared RALP with open retropubic prostatectomy. They found that any benefits of a robotic approach are related to its minimally invasive nature, and not in fact superiority of the surgical technique. This finding is also echoed by Ilic et al\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e in their review of the literature, which did not find any statistically significant benefit with respect to post-operative urinary continence, sexual function or oncological outcomes in their comparison of RALP against LRP, or indeed ORP. There was a statistically significant difference in post-operative urinary continence rates which extended from one month post-operatively, to twelve months post-operatively. This included all of the check-points used by these RCT\u0026rsquo;s. Stolzenburg et al\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, with the inclusion of the LAP-01 trial, provides over half of the patient cohort after their first data point, which was at three months post-operatively. Its results strongly favour RALP over LRP when comparing for post-operative urinary continence. This effect is most noticeable at the 3 month time-point whereby there is a strongly statistical difference. However, the overall rates of return to continence are lower in this study than the other included studies. Holze\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, a contributor in the LAP-01 trial, further analysed this discrepancy, posseting that this may be related to different definitions of urinary continence. Lee et al\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, agreed in their review that there appears to be a discrepancy in consistency of definitions of urinary continence, between trials and also between patient and caregiver.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths \u0026amp; limitations\u003c/h2\u003e \u003cp\u003eThis analysis has strength in the inclusion of only prospective randomised controlled trials. This should confer good quality of data analysed. While this is the case, there were only four such studies identified within the literature. This could be perceived as a limitation as the overall number of study subjects is small. Apart from the LAP-01 trial the raw numbers of study participants are also small, diluting the strength of the analysis. There may also be a lack of homogeneity within reporting standards within the studies. The relatively short timeframe of outcome reporting is also a limitation, although some of these studies have provided later updates with further outcome data. As previously mentioned inconsistencies of outcome definitions between the studies may also colour the results slightly. While this is the case, the comparison within the studies is equal so the statistical analysis should still hold strength. A greater number of dedicated RCTs in this space, with larger numbers of included study subjects would contribute to further strength of any future analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eRobot-assisted surgery is a growing field, in the surgical specialty of urology in particular. Robot-assisted laparoscopic radical prostatectomy is a procedure which, when compared to laparoscopic radical prostatectomy in this analysis of well-matched RCTs, appears to be at least equivocal in terms of oncological and operative outcomes. In addition to this, our analysis demonstrates a statistically significant difference in favour of RALP with respect to post-operative outcome profile when measuring urinary continence rates and sexual function at three months, six months, and twelve months post-operatively.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRALP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRobotic-Assisted Laparoscopic (radical) Prostatectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLaparoscopic Radical Prostatectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eORP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOpen Radical Prostatectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred reporting items for systematic review and Meta-analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOOSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e Reporting Guidelines for Meta-analyses of Observational Studies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBiochemical Recurrence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomised Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeighted Mean Differences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNewcastle-Ottawa Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.McD., D.H., F.O'K. synthesised the idea, wrote the main manuscript textG.C. prepared figuresAll authors reviewed the manuscript prior to submission\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMottet N, Cornford P, van den Bergh RCN, et al. EAU\u0026ndash;EANM\u0026ndash;ESTRO\u0026ndash;ESUR\u0026ndash;SIOG guidelines on prostate cancer. Edn. presented at the EAU Annual Congress Amsterdam 2021. ISBN 978-94-92671-13-4.\u003c/li\u003e\n\u003cli\u003eNovara G, Ficarra V, Rosen RC, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431-452.\u003c/li\u003e\n\u003cli\u003eBriganti A, Larcher A, Abdollah F, et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: The essential importance of the percentage of positive cores. Eur Urol. 2012;61(3):480-487.\u003c/li\u003e\n\u003cli\u003eAly M, Dagenais J, Ramsay C, et al. Comparing clinical and cost outcomes of robotic, laparoscopic, and open radical prostatectomy: Methodology of a Canadian prospective cohort study. BMC Urol. 2020;20(1):58.\u003c/li\u003e\n\u003cli\u003eSteinberg PL, Merglen A, Mir MC, et al. Laparoscopic radical prostatectomy: Perioperative and long-term outcomes in North America. J Endourol. 2012;26(5):546-550.\u003c/li\u003e\n\u003cli\u003eSatkunasivam R, Vilaseca A, Acosta M, et al. Robotic-assisted laparoscopic radical prostatectomy: State of the art in 2013. J Clin Oncol. 2013;31(20):2677-2681.\u003c/li\u003e\n\u003cli\u003ePorpiglia F, Checcucci E, De Cillis S, et al. Retzius-sparing robot-assisted radical prostatectomy: A systematic review. Int J Urol. 2016;23(6):465-473.\u003c/li\u003e\n\u003cli\u003eMontorsi F, Wilson TG, Rosen RC, et al. Best practices in robot-assisted radical prostatectomy: Recommendations of the Pasadena Consensus Panel. Eur Urol. 2015;68(4):521-529.\u003c/li\u003e\n\u003cli\u003eFicarra V, Novara G, Buffi NM, et al. The \u0026quot;retzius-sparing\u0026quot; technique in robotic-assisted laparoscopic prostatectomy: A review of the literature. Asian J Androl. 2017;18(5):710-716.\u003c/li\u003e\n\u003cli\u003eCerantola Y, Jeldres C, Tanguay S, et al. Cost-effectiveness and budget impact analyses of the introduction of robot-assisted laparoscopic prostatectomy in the Canadian public healthcare system: A health economic model. BMC Health Serv Res. 2016;16(1):353.\u003c/li\u003e\n\u003cli\u003eJens-Uwe Stolzenburg, Sigrun Holze, Petra Neuhaus, et al. Robotic-assisted Versus Laparoscopic Surgery: Outcomes from the First Multicentre, Randomised, Patient-blinded Controlled Trial in Radical Prostatectomy (LAP-01). https://doi.org/10.1016/j.eururo.2021.01.030\u003c/li\u003e\n\u003cli\u003eTrabulsi EJ, Zola JC , Colon-Herdman A, et al. Minimally invasive radical prostatectomy: transition from pure laparoscopic to robotic-assisted radical prostatectomy. Archivos Espanoles de Urologia, 2011, 64(8):823-829.\u003c/li\u003e\n\u003cli\u003eTal R, Hannah H. Alphs, Paul Krebs, et al. Erectile Function Recovery Rate after Radical Prostatectomy: A Meta-Analysis. https://doi.org/10.1111/j.1743-6109.2009.01351.x\u003c/li\u003e\n\u003cli\u003eCarbonara U., Maya Srinath Fabio Crocerossa, et al. Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes. https://doi.org/10.1007/s00345-021-03687-5 \u003c/li\u003e\n\u003cli\u003eHolze S., Meinhard Mende, Karl V. Healy, et al. Comparison of various continence definitions in a large group of patients undergoing radical prostatectomy: a multicentre, prospective study. https://doi.org/10.1186/s12894-019-0500-6 \u003c/li\u003e\n\u003cli\u003eLee S.R.,Hong Wook Kim,Jae Won Lee, et al. Discrepancies in Perception of Urinary Incontinence between Patient and Physician after Robotic Radical Prostatectomy.https://doi.org/10.3349/ymj.2010.51.6.883\u003c/li\u003e\n\u003cli\u003eIlic D, Sue M Evans, Christie Ann Allan, et al. Laparoscopic and robotic‐assisted versus open radical prostatectomy for the treatment of localised prostate cancer. https://doi.org/10.1002/14651858.CD009625.pub2\u003c/li\u003e\n\u003cli\u003eTrinh Q-D., Jesse Sammon, Maxine Sun, et al. Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample. doi:10.1016/j.eururo.2011.12.027\u003c/li\u003e\n\u003cli\u003eCoughlin G. D., John W Yaxley, Prof Suzanne K Chambers, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. https://doi.org/10.1016/S1470-2045(18)30357-7\u003c/li\u003e\n\u003cli\u003eHakimi A. A., Jeffrey Blitstein, Marc Feder, et al. Direct Comparison of Surgical and Functional Outcomes of Robotic-Assisted Versus Pure Laparoscopic Radical Prostatectomy: Single-Surgeon Experience. doi:10.1016/j.urology.2008.08.491 \u003c/li\u003e\n\u003cli\u003ePage M., McKenzie J., Bossuyt P. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. https://doi.org/10.1136/bmj.n71\u003c/li\u003e\n\u003cli\u003eBrooke BS, Schwartz TA, Pawlik TM. MOOSE Reporting Guidelines for Meta-analyses of Observational Studies. JAMA Surg. 2021 Aug 1;156(8):787-788. doi: 10.1001/jamasurg.2021.0522. PMID: 33825847.\u003c/li\u003e\n\u003cli\u003eStang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010 Sep;25(9):603-5. doi: 10.1007/s10654-010-9491-z. Epub 2010 Jul 22. PMID: 20652370.\u003c/li\u003e\n\u003cli\u003eSterne JAC, Savović J, Page MJ. RoB 2: a revised tool for assessing risk of bias in randomised trials. \u003cem\u003eBMJ\u003c/em\u003e 2019; 366: l4898.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6280174/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6280174/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eObjective:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo investigate the current evidence in post-operative outcomes to support the use of Robotic-Assisted Laparoscopic (radical) Prostatectomy (RALP) over Laparoscopic Radical Prostatectomy (LRP) in cases of organ-confined prostate cancer.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA systematic review was performed according to PRISMA/MOOSE guidelines.\u003c/p\u003e\n\u003cp\u003eDichotomous variables were pooled as odds ratios (OR). Continuous variables were pooled as weighted mean differences (WMD). Quality assessment was performed using the Newcastle-Ottawa score (NOS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFour suitable randomised controlled studies were identified from the literature. 1026 male patients with prostate cancer (LRP n=342, 33.33%; RALP n= 684, 66.67%) were identified as eligible for inclusion. These patients were randomised for definitive operative management to RALP or LRP. There was no statistically significant difference identified in operative time (MD -2.81, 95% CI -12.92 – 7.31, I\u003csup\u003e2\u003c/sup\u003e = 77%, P = 0.59). There was no statistically significant difference identified in operative blood-loss (MD -9.34, 95% CI -55.81 +37.12, I\u003csup\u003e2\u003c/sup\u003e = 77%, P = 0.69). There was no statistically significant difference identified in biochemical recurrence free rates at 12 months. Statistically significant differences were identified in meta-analysis of post-operative urinary continence, and post-operative potency. These favoured RALP over LRP. No statistically significant difference was identified in operative time, operative blood-loss, or biochemical recurrence free rates at 12 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is an statistically significant improved post-operative profile of patients having undergone RALP v LRP, in particular with respect to return of sexual function and urinary continence. 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