Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

Peer review under responsibility of Arab Association of Urology.

Figures & data

Fig. 1 PRISMA chart.

Table 1 Characteristics and summary of immediate outcomes of the included studies.

Reference	Approach/type of study	E-RP vs T-RP
		Number of patients	Mean operative, min	Mean EBL, mL	BTR, %	Mean LOS, days	Mean catheter indwelling, days
Bivalacqua et al. 2008 [8]	Laparoscopic/unclear	29 vs 21	216 vs 228	–	0 vs 0	1.9 vs 2.2	12 vs 12
Brown et al. 2005 [9]	Laparoscopic/retrospective	34 vs 122	191 vs 197	–	0 vs 4	1.6 vs 2.1	–
Cathelineau et al. 2004 [10]	Laparoscopic/retrospective	100 vs 100	163 vs 173	375 vs 360	3 vs 4	6.1 vs 5.8	6.2 vs 6
Eden et al. 2004 [13]	Laparoscopic/unclear	100 vs100	190.6 vs 338.9	201.5 vs 310.5	0 vs 2	2.6 vs 3.8	10.1 vs.11.3
Erdogru et al. 2004 [14]	Laparoscopic/prospective matched pair	53 vs 53	211.8 vs 197.1	–	13.2 vs 16.9	–	10.6 vs 10.9
Hoznek et al. 2003 [17]	Laparoscopic/retrospective	20 vs 20	169.6 vs 224.2	442.1 vs 600.5	10 vs 15	6.4 vs 6.5	4.2 vs 5.3
Phinthusophon et al. 2007 [20]	Laparoscopic/retrospective	69 vs 56	220 vs 350	605 vs 883	0.32 vs 1.23	–	8.9 vs 11.90
Porpiglia et al. 2006 [21]	Laparoscopic/unclear	80 vs 80	133.7 vs 179.4	594.34 vs 562.5	8.75 vs 11.25	8.52 vs 7.6	7.21 vs 7.53
Remzi et al. 2005 [22]	Laparoscopic/retrospective	41 vs 39	217 vs 279	189 vs 290	–	7 vs 7	6.1 vs 7.2
Ruiz et al. 2004 [23]	Laparoscopic/unclear	165 vs 165	220 vs 248	803 vs 678	5.4 vs 1.2	6.3 vs 6.7	6.6 vs 5.1
Siqueira et al. 2010 [24]	Laparoscopic/retrospective	40 vs 40	267.6 vs 175	292.4 vs 177.5	–	3 vs 3	–
Gao et al. 2006 [15]	Laparoscopic/unclear	19 vs 12	196 vs 262	261 vs 270	0 vs 8.3	10 vs 12	7.2 vs 7.4
Atug et al. 2006 [7]	Robotic/prospective	40 vs 40	229.15 vs 236.23	221 vs 250	–	1.2 vs 1.1	–
Capello et al. 2007 [3]	Robotic/randomised study	31 vs 31	181 vs 191	199 vs 163	–	–	–
Chung et al. 2011 [12]	Robotic/unclear	155 vs 105	150.3 vs 162.1	350.8 vs 361.7	–	5.1 vs 6.2	7.7 vs 7.3
Madi et al. 2007 [19]	Robotic/unclear	34 vs 21	214 vs 241	125 vs 150	–	1 vs 1	–
Lee et al. 2009 [25]	Robotic/unclear	30 vs 30	206.2 vs 202.1	445 vs 361.7	–	6.6 vs 6.2	7.7 vs 7.3
Jacobs et al. 2011 [18]	Robotic/prospective	167 vs 48	209 vs 310	125 vs 188	–	1.1 vs 1.5	–
Horstmann et al. 2012 [16]	Robotic/prospective	103 vs 67	192 vs 224	276 vs 281	–	7.8 vs 8.8	6.2 vs 6.5
Anderson et al. 2013 [11]	Robotic/prospective	70 vs 50	236.8 vs 255.7	372 vs 342	2.9 vs 2	1.94 vs 3.54	–

Fig. 2 Meta-analysis of operative time (A) and EBL (B).

Fig. 3 Meta-analysis of BTR (A) and LOS (B).

Fig. 4 Meta-analysis of analgesic usage (A) and early continence (B).

Fig. 5 Meta-analysis of 12-month continence (A) and PSM (B).

Table 2 Estimated Clavien–Dindo grading of reported complications in the studies using the laparoscopic approach.

Complication	Clavien–Dindo grade	E-RP, n	T-RP, n
Ileus	2/3A/3B	1	13
Urine leakage	2/3A/3B	21	33
Bladder neck stenosis	3B	4	8
Urethral stricture	3B	2	1
Meatal stricture	3B	1	0
Rectal injury	3B	4	8
Surgical intervention for bleeding	3B	2	6
Lymphocele	3A/3B	11	0
Epigastric injury	3B	2	0
Pelvic haematoma	2/3B	2	4
Scrotal haematoma	2	0	1
Rectal haematoma	2/3B	1	0
Subcutaneous haematoma	2	1	6
AUR	2	4	7
Nerve paraesthesias	2	1	3
Bladder injury	3B	1	0
Faecal incontinence	2/3B	0	1
Urethral bleeding	2	1	0
Recto-urethral fistula	3B	1	3
Port site hernia	3B	0	1
Incisional hernia	3B	1	0
UTI	1	0	10
Urosepsis	2	0	1
Unspecified wound complication	2/3B	2	3
Perineal pain	2	0	4
Pulmonary failure requiring intubation	4A	0	1
Pulmonites	2	0	1
C. difficile	2	0	1
Acute renal failure	2/4A	1	0
Myocardial infarction	2/3A/3B	1	1
Cerebrovascular accident	3B	0	2
Unspecified medical complication	–	4	4
Death	5	0	2
Total, n/N (%)		69/750 (9.2)	125/808 (15.5)

Table 3 Estimated Clavien–Dindo grading of reported complications in the studies using the robotic approach.

Complication	Clavien–Dindo grade	E-RP, n	T-RP, n
Ileus	2/3A/3B	1	11
Arm neuropraxia	1	0	1
Thromboembolism	4	2	3
Gross haematuria (no surgical intervention)	2	0	1
Prolonged drainage	2	1	0
Bladder neck stenosis	3B	1	1
AUR	1/2	1	1
Epigastric vessel injury	3B	1	1
Urine leak	2/3A/3B	1	3
Rectal injury	2/3B	1	2
Lymphocele	2/3A/3B	14	6
Port wound opening	1	1	0
Hernia	3B	1	2
Major haematoma	3A	3	0
Ureteric injury	2	0	1
Death (myocardial infarction)	5	1	0
Total, n/N (%)		29/630 (4.6)	33/717 (4.6)

Fig. 6 Meta-analysis of overall complications (A) and ileus (B).

Fig. 7 Meta-analysis of lymphocele (A) and anastomotic leakage (B).

Fig. 8 Meta-analysis of bladder neck stenosis (A) and rectal injury (B).

Fig. 9 Meta-analysis of mortality.

Fig. 10 Risk of bias chart.

Table 4 Evaluation of studies using the STROBE guidelines.

Reference	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22
Bivalacqua et al. 2008 [8]	N	Y	Y	N	P	P	N	P	N	Y	Y	P	Y	P	Y	P	NA	Y	N	P	Y	N
Brown et al. 2005 [9]	N	Y	Y	Y	P	P	N	N	N	Y	Y	P	Y	Y	Y	N	NA	Y	N	Y	Y	N
Cathelineau et al. 2004 [10]	N	Y	Y	Y	P	P	N	N	N	Y	Y	P	Y	Y	Y	N	NA	N	N	Y	Y	N
Eden et al. 2004 [13]	N	Y	Y	P	P	P	N	N	N	Y	N	N	Y	Y	Y	N	Y	Y	N	Y	Y	N
Erdogru et al. 2004 [14]	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	N
Hoznek et al. 2003 [17]	N	Y	Y	Y	P	P	P	Y	N	Y	P	P	Y	Y	Y	N	NA	Y	Y	Y	Y	N
Phinthusophon et al. 2007 [20]	N	Y	Y	Y	Y	Y	N	P	N	Y	Y	Y	Y	Y	Y	P	NA	P	N	Y	Y	N
Porpiglia et al. 2006 [21]	N	Y	Y	P	Y	Y	P	Y	P	Y	P	Y	Y	Y	Y	P	NA	Y	N	Y	Y	N
Remzi et al. 2005 [22]	N	Y	Y	Y	Y	Y	P	Y	P	Y	Y	Y	Y	Y	Y	P	NA	Y	N	Y	Y	N
Ruiz et al. 2004 [23]	N	Y	Y	P	Y	N	N	N	N	Y	N	Y	Y	Y	Y	P	Y	Y	Y	Y	Y	N
Siqueira et al. 2010 [24]	Y	Y	Y	Y	Y	Y	P	P	Y	Y	Y	Y	Y	Y	Y	P	NA	Y	N	Y	Y	N
Gao et al. 2006 [15]	N	P	P	P	N	P	Y	Y	N	Y	P	Y	Y	Y	Y	P	NA	Y	N	Y	Y	N
Atug et al. 2006 [7]	N	Y	Y	Y	P	N	Y	P	N	Y	Y	Y	Y	Y	Y	N	NA	Y	N	Y	Y	N
Chung et al. 2011 [12]	N	Y	Y	Y	P	N	Y	N	P	Y	Y	Y	Y	Y	Y	P	Y	Y	Y	Y	Y	N
Madi et al. 2007 [19]	N	Y	Y	P	P	N	P	Y	P	Y	Y	Y	Y	Y	Y	N	NA	P	P	Y	Y	N
Jacobs et al. 2011 [18]	N	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	N	NA	Y	Y	Y	Y	Y
Horstmann et al. 2012 [16]	N	Y	Y	Y	P	Y	Y	Y	Y	P	Y	Y	P	N	Y	Y	NA	Y	Y	Y	Y	N
Anderson et al. 2013 [11]	N	Y	Y	Y	Y	P	P	Y	N	Y	Y	Y	Y	N	Y	N	NA	Y	Y	Y	Y	N

1 – Title and abstract.

Introduction: 2 – Explain the scientific background and rationale for the investigation being reported, 3 – Objectives.

Methods: 4 – Study design, 5 – Setting, 6 – Participants, 7 – Variables, 8 – Data sources/measurement, 9 – Bias, 10 – Study size, 11 – Quantitative variables, 12 – Statistical methods.

Results: 13 – Participants, 14 – Descriptive data, 15 – Outcome data, 16 – Main results, 17 – Other analyses.

Discussion: 18 – Key results, 19 – Limitations, 20 – Interpretation, 21 – Generalisability, 22 – Funding.

Y, yes addressed by study; N, not addressed by study; P, partially addressed by study; NA, not applicable.

Table 5 Evaluation of Martin criteria for the studies reporting on complications.

Reference	1	2	3	4	5	6	7	8	9	10	TC, n
Bivalacqua et al. 2008 [8]	N	N	N	P	N	N	Y	N	Y	N	2
Brown et al. 2005 [9]	Y	N	Y	Y	N	Y	Y	N	Y	Y	5
Cathelineau et al. 2004 [10]	Y	P	N	Y	Y	Y	Y	N	Y	N	6
Eden et al. 2004 [13]	N	P	Y	P	N	Y	Y	N	Y	N	4
Erdogru et al. 2004 [14]	Y	Y	Y	Y	Y	Y	Y	N	Y	N	8
Hoznek et al. 2003 [17]	Y	N	N	Y	N	Y	Y	N	Y	Y	6
Phinthusophon et al. 2007 [20]	Y	Y	Y	Y	Y	Y	Y	N	N	N	7
Porpiglia et al. 2006 [21]	N	Y	Y	Y	N	Y	Y	Y	Y	N	7
Remzi et al. 2005 [22]	Y	Y	Y	Y	N	Y	Y	N	Y	N	7
Ruiz et al. 2004 [23]	N	Y	Y	Y	Y	Y	Y	N	Y	N	7
Siqueira et al. 2010 [24]	Y	Y	Y	N	Y	Y	Y	N	Y	N	7
Atug et al. 2006 [7]	Y	N	N	Y	N	Y	Y	N	Y	N	5
Capello et al. 2007 [3]	Y	N	N	N	N	Y	Y	N	N	N	3
Chung et al. 2011 [12]	N	Y	Y	Y	N	Y	Y	N	Y	N	6
Madi et al. 2007 [19]	N	Y	N	Y	N	Y	Y	N	Y	N	5
Horstmann et al. 2012 [16]	Y	N	N	Y	Y	N	Y	Y	Y	N	6
Anderson et al. 2013 [11]	Y	P	P	Y	N	Y	Y	Y	Y	N	6
Mean (SD) TC, n											5.71 (1.57)

1 – Method of accruing data defined – Prospective or retrospective accrual of data are indicated.

2 – Duration of follow-up indicated – Report clarifies the time period of postoperative accrual of complications such as 30 days or same hospitalisation.

3 – Outpatient information included – Study indicates that complications first identified following discharge are included in the analysis.

4 – Definition of complications provided – Article defines at least one complication with specific inclusion criteria.

5 – Mortality rate and causes of death listed – The number of patients who died in the postoperative period of study are recorded together with cause of death.

6 – Morbidity rate and total complications indicated – The number of patients with any complication and the total numbers of complications are recorded.

7 – Procedure-specific complications included.

8 – Severity grade utilised – Any grading system designed to clarify severity of complications including major and minor is reported.

9 – LOS data – Median or mean LOS indicated in the study.

10 – Risk factors included in the analysis – Evidence of risk stratification and method used indicated by study.

Y, yes study addressed criteria completely; N, no study did not address criteria; P, study partially addressed criteria; TC, total number of Martin criteria met by each study.