A systematic review and meta-analysis of the impact of preoperative surgical planning in robotic-assisted radical prostatectomy on trifecta outcomes.

Abstract

Introduction: Surgical planning in robotic assisted radical prostatectomy (RARP) recommends the maximal use of function persevering techniques without compromising oncological outcomes. There is no consensus on how to define the optimal surgical approach. This review aims to collate available evidence on the impact of preoperative planning interventions on the trifecta of oncological, functional or operative outcomes.

Evidence acquisition: A systematic review according to the PRISMA guidelines was performed using the terms ((prostatectomy) AND (robot*)) AND (plan*) OR (image*) OR (decision*) for articles published between January 2000 and January 2024. Prospective studies reporting patients undergoing RARP with a preoperative planning intervention, compared to no planning, to determine at least one of trifecta outcome were included. Results were synthesized in a narrative review with a metanalysis when two or more studies reported the same outcomes.

Evidence synthesis: Eight studies, one RCT and seven non-randomised prospective comparative studies, including 1945 patients, applying clinical nomograms, MRI and histology review were included. The outcomes reported were positive surgical margins (PSM) (oncological) and nerves sparing rates (functional). No operative outcomes were reported. Metanalysis demonstrated that positive surgical margins (PSM) were reduced in both clinical nomogram (RR=0.56, 95% CI: 0.37-0.87, P=0.009; two studies 563 patients) and MRI (RR=0.72, 95% CI: 0.54-0.96, P=0.02; three studies, 801 patients) intervention groups. Additionally, metanalysis of all nerve-sparing cases demonstrated lower PSM rates in the intervention group (RR=0.65, 95% CI: 0.47-0.90, P=0.01; three studies, 823 patients). No significant changes were seen in nerve-sparing rates.

Conclusions: Preoperative surgical planning with nomograms and MRI has the potential to improve PSM rates without compromising nerve sparing. It is not possible to identify the optimal approach, but it is likely that the incorporation of biopsy and MRI information will lead to the best outcomes. Further studies using universally accepted standards of the trifecta outcomes are needed.