Open, Laparoscopic, Retropubic, or Robotic? A Network Meta-Analysis of Post-Prostatectomy Oncologic Outcomes and Health-Related Quality of Life in Localized Prostate Cancer Patients.

Abstract

Objective: Prostatectomy remains a standard surgical treatment for localized prostate cancer, a malignancy with substantial global incidence and clinical impact in men. Its rapid adoption of surgical modalities has outpaced supporting evidence, resulting in limited consensus in reporting HRQoL and oncologic outcomes. This paper aims to compare the oncologic and Health-Related Quality of Life (HRQoL) outcomes of open (ORP), retropubic (RRP), laparoscopic (LRP), and robot-assisted radical prostatectomy (RARP) in patients with localized prostate cancer.

Methods: A systematic search of MEDLINE/PubMed, Embase, Cochrane Library, and grey literature for randomised controlled trials and comparative studies was performed from database inception to November 2025. Risk of bias was assessed using RoB 2.0 and ROBINS-I. A network meta-analysis evaluated oncological outcomes that consist of Biochemical Recurrence (BCR) and Positive Surgical Margins (PSM), and HRQoL metrics including urinary incontinence and erectile dysfunction. Ranking probabilities were estimated using Surface Under the Cumulative Ranking (SUCRA) values.

Result: Thirty-three studies that met the inclusion criteria were included involving 69986 patients. Overall risk of bias for both randomized and observational studies was low. RARP ranked highest for oncologic outcomes, demonstrating the greatest likelihood of minimizing BCR (SUCRA 84.2%; 14 trials, 17,932 patients) and PSM (SUCRA 93%; 29 trials, 38,509 patients). For HRQoL, non-robotic techniques were favored across specific domains: ORP showed a 76% probability of fewer urinary incontinence events; LRP demonstrated an 87% likelihood of requiring fewer pad changes; and RRP demonstrated a 95% probability of being the best-tolerated technique regarding postoperative erectile dysfunction.

Conclusion: RARP appears as the most favourable oncological outcome, whereas non-robotic approaches showed advantages in HRQoL domains. Future randomized trials are needed to prove the superiority of the techniques.