Open, Laparoscopic, and Robot-Assisted Radical Prostatectomy Oncological Results: A Reverse Systematic Review

Context: Systematic reviews (SR) have always been used as the best evidence to compare three radical prostatectomy (RP) techniques: retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic radical prostatectomy (RARP). Despite the superiority of minimally invasive surgery in relation to perioperative outcomes, the literature still cannot establish which technique is superior in relation to oncological outcomes. A new methodology called Reverse Systematic Review (RSR) was created to gather the best evidence in the literature based on a heterogeneous sample, allowing the comparison of oncological outcomes from a population point of view.Objective: To apply the RSR to compare RP techniques in relation to oncological outcomes: positive surgical margin (PSM) and biochemical recurrence rate (BCR).Evidence Acquisition: A search was carried out in eight databases between 2000 and 2020 through SR studies referring RRP, LRP, or RARP (80 SR). All references used in these SR were captured referring to 1724 reports. Preoperative and oncological outcomes were compared and correlated among RRP, LRP, and RARP.Evidence Synthesis: Five hundred fifty-nine (32.4%) reports for RRP, 413 (23.9%) for LRP, and 752 (43.7%) for RARP, and a total of 1,353,485 patients were found. Regarding PSM, 284 reports were collected for RRP, 324 for LRP, and 499 for RARP, with rates of 23.6%, 20.7%, and 19.2%, respectively, and only the RRP with statistical difference (p < 0.001). Using a nonlinear regression model, the BCR was correlated with follow-up time at 1, 2, 3, 5, 7, and 10 years: 10%, 15%, 18%, 20%, 23%, and 38% for RRP; 6%, 9%, 13%, 20%, 23%, and 10% for LRP; and 8%, 12%, 16%, 23%, 27%, and 19% for RARP. The absence of long-term work for RARP prevented more accurate projections of BCR.Conclusions: RSR proved to be effective in generating a population and heterogeneous sample capable of demonstrating better oncological results for minimally invasive surgery (LRP and RARP) compared to RRP. It demonstrated the maturity of temporal follow-up data for RRP and LRP and the impact of absence of late follow-up from RARP studies on the long-term rate of BCR.Patient Summary: After 20 years of coexistence of the three main radical prostatectomy techniques, the RSR was able to detect better results from minimally invasive surgery in relation to PSMs and long-term BCRs.